How To Fix Denial Code 90 | Common Reasons, Next Steps & How To Avoid It

Denial Code 90 means that a claim has been denied due to an ingredient cost adjustment. This denial code is specific to pharmaceutical claims. In this article, we will provide a description of denial code 90, common reasons for its occurrence, next steps to resolve the denial, tips on how to avoid it in the future, and examples of denial code 90 cases.

2. Description

Denial Code 90 is a claim adjustment reason code (CARC) that is used exclusively for pharmaceutical claims. It indicates that the claim has been denied due to an adjustment in the cost of the ingredients used in the medication. This adjustment may be made by the insurance company to reflect the actual cost of the ingredients or to account for any contractual agreements between the insurer and the pharmacy.

2. Common Reasons

The most common reasons for denial code 90 in pharmaceutical claims are:

1. Ingredient Cost Discrepancy: Denial code 90 may occur when there is a discrepancy between the cost of the ingredients listed on the claim and the actual cost determined by the insurance company. This could be due to outdated pricing information or errors in the claim submission.
2. Contractual Agreements: Insurance companies often have contractual agreements with pharmacies that determine the reimbursement rates for medications. If the cost of the ingredients exceeds the agreed-upon rate, the claim may be denied under code 90.
3. Missing or Incomplete Information: If the claim does not provide sufficient information about the ingredients used in the medication, the insurance company may deny the claim under code 90. This could include missing or inaccurate ingredient codes or incomplete documentation.
4. Non-Covered Ingredients: Some insurance plans may have restrictions on certain ingredients or medications. If the claim includes ingredients that are not covered by the patient’s insurance plan, it may be denied under code 90.

3. Next Steps

If you receive a denial with code 90, here are the next steps to resolve the issue:

1. Review the Claim: Carefully review the claim to ensure that all the information, including ingredient codes and costs, is accurate and complete. Check for any discrepancies or missing information that may have led to the denial.
2. Contact the Pharmacy: If there is an ingredient cost discrepancy or a contractual agreement issue, reach out to the pharmacy to clarify the situation. They may be able to provide additional information or make corrections to the claim if necessary.
3. Appeal the Denial: If you believe the denial was made in error or there are valid reasons to challenge it, consider filing an appeal. Gather any supporting documentation, such as ingredient cost invoices or contractual agreements, to strengthen your case.
4. Follow Up with the Insurance Company: Contact the insurance company to discuss the denial and provide any additional information or documentation requested. Engage in open communication to resolve the issue and seek clarification on any unclear aspects of the denial.
5. Resubmit the Claim: If the denial was due to missing or incomplete information, make the necessary corrections and resubmit the claim. Ensure that all required documentation and ingredient codes are included to avoid further denials.

4. How To Avoid It

To prevent denial code 90 in the future, consider the following tips:

1. Stay Updated on Ingredient Costs: Regularly review and update your knowledge of ingredient costs to ensure accurate billing. Stay informed about any changes in pricing or reimbursement rates that may affect pharmaceutical claims.
2. Double-Check Ingredient Codes: Verify that the ingredient codes used in the claim are accurate and up to date. Use the most recent code sets and ensure that all required information is included for each ingredient.
3. Verify Coverage and Restrictions: Before submitting a claim, confirm that the ingredients and medications being prescribed are covered by the patient’s insurance plan. Check for any restrictions or limitations that may apply.
4. Communicate with the Pharmacy: Maintain open lines of communication with the pharmacy to ensure that they are aware of any specific requirements or restrictions related to ingredient costs. Collaborate to address any potential issues before submitting the claim.

5. Example Cases

Here are two examples of denial code 90:

• Example 1: A pharmacy submits a claim for a medication that includes an ingredient with a higher cost than the agreed-upon reimbursement rate. The claim is denied under code 90 due to the ingredient cost adjustment.
• Example 2: The claim submitted by a healthcare provider does not include the necessary ingredient codes for the medication prescribed. As a result, the claim is denied under code 90 for missing or incomplete information.

Source: Claim Adjustment Reason Codes