CO96 denial code description and corrective action

• This denial falls into two categories.

  1.  Non-covered charges as per the patient’s plan.

  This occurs when either the provider is out-of-network (OON) or the diagnosis (DX) or procedure code (CPT) is not covered under the member’s plan.

  2. Non-covered charges as per the provider contract.

  This occurs when the procedure is not covered under the provider’s contract.

Actions

• First, we need to verify the status of the claim. This can be done by checking the status through the insurance web portal or by calling the payer.

• Call the insurance company, if claims in the member’s history with the same coding have been paid, and ask the representative to reprocess the claim. Be sure to note the claim number, rep name and call reference number, and then follow up on the claim after the provided TAT.

• Confirm with the representative whether the service is not covered under the member’s plan or the provider’s contract.

• If it is non-covered under the member’s plan, obtain specific information to determine whether the denial is due to the provider’s status with the insurance, a non-covered diagnosis, or a non-covered procedure.

  If the denial is due to the provider being out-of-network (OON), then click here for further steps.

• If the diagnosis (DX) or procedure code (CPT) is not covered, assign the claim to the coding team to suggest an alternate DX or CPT.

• If they provide an alternate CPT or diagnosis code, submit a corrective claim with the updated coding.

• Medicare does not accept corrected claims, so in the case of any denial, a new claim must always be submitted.

• If the coding team confirms that there is no alternate procedure or diagnosis, bill the claim to the secondary insurance after verifying eligibility. If there is no active secondary insurance, release the claim to the patient.

• If the service is not covered under the provider’s contract and no payment has been received in the past for the same services, proceed by either submitting an appeal or writing it off as per practice SOPs.

Description