Denial Code 26 / 27: Expenses Incurred Prior to Coverage / After Coverage Terminated (Easy Guide)
In medical billing, Denial Code 26 and Denial Code 27 are very common. These denials usually happen when the insurance coverage is not active on the Date of Service (DOS).
This guide explains what this denial means, why it happens, and how to resolve it effectively during an insurance follow-up call.
What is Denial Code 26 / 27?
✅ Denial Code 26
Expenses incurred prior to coverage
This means the service was provided before the policy effective date.
✅ Denial Code 27
Expenses incurred after coverage terminated
This means the service was provided after the insurance coverage ended.
Why Does Denial Code 26 / 27 Occur?
This denial occurs when the Date of Service (DOS) does NOT fall between:
• Policy Effective Date
and
• Policy Termination Date
In simple words:
If the patient’s insurance was not active on the DOS, the claim gets denied.
How to Handle This Denial (Simple Call Flow)
When you call the insurance payer and they say:
“Claim denied as member coverage terminated / policy termed.”
Follow this step-by-step process.
Step 1: Ask for the Denial Date
Start with:
✅ “May I get the denial date?”
Step 2: Ask for Policy Dates
Then confirm policy details:
✅ “May I have the policy effective date and termination date?”
Step 3: Check the Date of Service (DOS)
Now compare:
• DOS
vs
• Effective Date to Term Date
Decision: Is DOS Between Effective & Term Date?
✅ If YES (Policy Active on DOS)
That means payer denied incorrectly.
Action:
✅ Ask rep to reprocess:
“Could you please send the claim back for reprocessing since the policy was active on DOS?”
Then ask:
• “What is the TAT for reprocessing?”
• “May I get the claim number and call reference number?”
📌 Set follow-up reminder based on TAT.
❌ If NO (Policy Not Active on DOS)
Then proceed to check for alternate coverage.
Ask:
✅ “Is there any other policy active for the patient on DOS?”
If Another Policy is Active on DOS
✅ If YES
Collect details:
• Policy ID
• Policy effective date
• Policy termination date
Then confirm:
✅ “May I have the claim number and call reference number?”
Next Step:
• Update new policy in billing system
• Resubmit the claim with correct policy details
If No Other Policy is Active
❌ If NO
Collect:
✅ Claim number and call reference number
Then:
➡️ Release claim to the patient (Patient Responsibility)
But before releasing, do these checks:
Important Notes Before Releasing Claim to Patient
Before you transfer balance to patient, always verify:
1) Check if Any Other Insurance Exists
• Secondary insurance?
• Previous payer coverage?
2) If Other Insurance is Available
If you have portal access:
• Check eligibility on payer portal
• If insurance is active as primary on DOS → update it and resubmit claim
3) Review Previous DOS Payments
Always check old claims:
✅ Was payment received from another insurance previously?
If yes:
• verify eligibility for that payer on DOS
• resubmit if active
Summary (Quick Resolution Checklist)
Use this quick list when handling Denial Code 26/27:
✅ Ask denial date
✅ Ask policy effective & termination date
✅ Compare DOS with policy dates
✅ If policy active → send for reprocessing + note TAT
✅ If policy inactive → check alternate policy
✅ If alternate policy exists → update policy + resubmit
✅ If no coverage → release to patient (after checking other insurance)
Final Tip for Medical Billing Teams
Denial 26/27 can be resolved quickly if you always:
• verify the exact DOS
• confirm policy dates
• check for secondary/alternate coverage
• keep claim# and call reference#
This saves time and prevents unnecessary patient billing errors.
