Denial Code CO 96

Denial Code CO 96 – Non covered charges

• Insurance companies will deny claims with denial Code CO 96 when the services provided are not covered under the patient’s current benefit plan. This denial typically occurs when the services rendered fall outside the scope of coverage outlined in the patient’s insurance policy.
• Additionally, claims may also be denied with denial Code CO 96, if the provided services do not align with the terms and conditions specified in the provider contract with the insurance company. In such cases, the denial is based on discrepancies between the services delivered and the contractual agreements between the healthcare provider and the insurance company. It is crucial for healthcare providers and patients to review and understand the details of their insurance plans and provider contracts to avoid potential claim denials under Code CO 96.

Denial code CO 96 Resolution:

To address this issue, the first step is to communicate with the insurance representative to verify whether the denial is due to services not being covered under the patient’s plan or if it is a result of a discrepancy with the 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:

Scenario 1:

Consider a patient undergoes dental treatment and submits a claim to their insurance company for reimbursement, the claim may be denied if dental services are not covered under the patient’s plan. Denial code CO 96 is typically used in this scenario, signalling that the charges are non-covered as per the patient’s current benefit plan.

• When encountering a situation where services are not covered according to a patient’s plan, it is essential to follow proper protocol to maximize reimbursement. In the case of a patient receiving dental treatment that is not covered by their current insurance plan, resulting in a denial with CO 96 code, the first step is to acquire the denied Explanation of Benefits (EOB) from the insurance company. Upon receiving the denied EOB, it is crucial to investigate if the patient has an additional active insurance plan that covers the specific service rendered. If such alternative coverage exists, the denied claim, along with the EOB, should be submitted to the secondary insurance for potential reimbursement.
• However, if the patient does not have any other insurance coverage, the next step would be to bill the patient directly for the services provided.

Scenario 2:

When a patient with an HMO plan seeks treatment from an out-of-network provider, the insurance company will typically deny the claim with a denial code CO 96. This denial code indicates that the services are not covered because the patient received treatment from a provider that is not in the HMO network. HMO plans are structured to provide coverage for services rendered by in-network providers, and any services received from out-of-network providers may not be covered or may be subject to additional out-of-pocket expenses for the patient.

• In the scenario provided, it is crucial to differentiate between emergency care and non-emergency care to determine appropriate coverage under an HMO plan. If the service is classified as emergency care, even if it is out of network, the HMO plan should cover it according to regulatory requirements. In such cases, it is essential to reprocess the claims, clearly stating that the HMO plan includes coverage for emergency care regardless of network status.
• However, if the care provided is not classified as emergency care, the denied EOB should be requested and the claim should be submitted to the subsequent insurance for reimbursement.
• If there are no additional insurances available for the patient, billing the patient directly may be necessary.

Services not covered under as per provider’s contract:

In adhering to the terms of the provider contract with an insurance company, it is imperative for the provider to deliver services that align with the specified guidelines outlined in the contract or payer’s directives. Any deviation from these authorized services may result in claim denials by the insurance company, signified by denial code CO 96, indicating that the charges are considered non-covered under the provider’s contract

• When encountering denial code CO 96, the initial course of action should be to verify the prior date of service to confirm if the same CPT (Current Procedural Terminology) and Dx (Diagnosis) code had been reimbursed. If it has been paid previously, then the next step involves resubmitting the claim for reprocessing while clearly indicating the precedent approval.
• If the same CPT and Dx codes have not been paid previously, the next course of action is to review the remark codes attached to the denial. Investigating the remark codes will provide insight into the precise reason for the denial. It is advisable to reach out to a representative if further clarification is needed. Common remark codes often associated with CO 96 denials can shed light on intricate details affecting claims processing.

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.

N180 or N56 – Wrong diagnosis code is used on a claim for a billed procedure code

N115 – Claim denied based on the Local Coverage Determination (LCD).

• It is essential to consult the Local Coverage Determination (LCD) database list. By referencing this database, healthcare providers can determine if the specific procedure and diagnosis are covered under the Medicare program or other insurance plans. Moreover, it is crucial to check if any modifiers are required for the procedure to be reimbursed appropriately.
• If the procedure or diagnosis code is not covered based on the LCD database, it is essential to collaborate with the coding team to rectify the issue. The coding team can assist in identifying an appropriate and valid procedure code and diagnosis code that align with the insurance provider’s coverage policies.
• If the procedure or diagnosis code billed is covered based on the LCD database, but still insurance denied with the denial code CO 96, then we need to appeal the claim with supporting documents.
• In the event that an appeal is withheld from an insurance company, the final option available is to write off the claim.

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