How To Fix Denial Code 95 | Common Reasons, Next Steps & How To Avoid It

Denial Code 95 means that the claim has been denied because the plan procedures were not followed. In this article, we will provide a description of Denial Code 95, common reasons for its occurrence, next steps to resolve the denial, tips on how to avoid it in the future, and examples of cases related to this denial code.

2. Description

Denial Code 95 is a Claim Adjustment Reason Code (CARC) that indicates the claim has been denied because the plan procedures were not followed. This means that the healthcare provider or the patient did not adhere to the specific guidelines and requirements outlined by the insurance plan for the services rendered. As a result, the claim is not eligible for reimbursement.

2. Common Reasons

The most common reasons for Denial Code 95 include:

1. Missing or Incomplete Documentation: The claim may be denied if the necessary documentation, such as medical records, referral forms, or prior authorization, is missing or incomplete. Insurance plans often require specific documentation to support the medical necessity and appropriateness of the services provided.
2. Non-Covered Services: Denial Code 95 may occur when the services rendered are not covered under the patient’s insurance plan. This could be due to exclusions, limitations, or specific requirements outlined in the plan’s policy.
3. Out-of-Network Providers: If the patient receives services from a healthcare provider who is not in-network with their insurance plan, Denial Code 95 may be applied. Insurance plans often have preferred networks of providers, and receiving services outside of these networks may result in denials.
4. Failure to Obtain Prior Authorization: Some services require prior authorization from the insurance plan before they can be covered. If the provider or patient fails to obtain the necessary authorization, Denial Code 95 may be issued.
5. Incorrect Coding or Billing: Errors in coding or billing, such as using incorrect procedure codes or modifiers, can lead to Denial Code 95. Insurance plans have specific coding guidelines, and any deviations from these guidelines may result in claim denials.

3. Next Steps

If you receive Denial Code 95, here are the next steps to resolve the denial:

1. Review the Denial Explanation: Carefully review the denial explanation provided by the insurance company. Understand the specific reason for the denial and any additional information or documentation required.
2. Address Documentation Issues: If the denial is due to missing or incomplete documentation, gather the necessary records and resubmit the claim with the appropriate documentation. Ensure that all required forms, referrals, or prior authorizations are included.
3. Verify Coverage and Eligibility: Double-check the patient’s insurance coverage and eligibility for the services rendered. If there are any discrepancies or uncertainties, contact the insurance company to clarify the coverage details.
4. Appeal the Denial: If you believe the denial was issued in error or have additional information to support the claim’s validity, consider filing an appeal. Follow the insurance company’s appeal process and provide any relevant documentation or explanations to support your case.
5. Communicate with the Patient: Keep the patient informed about the denial and the steps being taken to resolve it. Discuss any potential out-of-pocket costs they may be responsible for and provide guidance on how to navigate the insurance process.
6. Seek Professional Assistance: If you encounter challenges in resolving the denial or navigating the appeals process, consider seeking assistance from a healthcare billing or coding professional who can provide expertise and guidance.

4. How To Avoid It

To avoid Denial Code 95 in the future, consider the following tips:

1. Verify Coverage and Requirements: Before providing services, verify the patient’s insurance coverage and familiarize yourself with the plan’s specific requirements, including documentation, prior authorization, and network participation.
2. Obtain Prior Authorization: If a service requires prior authorization, ensure that the necessary approval is obtained before rendering the service. Familiarize yourself with the insurance plan’s process for obtaining prior authorization and follow it diligently.
3. Accurate Coding and Billing: Ensure that coding and billing are accurate and adhere to the insurance plan’s guidelines. Regularly update your knowledge of coding rules and guidelines to minimize errors that could lead to denials.
4. Communicate with Patients: Educate patients about their insurance coverage, including any limitations or requirements. Clearly communicate the potential financial responsibilities they may have and guide them through the process to avoid surprises or misunderstandings.
5. Stay In-Network: Whenever possible, refer patients to in-network providers to minimize the risk of denials due to out-of-network services. Familiarize yourself with the insurance plan’s network and update your referral processes accordingly.

5. Example Cases

Here are two examples of Denial Code 95:

• Example 1: A healthcare provider submits a claim for a specialized procedure that requires prior authorization. However, the provider fails to obtain the necessary authorization before performing the procedure, resulting in Denial Code 95.
• Example 2: A patient seeks treatment from an out-of-network specialist without realizing that their insurance plan only covers services from in-network providers. As a result, the claim is denied under Denial Code 95.

Source: Claim Adjustment Reason Codes