Denial code 96 is issued when a billed service, procedure, or item is not covered under a patient’s insurance plan. These denials can result from policy exclusions, incorrect coding, or lack of pre-authorization, leading to payment delays and lost revenue for healthcare providers.
For practice managers, billing teams, and healthcare providers, understanding the root causes of denial code 96 and implementing preventative strategies is crucial for reducing claim rejections and optimizing revenue cycles.
Common Causes of Denial Code 96
- Non-Covered Services – The procedure or supply isn’t included in the payer’s plan (e.g., cosmetic procedures, experimental treatments).
- Incorrect Coding – Using the wrong CPT or HCPCS code can lead to claim denial.
- Medical Necessity Issues – Insufficient documentation to justify the service can result in a claim rejection.
- Pre-Authorization Missing – Failing to obtain required pre-approvals leads to automatic denials.
- Coordination of Benefits (COB) Errors – When patients have multiple insurance plans, improper COB handling can trigger denials.
- Payer Policy Violations – Services that don’t comply with LCD (Local Coverage Determination) or NCD (National Coverage Determination) policies may be denied.
How to Prevent Denial Code 96
To minimize these denials and improve reimbursement rates, follow these key strategies:
- Verify Patient Benefits in Advance – Check coverage limitations, exclusions, and pre-authorization requirements before services are rendered.
- Ensure Accurate Medical Coding – Use correct CPT, HCPCS, and ICD-10 codes, and match them to covered services.
- Submit Comprehensive Documentation – Justify medical necessity with detailed physician notes, treatment plans, and supporting records.
- Obtain Required Pre-Authorizations – Secure necessary approvals before providing services to avoid automatic denials.
- Stay Updated on Payer Policies – Regularly review LCD, NCD, and payer-specific policies to remain compliant.
- Implement a Strong Claim Review Process – Identify coding errors and missing documentation before submission.
- Develop an Effective Appeals Strategy – Dispute denials with proper documentation to recover lost revenue.
Overcome Denial Code 96 with Claims Med
Handling denial code 96 can be frustrating, but Claims Med simplifies the process. Our expert billing solutions, denial management, and revenue cycle optimization services help healthcare providers reduce denials and maximize reimbursements.
Don’t let uncovered service denials impact your revenue! Contact Claims Med today and discover how our specialized solutions can boost your financial performance.