CO 96 denial code: Handling Non-Covered Therapy Charges

What is Denial Code CO-96 Means?

The service provided is not covered under the patient’s insurance plan.

This denial typically arises when a service is deemed non-essential, outside the insurance coverage criteria, or restricted due to policy terms.

In medical billing, understanding CO-96 is essential as it helps clinics quickly identify non-covered services, preventing revenue losses and reducing claim rejections. By identifying uncovered services early, clinics can advise patients on potential out-of-pocket costs and manage billing more efficiently.

Example of a Claim Denied with CO-96

Initial Billing:CPT 97124: Therapeutic Massage Therapy

Outcome:
The claim was denied under CO-96 because massage therapy is not covered by the patient’s insurance plan. This outcome highlights the importance of verifying coverage details before providing the service to avoid denials for non-covered services.

Common Reasons for CO-96 Denials 

Let’s have a look at the most common causes of CO-96 denials.

• Policy Exclusions: Insurance policies often exclude specific services or treatments, which can result in claim denials for any excluded items.

• Benefit Limitations: Certain treatments may have a capped number of covered sessions; exceeding these limits can lead to a CO-96 denial.

• Non-Covered Services: Wellness and preventive services may fall outside standard coverage, making them ineligible for reimbursement.

• Out-of-Network Provider: If a patient receives treatment from an out-of-network provider, their claim may be denied based on coverage restrictions.

• Incorrect Service Codes: Using codes for services that aren’t typically covered under the patient’s plan can result in denials under CO-96.

Understanding these causes helps clinics proactively address common issues and minimize CO-96 denials.

How to Resolve Denial Code CO-96

Here’s a step-by-step guide to address CO-96 denial effectively:

Step 1: Review the Denial Notice

Examine the CO-96 denial notice to identify the specific reason for denial. This will help you determine if the denied service falls under policy exclusions or other non-covered services, allowing you to take appropriate action.

Step 2: Verify Service Eligibility
Confirm whether the service provided is covered by the patient's insurance policy. Double-check the patient's benefits and coverage limits.

Step 3: Check for Policy Exclusions
If the service is excluded, verify it falls outside the scope of the patient’s insurance. If it’s a covered service but not eligible due to plan restrictions, discuss alternatives with the insurance provider.

Step 4: Confirm Correct Coding
Ensure the correct service codes are used. Verify that the service code aligns with the patient’s policy requirements and that billing is accurate.

Step 5: Appeal the Denial
If you believe the service should be covered or the denial is based on incorrect information, file an appeal with the insurance provider. Provide supporting documentation, such as the patient’s plan details, relevant medical history, or any additional information that may be required.

By following these steps, you can resolve CO-96 denials efficiently, ensuring that future claims are processed smoothly and reimbursed appropriately.

How SPRY Helps Prevent CO-96 Denials

With SPRY’s integrated billing solutions, you can minimize the risk of denials by ensuring all claims meet payer requirements before submission. By streamlining the process of verifying insurance coverage, selecting the correct services, and flagging errors, SPRY helps prevent the most common causes of CO-96 denials, ensuring faster, more accurate claims processing. 

Let’s explore how SPRY can support your practice in avoiding these costly setbacks.

Billing Accuracy & Compliance: SPRY helps reduce the risk of CO-96 denials by streamlining billing workflows. With auto-selected CPT and ICD codes, our system simplifies the coding process, ensuring that only the right services are billed, minimizing the chances of submitting non-covered services.

Insurance Verification: Our one-click eligibility checks provide real-time verification of patient coverage. This enables you to confirm whether a service is covered by the insurance plan upfront, preventing issues with non-covered services or policy exclusions.

Transparent Claim Management: SPRY’s claim lifecycle management tool keeps you informed about each claim’s progress, ensuring accurate payer submission. By tracking claims in real-time, SPRY helps avoid denials due to incorrect payer selection or non-covered services, ensuring faster and more accurate claims processing.

Error Flagging & Denial Management: With automated error flagging, SPRY identifies discrepancies and issues such as non-covered services or policy limitations before submission. Our denial management system ensures you can quickly address any issues and reduce the likelihood of CO-96 denials.

To see how SPRY can streamline your billing and minimize denials, schedule a demo today!

FAQs

What does Denial Code CO-96 mean?

Denial Code CO-96 indicates that the claim has been denied because the service provided is not covered under the patient’s insurance plan.

How can I prevent CO-96 denials?

To avoid CO-96 denials, ensure the service is covered by the patient's insurance policy. Verify eligibility before providing the service and confirm that the correct service codes are used.

What should I do if my claim is denied with CO-96?

Review the patient’s insurance plan to confirm if the service is covered. If necessary, adjust the claim or contact the insurance provider for clarification.

Can CO-96 denials be appealed?

Yes, if the service is covered under the patient's insurance plan but was denied due to incorrect coding or other issues, you may file an appeal with supporting documentation.

How can SPRY help with CO-96 denials?

SPRY’s automated eligibility checks and claim management tools ensure that services are covered before they are provided, minimizing the risk of CO-96 denials.