Denial Code CO 96

Denial Code CO 96 – Non covered charges

• Insurances will deny the claim with denial Code CO 96, if the services are not covered as per the patient current benefit plan or
• It will deny with the denial code CO 96, as per provider contract with insurance company.

Denial code CO 96 Resolution:

1. First step is to check with rep, whether the services are not covered as per patient plan or provider’s contract.

• Services not covered as per the patient current benefit plan:

Below are some of the scenarios we come across when we the services are not covered as per the patient plan:

Consider patient took the treatment for dental and claim billed to an insurance company for reimbursement. But as per the policy, patient plan covers only medical service and dental service is not covered. In this case insurance company will deny the claim with denial code CO 96, indicating charges are non-covered as per the patient current benefit plan.

• In the above scenario, we need to request the denied EOB from the insurance and check the application to see if patient is having other or consecutive insurance which is active and covers the service. If yes then we should bill the claim to that insurance along with denied EOB for reimbursement.
• If patient doesn’t have other insurance, then go ahead and bill the patient.

Patient covers only in-network benefits but patient took the treatment from Out of network provider. Let us assume patient is having HMO plan but took the treatment from out of network provider. In this case, insurance will deny the claim with CO 96 – stating services are not covered as patient took the treatment from out of network provider and as per patient plan HMO covers only in-network providers.

• In the above scenario, as we know HMO plan covers only in-network benefits. First, we need to check whether service performed in an emergency care or not. If it’s an emergency care, then send those claims back for reprocessing stating HMO plan covers an emergency care even though its out of network benefits.
• If patient plan is HMO and it’s not an emergency care, then request the denied EOB and submit the claim to the consecutive insurance for reimbursement.
• If no other insurance found for the patient, then go ahead and bill the patient.

• Services not covered under as per provider’s contract:

As per the provider contract with the insurance company, provider has to perform the services which is listed as per the contract or payer guidelines. But if provider performs the service which is not listed as per the payer’s contract or payer guidelines, then the insurance company will deny those claims with denial code CO 96 indicating charges are non-covered as per the provider’s contract.

Most of the case we get denial stating – Diagnosis (DX code) or service (CPT code) performed or billed are not covered based on the LCD.

• Whenever you receive this denial code CO 96, the very first step is to check the previous date of service whether the same CPT and Dx code is paid or not. If it is paid then we need to send the claim back for reprocessing indicating the same.
• Next step is to check the remark codes to find out the exact reason or reach out representative for exact reason for denials. Some of the most common remark codes are as follows

N180 or N56 – Wrong Diagnosis code was used on the claim for the procedure code billed.

N115 – Claim denied based on the Local Coverage determination (LCD) submitted

• Check Local coverage determination database list and verify the submitted procedure code and diagnosis code is covered or not and also check whether any modifier is missing.
• Check with coding team to correct and resubmit the valid procedure code and diagnosis code.
• If CPT and DX billed is correct, but still insurance denied with the denial code CO 96, then we need to appeal the claim with supporting documents.
• If appeal withheld from an insurance company, then the final option is to write off the claim.

Medical Billing Denials and actions – Top Denial codes Solutions (medicalbillingcycle.com)