Denial code 96 is for non-covered charges. It means that there is missing information in the claim, such as a remark code. Check the 835 Healthcare Policy Identification Segment for more details.
Denial code 96 is used to indicate that the charge(s) in question are not covered by the insurance policy. In order to provide more information about the denial, at least one Remark Code must be provided. This Remark Code can be either the NCPDP Reject Reason Code or a Remittance Advice Remark Code that is not an ALERT. To get further details about the denial, it is recommended to refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if it is present in the documentation.
Common causes of code 96 are:
1. Non-covered services: The service or procedure provided is not covered by the patient's insurance plan. This could be due to the service being considered experimental or not medically necessary.
2. Lack of prior authorization: The healthcare provider did not obtain prior authorization from the insurance company before providing the service. Some services require pre-approval to ensure coverage.
3. Incorrect coding: The service or procedure was coded incorrectly, leading to a non-covered charge. This could be a result of using the wrong CPT code or not providing sufficient documentation to support the code used.
4. Out-of-network provider: The healthcare provider is not in the patient's insurance network, and therefore, the service is not covered. Patients may be responsible for a larger portion of the cost or the entire charge.
5. Policy limitations: The insurance plan has specific limitations or exclusions for certain services or procedures. These limitations may be outlined in the policy documents or communicated by the insurance company.
6. Missing or incomplete documentation: The healthcare provider did not provide sufficient documentation to support the medical necessity of the service or procedure. Without proper documentation, the insurance company may deny coverage.
7. Coordination of benefits issues: The patient has multiple insurance plans, and there may be coordination of benefits issues between the primary and secondary insurance. This can result in non-covered charges.
8. Lapsed coverage: The patient's insurance coverage may have lapsed or been terminated at the time the service was provided. Without active coverage, the service will not be covered.
9. Billing errors: Errors in the billing process, such as incorrect patient information, incorrect insurance information, or missing information, can lead to non-covered charges.
10. Plan exclusions: The insurance plan specifically excludes coverage for the service or procedure provided. This could be due to the plan's design or the patient's specific policy.
It is important for healthcare providers to review denial codes like code 96 to identify the root causes and take appropriate actions to prevent future denials. This may involve improving documentation practices, verifying insurance coverage, obtaining prior authorizations, and ensuring accurate coding.
Ways to mitigate code 96 include:
- Verify insurance coverage: Before providing any services, it is essential to verify the patient's insurance coverage. This can help identify any non-covered charges and prevent denials related to code 96. Ensure that the patient's insurance information is up to date and accurate.
- Obtain prior authorization: For services that require prior authorization, make sure to obtain the necessary approval from the insurance company before providing the service. This can help prevent denials due to non-covered charges.
- Review coding guidelines: Familiarize yourself with the coding guidelines provided by the insurance company. Ensure that the services provided are coded correctly and are eligible for coverage. Regularly update your knowledge of coding guidelines to stay up to date with any changes.
- Document medical necessity: It is crucial to document the medical necessity of the services provided. Include detailed and accurate documentation that supports the need for the services. This can help prevent denials related to non-covered charges.
- Communicate with payers: Establish open lines of communication with the insurance company. If you receive a denial with code 96, reach out to the payer to understand the reason behind the denial and to provide any additional information or clarification that may be required.
- Conduct regular audits: Regularly audit your billing and coding processes to identify any potential issues that may lead to denials. This can help identify and rectify any coding errors or non-covered charges before they result in denials.
- Stay updated with policy changes: Keep yourself informed about any changes in the insurance company's policies and guidelines. Regularly review updates and communicate them to your billing and coding team to ensure compliance and prevent denials related to non-covered charges.
By implementing these strategies, healthcare providers can mitigate code 96 and reduce the number of denials related to non-covered charges.
The steps to address code 96 are as follows:
1. Review the claim details: Carefully examine the claim to determine which charge(s) have been marked as non-covered. This will help you understand the specific services or procedures that are being denied.
2. Verify the Remark Code: Check the remittance advice or explanation of benefits (EOB) for the presence of a Remark Code. This code will provide additional information about why the charge(s) have been denied.
3. Understand the denial reason: Analyze the Remark Code to understand the exact reason for the denial. It may indicate that a required code is missing or that the charge is not covered under the patient's insurance plan.
4. Check for NCPDP Reject Reason Code: If the Remark Code refers to the NCPDP Reject Reason Code, locate this code in the claim documentation. This will provide further insight into the specific reason for the denial.
5. Review the 835 Healthcare Policy Identification Segment: If the Remark Code suggests referring to the 835 Healthcare Policy Identification Segment, locate this segment in the claim documentation. It may contain additional information or guidelines related to the denial.
6. Take corrective action: Based on the information gathered, take the necessary steps to address the denial. This may involve resubmitting the claim with the correct codes, providing additional documentation, or appealing the denial if appropriate.
7. Document the resolution: Keep a record of the actions taken to address the denial. This will help in case of future inquiries or audits.
By following these steps, healthcare providers can effectively address code 96 denials and work towards resolving the issue to ensure proper reimbursement for the services provided.