RemitBench/Denial codes/CO-95

CO-95 denial code

Code 95 is vague on purpose. Some rule of the plan's own process was not followed, and the code does not say which. The remark is the only thing that makes it actionable.

The code list's own wording: Plan procedures not followed.

What it means: The plan has rules about how care is accessed and claims are submitted, and one of them was not met. Nothing about the treatment itself was assessed.
Who owes the money: Read the letters CO is common, making it a write-off on the basis that following the plan's process was your job. PR appears where the plan says the member did not follow their own plan's rules.
Is appealing worth it: Depends entirely on which rule. You cannot decide whether to appeal until you know what the code is standing in for, so the first move is always to find that out.

This code is an envelope, not a letter. On its own it tells you nothing you can act on. Every minute spent guessing at which rule was missed is wasted, and one phone call replaces it. Ask the payer which specific requirement was not met and write the answer down, because it will recur.

Why the payer sent it

Prior authorisation was required and not obtained, which is really CO-197.
A referral was required, which is CO-288.
The claim was filed in the wrong way or to the wrong address.
A network requirement was not followed.
The patient did not use a required facility or provider.
A notification requirement, such as telling the plan within a set time, was missed.

Remark codes you will see with it

Remark code	What it adds
N130	Read the plan document. Its own page.
N54	The claim information is inconsistent with the pre-certified or authorised services.
N418	The claim was misrouted.

Remark code

What it adds

N130

Read the plan document. Its own page.

N54

The claim information is inconsistent with the pre-certified or authorised services.

N418

The claim was misrouted.

Read the letters in front of the 95

CO-95: Contractual obligation. Your write-off.
PR-95: Patient responsibility. Seen where the plan holds the member responsible for their own plan's rules. Check the contract.
PI-95: Payer initiated. The patient owes nothing.

What to do next

Read the remark, and if there is none, call

There is no way to work this code from the number alone. Get the specific requirement named.
Once you know the rule, work the specific code instead

Almost every 95 is really an authorisation, referral, network or routing problem, and those have their own pages and their own fixes.
Write down what this payer means by it

Payers are individually consistent even though they are not consistent with each other. Once you know that a given payer uses 95 for one particular requirement, you know it for every future claim from them.

Codes that get mixed up with 95

Code	How it differs from 95
197	Authorisation absent. The most common thing hiding behind a 95. See CO-197.
288	Referral absent. The second most common. See CO-288.
242	Not provided by network providers. See CO-242.
16	The claim lacks information. Also a code that needs a remark to mean anything. See CO-16.
272	Coverage guidelines not met. See CO-272.

Codes 16, 95, 96 and 272 share a shape: the number is the envelope and the remark is the letter. If you learn one habit from this reference, let it be finding the remark before doing anything else.

Code 95 in dental

On dental plans this usually stands for a managed care rule: the patient went somewhere other than their assigned office, a specialist was seen without a referral, or an approval step was skipped.

Check the assignment first on managed care plans

The most common dental cause is a patient being treated at an office they are not assigned to. That is worth checking before anything else, because it is quick and because it also explains a CO-24 if one appears.

Questions people ask about CO-95

What plan procedure was not followed?

The code never says, which is its whole problem. Read the remark code first, and if there is none, call the payer and ask which specific requirement was not met. It is nearly always authorisation, a referral, a network rule or how the claim was filed.

Related codes

Back to all denial codes

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