Guide: Conquering Denial Code 55

​Denial code 55, a significant revenue challenge for healthcare providers, indicates that a procedure, treatment, or drug has been deemed experimental or investigational by the payer. This blog delves into the root causes of these denials, strategies to prevent them, and steps to take if your practice encounters this issue.

Understanding Denial Code 55
When a claim is denied with code 55, it signifies the payer doesn't recognize the service as established or safe.  Common reasons include:

• Investigational Care: Services linked to clinical trials or emerging treatments.
• Lack of Coverage: The procedure or drug might not be covered by the patient's plan.
• Coding Errors: Incorrect, missing, or under-coding value codes can lead to denials.
• Advance Notice: Failure to provide required patient notice of non-coverage.
• Insufficient Documentation: Inadequate medical records to support the service.
• Incorrect Billing: Billing for unperformed procedures.

Preventing Denial Code 55
To mitigate the risk of denial code 55:

• Thorough Research: Ensure treatments align with clinical guidelines and research.
  
• Accurate Coding: Verify all codes and amounts are correct.
  
• Patient Notification: Adhere to payer requirements for advance notice.
  
• Comprehensive Documentation: Maintain detailed medical records to support medical necessity.
  
• Payer Guidelines: Stay informed about payer policies.

Overcoming Denial Code 55
If you encounter denial code 55:

• Review Claim Details: Understand the specific denial reason.
• Gather Documentation: Collect supporting medical records and research.
• Appeal Process: Initiate an appeal with strong evidence.
• Payer Communication: Contact the payer for clarification.

Partner with Claims Med for Revenue Cycle Success
By understanding and addressing denial code 55, healthcare providers can improve revenue cycle management. Claims Med offers specialized revenue cycle management solutions to help practices thrive. Our expertise in denial management, coding, and payer relations can optimize your revenue.

Contact Claims Med today for assistance in overcoming denial code 55 and improving the financial health of your practice.