Worked Example — Denial Code Decoder
How a generic BSNC becomes a specific telehealth exclusion.
This is a fully anonymized worked example. A real patient was denied out-of-network telehealth for months under the generic code "BSNC" (Benefit Not Covered). The decoder identifies the most likely specific plan provision and gives the regulatory language that demands the insurer provide the corrected notice in writing.
No real PHI. The carrier name, member name, and plan number are fictional composites. The SBC provisions are real plan language patterns but not copied from any one document.
Synthetic denial input
SAMPLE COUNSELING ASSOCIATES Member: [REDACTED] Plan: Sample Blue PPO Bronze 24A01-01 Denial of Out-of-Network Telehealth Service Date: [DATE] Your claim for out-of-network telehealth services has been denied. Denial code: BSNC Reason: Benefit not covered. If you have questions, contact Member Services at the number on your ID card.
SBC plan provisions (cross-referenced)
Out-of-network telehealth services are not covered under this plan. Telehealth benefits are limited to in-network providers only. Mental health services require prior authorization for out-of-network care.
Decode output
BSNC
high confidence
Out-of-network telehealth excluded under plan
29 CFR 2560.503-1(g)(1)(i) — the notice must describe the specific reason for the adverse determination; and (g)(1)(ii) — the notice must describe the plan provisions on which the determination is based.
The adverse benefit determination dated [DATE OF DENIAL] cites the generic code BSNC (Benefit Not Covered) without identifying the specific plan provision or exclusion that applies. Under 29 CFR 2560.503-1(g)(1)(i) — the notice must describe the specific reason for the adverse determination; and (g)(1)(ii) — the notice must describe the plan provisions on which the determination is based., the notice must describe the specific reason for the adverse determination and the plan provisions on which the determination is based. A generic code alone does not satisfy this requirement. Please provide, in writing, (1) the specific plan provision or exclusion that excludes this service, (2) the full text of that provision, and (3) the date the provision was last updated. Based on the plan provisions reviewed, the most likely specific basis is: Out-of-network telehealth excluded under plan.
Deployable demand scripts
Three ready-to-deploy versions of the same demand — pick the channel you are using. Each cites the specific telehealth exclusion and the regulatory notice requirement.
Carrier chat
Hello — my claim was denied with code BSNC (Benefit Not Covered), but the notice does not name the specific plan provision behind it. Under federal claims rules — 29 CFR 2560.503-1(g)(1)(i) and (g)(1)(ii) — an adverse benefit determination must state the specific reason for the denial and the specific plan provision it is based on. A generic code by itself does not meet that requirement. Please send me, in writing: (1) the exact plan provision or exclusion you applied, (2) the full text of that provision, and (3) the date it was last updated. My plan documents suggest the basis may be: Out-of-network telehealth excluded under plan. Please confirm or correct this in writing.
Phone call
I'm calling about a denied claim. The denial code is BSNC, which only says "Benefit Not Covered." That does not tell me the specific plan provision you relied on. Under federal claims rules — 29 CFR 2560.503-1(g)(1)(i) and (g)(1)(ii) — an adverse benefit determination must state the specific reason for the denial and the specific plan provision it is based on. A generic code by itself does not meet that requirement. I'd like you to (1) name the exact provision or exclusion, (2) read me its full text, and (3) tell me when it was last updated. From my plan documents, I think the basis may be "Out-of-network telehealth excluded under plan" — please confirm or correct that. Please also send this to me in writing through my Message Center, and give me a reference number for this request.
Message Center
Re: Denied claim citing code BSNC (Benefit Not Covered), date of denial [DATE OF DENIAL]. The adverse benefit determination cites the generic code BSNC without identifying the specific plan provision or exclusion that applies. Under federal claims rules — 29 CFR 2560.503-1(g)(1)(i) and (g)(1)(ii) — an adverse benefit determination must state the specific reason for the denial and the specific plan provision it is based on. A generic code by itself does not meet that requirement. Please provide, in writing: (1) the specific plan provision or exclusion applied to this claim, (2) the full text of that provision, and (3) the date the provision was last updated. My plan documents suggest the basis may be: Out-of-network telehealth excluded under plan. Please confirm or correct this in writing. Please treat this as a request for a corrected adverse benefit determination notice that complies with 29 CFR 2560.503-1(g)(1)(i) and (g)(1)(ii), and provide a reference number for this request.
The decoder does not know the real case. It works from the generic code + the most common plan provisions for that carrier and plan type. The SBC cross-reference narrows the candidates. The output is what the member can paste into their carrier portal or Message Center to demand the specific plan provision in writing.
Try your own denial
Paste a redacted or synthetic denial below. No real PHI. The decoder returns the generic code, the most likely specific basis, and the regulatory citation to demand the corrected notice.
Not legal advice. This decoder is an administrative tool, not a legal opinion. The output is based on the most common plan provisions and generic code mappings. Always verify with your own plan documents. We do not submit anything to your carrier; you review and send the generated text yourself.