Denial code 95 means the insurance company won't cover the procedure because the proper plan guidelines weren't followed.
Denial code 95 means that the claim has been denied because the procedures outlined in the patient's insurance plan were not followed. This could include situations where the patient did not obtain prior authorization for a specific procedure or treatment, or if the provider did not submit the necessary documentation or meet the requirements specified by the insurance plan.
Common causes of code 95 are:
- Lack of proper documentation: When healthcare providers fail to document the necessary information related to the patient's treatment or procedure, it can result in a denial with code 95. This may include missing or incomplete medical records, diagnostic test results, or treatment plans.
- Failure to obtain prior authorization: Certain procedures or treatments require prior authorization from the insurance company. If the healthcare provider fails to obtain the necessary approval before performing the procedure, it can lead to a denial with code 95.
- Non-compliance with medical policies: Insurance companies have specific medical policies and guidelines that healthcare providers must adhere to when providing treatment. If the provider deviates from these policies, such as using an unapproved treatment method or medication, it can result in a denial with code 95.
- Inadequate medical necessity documentation: Insurance companies require healthcare providers to demonstrate the medical necessity of a procedure or treatment. If the documentation submitted does not sufficiently justify the need for the service, it can lead to a denial with code 95.
- Incorrect coding or billing errors: Mistakes in coding or billing can also result in a denial with code 95. This may include using incorrect procedure codes, modifiers, or billing for services that are not covered by the patient's insurance plan.
- Lack of supporting documentation: Along with proper documentation, healthcare providers must also provide supporting documentation to justify the services rendered. This may include clinical notes, progress reports, or any other relevant information. Failure to include adequate supporting documentation can lead to a denial with code 95.
- Failure to meet timely filing deadlines: Insurance companies have specific deadlines for submitting claims. If the healthcare provider fails to submit the claim within the designated timeframe, it can result in a denial with code 95.
- Incomplete or inaccurate patient information: Errors or omissions in patient information, such as incorrect demographic details or insurance information, can lead to a denial with code 95. It is crucial for healthcare providers to ensure that all patient information is accurate and up to date.
- Lack of medical necessity review: Some insurance plans require a medical necessity review before certain procedures or treatments can be approved. If the healthcare provider fails to initiate or complete the review process, it can result in a denial with code 95.
- Insufficient documentation of follow-up care: After performing a procedure or treatment, healthcare providers are often required to provide follow-up care. If there is insufficient documentation of the follow-up care provided, it can lead to a denial with code 95.
Ways to mitigate code 95 include:
- Ensure proper documentation: Accurate and complete documentation is crucial to prevent code 95 denials. Healthcare providers should ensure that all procedures and treatments are clearly documented, including the rationale for the chosen course of action. This documentation should align with the specific guidelines and requirements of the payer.
- Stay updated with payer policies: It is essential to stay informed about the policies and guidelines of each payer. Regularly review and understand the specific requirements for each procedure or treatment to avoid denials related to non-compliance with the payer's policies.
- Verify patient eligibility: Before providing any services, verify the patient's eligibility and coverage with the payer. This step helps identify any potential issues or limitations that may result in a denial. By confirming eligibility upfront, providers can address any discrepancies or obtain necessary authorizations in a timely manner.
- Communicate effectively with the payer: Establishing clear lines of communication with the payer can help prevent code 95 denials. Providers should proactively reach out to payers to clarify any uncertainties or seek pre-authorization when required. Maintaining open lines of communication can help resolve any potential issues before claims are submitted.
- Educate staff on payer requirements: Ensure that all staff members involved in the revenue cycle management process are well-informed about the specific requirements of each payer. Conduct regular training sessions to keep them updated on any changes in policies or guidelines. This will help minimize errors and ensure compliance with payer requirements.
- Implement technology solutions: Utilize technology solutions such as electronic health record (EHR) systems and revenue cycle management software to streamline processes and reduce the risk of code 95 denials. These tools can help automate documentation, flag potential issues, and provide real-time alerts for non-compliance with payer policies.
- Conduct regular audits: Regularly audit claims and documentation to identify any patterns or trends that may lead to code 95 denials. By proactively identifying and addressing these issues, providers can improve their overall revenue cycle management and reduce the likelihood of future denials.
Remember, preventing code 95 denials requires a proactive approach, attention to detail, and a thorough understanding of payer policies. By implementing these strategies, healthcare providers can minimize denials and optimize their revenue cycle management processes.
The steps to address code 95, "Plan procedures not followed," are as follows:
1. Review the patient's medical records: Carefully examine the patient's medical records to ensure that all necessary procedures were documented and followed according to the plan's guidelines. Look for any missing or incomplete documentation that may have led to the code being triggered.
2. Communicate with the healthcare provider: Reach out to the healthcare provider responsible for the patient's care to discuss the reasons behind the code. Seek clarification on any discrepancies or issues identified in the medical records. This communication can help identify any misunderstandings or gaps in the documentation process.
3. Educate the healthcare provider: If it is determined that the code was triggered due to a lack of understanding or knowledge of the plan's procedures, provide education and training to the healthcare provider. This can include sharing relevant policies, guidelines, or resources to ensure that they are aware of and follow the required procedures in the future.
4. Implement process improvements: If the code was triggered due to systemic issues within the healthcare provider's practice, work collaboratively to identify and implement process improvements. This may involve updating documentation templates, streamlining communication channels, or providing additional training to staff members.
5. Monitor and track progress: Continuously monitor the healthcare provider's adherence to the plan's procedures and track the progress made in addressing code 95. Regularly review claims and documentation to ensure that the necessary steps are being followed correctly. This ongoing monitoring can help identify any recurring issues and allow for timely intervention and resolution.
By following these steps, healthcare providers can effectively address code 95 and work towards minimizing future occurrences.
Get paid in full by bringing clarity to your revenue cycle
Subscribe to the
Healthcare Clarified newsletter
Get the latest insights on RCM and healthcare policy in your inbox
