Quick Explanation
Denial code 163 indicates that the payer processed a claim containing an attachment indicator but did not successfully receive or match the supporting medical documentation required to adjudicate the services. This typically occurs when clinical notes, operative reports, or certificates of medical necessity referenced in the claim submission are not received within the payer's designated matching window.
Common Causes for 163
Denials with code 163 typically happen for the following specific reasons:
- An electronic claim was submitted with a PWK (Paperwork) segment indicating an attachment, but the physical or electronic documentation was never transmitted.
- The supporting documentation was faxed or mailed without the required barcode coversheet or Claim Control Number, preventing the payer's system from matching it to the electronic claim.
- The attachment was sent after the payer's strict matching timeframe had elapsed, leading to an automated denial.
- Technical transmission failures occurred during the submission of the electronic 275 attachment transaction through the clearinghouse.
How to Prevent 163 Denials
To avoid receiving this denial in the future, implement these specific checks:
- Always utilize standard payer-approved barcode coversheets that include the unique Claim Control Number (CCN) for all faxed or mailed attachments.
- Establish a strict administrative workflow to transmit referenced attachments within 24 to 48 hours of electronic claim submission to prevent matching window expiration.
- Configure claim scrubbing software to only append attachment indicators (PWK segments) when the documentation has been finalized and queued for delivery.
- Transition to electronic 275 attachment transactions where supported by the clearinghouse and payer to ensure automated, secure matching.
Appeal Letter Template for 163
If you believe this claim was denied incorrectly, you can use the following template to submit an appeal.
[Your Practice Header]
[Date]
[Payer Name]
[Appeals Department Address]
RE: Appeal for Claim [Claim Number]
Patient: [Patient Name]
ID: [Patient ID]
Date of Service: [Date]
Denial Code: 163 - Attachment referenced on the claim was not received
Dear Appeals Department,
I am writing to appeal the denial of the above-referenced claim, which was denied with code 163: "Attachment referenced on the claim was not received".
We are writing to appeal the denial of this claim under denial code 163. In accordance with CMS guidelines and HIPAA administrative standards regarding electronic claims and supporting documentation (PWK segment), we are enclosing the complete, requested medical documentation, including clinical notes and operative reports, to support the services billed. Please associate these enclosed records with Claim Control Number [Insert Claim Control Number] and reprocess the claim for immediate adjudication and payment as contractually required.
Attached please find:
1. A copy of the original claim.
2. The relevant medical records supporting the service.
3. [Any other supporting documents].
We respectfully request that you reprocess this claim for payment.
Sincerely,
[Your Name]
[Title]
[Practice Name]
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