Conquer Denial Code 96: A Guide for Healthcare Providers

Denial code 96, indicating a service is not covered under the patient's insurance plan, can significantly impact your practice's revenue cycle. Understanding the root causes of these denials and implementing effective strategies can help prevent them.

Common Causes of Denial Code 96

• Non-Covered Services: The service or supply may not be included in the payer's fee schedule or contracted arrangements.
• Incorrect Coding: Using the wrong CPT or HCPCS code can lead to denial if the code doesn't accurately represent the service provided or is not covered by the payer.
• Medical Necessity Documentation: Insufficient or missing documentation to support the medical necessity of the service can result in denial.
• Pre-authorization Issues: Failure to obtain required pre-authorization for specific services can result in denial.
• Coordination of Benefits (COB) Issues: When a patient has multiple insurance plans, COB complexities can contribute to denials.
• Payer Policy Violations: The service may not comply with specific payer policies, such as Local Coverage Determinations (LCDs) or National Coverage Determinations (NCDs).

Strategies to Prevent Denial Code 96

• Thorough Benefit Verification: Always verify patient insurance benefits before providing services, paying close attention to coverage limitations and exclusions.
• Accurate Coding and Documentation: Ensure that services are correctly coded and supported by comprehensive medical documentation.
• Prior Authorization Compliance: Obtain necessary pre-authorizations for services requiring prior approval and maintain accurate records.
• Payer Policy Adherence: Stay updated on payer policies, LCDs, and NCDs to ensure compliance.
• Effective Claim Review: Implement a robust claim review process to identify and correct potential issues before submission.
• Appeals Process: Develop a systematic approach to appealing denied claims, gathering comprehensive documentation to support the medical necessity of the service.

By understanding the common causes of denial code 96 and implementing these strategies, healthcare providers can significantly reduce claim denials, improve cash flow, and enhance overall billing efficiency.

Looking for Additional Support?
Claims Med can help you navigate the complexities of healthcare billing and coding. Our team of experts can assist with claim review, benefit verification, and payer policy adherence to ensure optimal claim acceptance rates. Contact Claims Med today to learn more.