How To Fix Denial Code 91 | Common Reasons, Next Steps & How To Avoid It

Denial Code 91 (CARC) means that a claim has been denied due to a dispensing fee adjustment. Below you can find the description, common reasons for denial code 91, next steps, how to avoid it, and examples.

2. Description

Denial Code 91 is a Claim Adjustment Reason Code (CARC) and is described as a ‘Dispensing Fee Adjustment’. This denial code indicates that the insurance company has made an adjustment to the dispensing fee for the billed service. It means that the amount charged for dispensing medication or medical supplies has been modified, resulting in a denial or reduction in payment.

2. Common Reasons

The most common reasons for denial code 91 are:

1. Incorrect Dispensing Fee: Denial code 91 may occur if the dispensing fee charged by the healthcare provider does not align with the fee schedule or reimbursement rates set by the insurance company. This could be due to a billing error or a misunderstanding of the fee structure.
2. Non-Covered Medication or Supply: Some insurance plans have restrictions on certain medications or medical supplies, and they may not cover the full cost or any cost associated with these items. If a claim includes a non-covered medication or supply, denial code 91 may be applied to adjust the dispensing fee accordingly.
3. Exceeding Maximum Allowable Quantity: Insurance plans often have limitations on the quantity of medication or supplies that can be dispensed within a specific timeframe. If a claim exceeds the maximum allowable quantity, denial code 91 may be used to adjust the dispensing fee based on the approved quantity.
4. Missing or Incomplete Documentation: Insufficient or incomplete documentation related to the dispensing of medication or supplies can lead to denial code 91. This may include missing prescription details, lack of supporting medical records, or incomplete information about the dispensed item.
5. Non-Compliance with Prior Authorization Requirements: Some insurance plans require prior authorization for certain medications or supplies. If a claim is submitted without obtaining the necessary prior authorization, denial code 91 may be applied to adjust the dispensing fee.

3. Next Steps

You can address denial code 91 as follows:

1. Review Fee Schedule: Verify the fee schedule or reimbursement rates provided by the insurance company to ensure that the dispensing fee charged aligns with the approved amounts. If there are any discrepancies, correct the billing information and resubmit the claim.
2. Check Coverage and Quantity Limits: Confirm whether the medication or supply being dispensed is covered by the patient’s insurance plan and if there are any limitations on the quantity that can be dispensed. If necessary, adjust the quantity or explore alternative covered options to comply with the insurance requirements.
3. Ensure Complete Documentation: Double-check that all necessary documentation, including prescription details and supporting medical records, is included with the claim submission. Address any missing or incomplete information to avoid denial code 91.
4. Obtain Prior Authorization: If prior authorization is required for the medication or supply being dispensed, ensure that the necessary authorization is obtained before submitting the claim. Failure to comply with prior authorization requirements can result in denial code 91.
5. Appeal or Resubmit: If you believe the denial code 91 was applied in error, gather any additional supporting documentation or evidence to challenge the denial. Prepare an appeal or resubmit the claim with the necessary information to address the insurance company’s concerns.
6. Improve Billing Practices: Implement processes to regularly review and update fee schedules, verify coverage and quantity limits, and ensure complete documentation. This will help minimize the occurrence of denial code 91 in future claim submissions.

4. How To Avoid It

You can prevent denial code 91 in the future by following these steps:

1. Understand Fee Schedules: Familiarize yourself with the fee schedules or reimbursement rates provided by the insurance company. Ensure that your billing practices align with these approved amounts to avoid denial code 91.
2. Verify Coverage and Quantity Limits: Before dispensing medication or supplies, confirm the patient’s insurance coverage and any limitations on the quantity that can be dispensed. This will help you avoid submitting claims for non-covered items or exceeding approved quantities.
3. Document Completely and Accurately: Maintain thorough and accurate documentation related to the dispensing of medication or supplies. Include all necessary prescription details, supporting medical records, and any other relevant information to avoid denial code 91 due to missing or incomplete documentation.
4. Follow Prior Authorization Requirements: Familiarize yourself with the insurance plan’s prior authorization requirements for specific medications or supplies. Ensure that you obtain the necessary authorization before dispensing these items to avoid denial code 91.
5. Regularly Update Billing Practices: Stay updated on changes to fee schedules, coverage policies, and quantity limits. Regularly review and update your billing practices to ensure compliance with the insurance company’s requirements and minimize the occurrence of denial code 91.

5. Example Cases

Below are two examples of denial code 91:

• Example 1: A healthcare provider submits a claim for a medication that is not covered by the patient’s insurance plan. As a result, denial code 91 is applied to adjust the dispensing fee to zero.
• Example 2: A provider dispenses a larger quantity of a medication than the insurance plan allows within a specific timeframe. Denial code 91 is applied to adjust the dispensing fee based on the approved quantity.

Source: Claim Adjustment Reason Codes