CO 96 Denial Code is an insurance denial code that represents a non-covered charge. The payers use this code to indicate when certain services or items are not eligible for reimbursement under the terms & conditions of the patient’s policy. The insurance company basically says that the service provided is not covered according to their policy, hence they will not reimburse for it.

Fact Sheet:

• The CO 96 denial code represents a charge non-covered by insurance.
• This denial code is invoked when the service provided did not meet the coverage criteria of the patient’s plan.
• The rejection code can be found frequently among both private insurance as well as government programs like Medicare or Medicaid.

Healthcare providers find this code challenging, particularly when patients are of the opinion that the covered service should have been billed on their behalf. Therefore, understanding the why of the denial becomes crucial to resolving it.

Reasons for CO 96 Denial Code

There may be several reasons why an insurance company denies the claim using the CO 96 denial code. The common ones will allow you to prevent the recurrence of this issue. These are the general reasons for which you might receive such a denial:

1. Service Not Covered Under the Patient’s Plan

The common reason for a CO 96 denial code is that the service is not included in the insurance policy of the patient. Some services may not be covered even if they are medically necessary, such as some elective procedures and treatments.

• Example: A cosmetic surgery procedure might be denied if the insurance plan covers only those surgeries that are medically necessary.

2. Incorrect Procedure Code

If the procedure or service was incorrectly coded in the claim, CO 96 denial code would appear on insurance rejection. Incorrect coding may cause confusion as to what is covered, and the claim gets denied.

• Example: Incorrectly submitting a code for a different treatment or procedure that is not in the patient’s policy.

3. By Out-of-Network Providers

Services provided by out-of-network providers may also lead to a CO 96 denial code. Many insurance policies have preferred providers within the network, and these services out of this network may not be covered or may be covered at a lower reimbursement level.

• Example: Services from a doctor who is not part of the insurance network result in denial.

4. Exceeding Plan Limits

Insurance policies generally impose limits on certain types of services, such as the allowed number of physical therapy sessions or specialist visits per year. Any services thereafter would be denied with the CO 96 denial code, since the patient has already reached the set limit.

• Example: A patient has exceeded the policy limit for physical therapy sessions for the current year.

Pre-Authorization Not Obtained

Some services require pre-authorization prior to being rendered to the patient. Should the provider fail to obtain this pre-authorization, the insurance company would issue the CO 96 denial code.

• Example: Surgery requiring pre-authorization but performed without approval.

How to Appeal CO 96 Denial Code

Without trying to be disheartening, a CO 96 denial code does not imply that the denial cannot be overturned. If indeed the service should have been covered or if there was an error in denying the claim, it can always be appealed. To know how to go about that, here are the steps to follow:

Step 1: Review the Insurance Policy

The primary step is to check the insurance policy of the patient. You should find out about the service if it should have been covered. Any clauses implying certain exclusions or limitations needed to be scrutinized.
Next, ascertain that the service is considered medically necessary since some insurance companies will cover only medical necessity treatments.

Step 2: Claim Check for Errors

Claim check if has all the correct procedure codes, diagnosis codes, and any other required information submitted with the claim. A simple error in coding could be the reason for the denial.
Double-check the patient’s network status to ensure service provider is in-network, or if out-of-network coverage applies.

Step 3: Have Supporting Documents

In many situations, there is a need for a medical necessity letter or supporting documentation to accompany the appeal.
Include it when filing appeal if the procedure is medically necessary or if the patient’s plan has specific coverage requirements.

Step 4: Appeal Submission

Submit the appeal according to the insurance company’s procedures. This could involve filling out an appeal form, attaching supporting documentation, and mailing or electronically submitting it.
Again, make sure to follow very carefully the appeals process and deadlines for insurance companies. Otherwise, the appeal might get denied.

Step 5: Follow Up

When you file an appeal, ensure that you also follow the insurance company to confirm that they actually received your appeal and to find out its status.
If the appeal is successful, the insurance company will go ahead and reprocess the claim and refund the provider.

Preventing CO 96 Denial Code

The Best Policy in the Long Run: Fixing CO 96 denial code Issues with Appeals. Few Prevention Steps to Follow towards Minimizing the Chances of this Denial Code:

1. Proper Coding

Proper coding is critical in preventing denials, and claims should be checked for the correct codes matching the patient’s diagnosis and treatment.

• Use current coding manuals and guidelines.
• Use coding software or tools to check on code assignments.

2. Confirm Coverage before Delivering Services

It is prudent to confirm the patient’s insurance coverage before providing non-routine or elective services. It helps limit the likelihood of a CO 96 denial code being issued.

• Call the insurance company for pre-authorization or pre-certification if applicable.
• Confirm that the patient’s policy includes the particular service or procedure.

3. Ensure it is In-Network

If possible, have the provider performing the service be in-network with the patient’s insurance. These out-of-network providers are more likely to have their claims denied.

• Patients should check whether the healthcare provider is in-network for their insurance plan.
• A list of in-network providers is provided to your patients.

4. Submission of Full Documentation

Incomplete documentation is a common reason for denials. Hence, ensure to submit all of the required documentation with the respective claim so that you don’t incure the CO 96 denial code.

Append the required medical records, consent forms, and letters of medical necessity.
Dates of service and correct billing must be included.