PR 96 & CO 96 Denial Code and Action – Non-covered Charges

Reasons for Non-covered Charges:

• Diagnosis or service (CPT) performed or billed are not covered based on the LCD.
• Services not covered due to patient current benefit plan.
• It may be because of provider contract with insurance company.

So when you come across CO 96 – Non Covered Charges, the first thing is to check the remarks code listed with that denial to identify the correct denial reason.

Take a look at some of the important remark codes for Denial Code 96:

COMMON REASONS FOR DENIAL

The actual meaning for this denial is billing for services not covered under the contract. This could be differentiated between Providers’ and Patients’ Contract. All carriers have their list of Non-covered services mentioned in the Providers’ & Patients’ handbook / manual. This also includes Providers’ participation with the carrier and the patients’ choosing of one such provider who participates.

NEXT STEP

If billed incorrectly (such as inadvertently omitting a required modifier), request a reopening. If is for the KX, GA, GZ, or GY modifiers, you must request a redetermination request. Check Local Coverage Determination (LCD) documentation requirements for coverage and use of modifiers.

But most of times this denial is not able to be corrected.

If you are submitting non-covered services to receive a denial for secondary or supplemental insurance, ensure to bill services with the modifier GY, indicating “statutorily non-covered services.” Generally secondary insurance would cover these rejections.

CO 96 DENIAL CODE CATEGORIES

Non-Covered denial (CO 96) is grouped majorly under the following categories by the carriers:

PR 96 DENIAL CODE: PATIENT RELATED CONCERNS

When a patient meets and undergoes treatment from an Out-of-Network provider.

• Based on Provider’s consent bill patient either for the whole billed amount or the carrier’s allowable. Cross verify in the EOB if the payment has been made to the patient directly. If yes, please bill the patient without any delay.
• Prior verification notes should explain in detail for the front desk executive so that they could inform patient about provider’s participation. In most cases they would avoid seeing those patients except for an emergency need.
• Cross verify with the insurance if the payment would be made to the patient if the claims are filed. If yes, document the same in the notes and alert the front office to collect the calculated (calculate separately based on the CPT’s allowed amount) amount from the patient at the time of service.

CO 96 DENIAL CODE: PROVIDER RELATED CONCERNS

• Coding: ICD – LCD guidelines not met; Multiple procedures performed on the same day billed; Invalid POS/type billed; When a service is performed within a period of time prior to or after inpatient services; Invalid NDC code; Inclusive to primary procedure billed; or Invalid CPT billed and Others.
• When service is not related to Providers’ specialty: Inform provider about the procedure listed in the superbill and suggests an alternate active CPT code to be billed – to be done during coding and charge entry process itself before claim submission.
• Non-covered services listed by the carriers billed: List the services which are denied for the given reason from specific carriers and forward it to client for W/O approval. Note: Ensure that we have billed the CPTs correctly.
• If provider is not participating with the carrier: Credentialing process to be initiated and affected claims are to be compiled and sent for provider’s approval for W/O

Learn More…

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