CO-95: Plan Procedures Not Followed

What Does CO-95 Mean?

With CO (Contractual Obligation), the CARC 95 adjustment is the provider's responsibility. The payer denied or reduced payment because of the provider did not obtain required prior authorization or precertification before rendering the service, and the payer denied the claim for failure to follow plan procedures. The patient is not liable for this amount. If the denial is in error, the provider can correct and resubmit the claim or file an appeal with supporting documentation.

CARC 95 relates to plan procedures not followed. The payer requires specific authorization, certification, or referral for this service, and the claim was adjusted because that requirement was not satisfied.

Common scenarios that trigger this adjustment include: the provider did not obtain required prior authorization or precertification before rendering the service, and the payer denied the claim for failure to follow plan procedures; The patient's plan requires a referral from the PCP for specialist visits, and the referral was not obtained or not on file at the time of service; The provider is out of network and the plan requires preapproval for out-of-network services, which was not obtained. The group code paired with CARC 95 determines who bears the financial responsibility — CO places it on the provider as a contractual obligation, PR shifts it to the patient, OA indicates a coordination of benefits or other payer adjustment.

Common Causes

How to Resolve

1. Review the remittance details Examine the CO-95 adjustment and any accompanying RARC codes to identify the specific reason for the denial.
2. Identify the root cause Determine which issue applies: missing prior authorization, referral not obtained from primary care physician, out-of-network service without required approval, among others.
3. Correct the claim Address the identified issue — update the claim data in your billing system to resolve the plan procedures not followed problem.
4. Resubmit the corrected claim Submit the corrected claim following the payer's resubmission guidelines. Include any supporting documentation that addresses the denial reason.
5. Appeal if the original claim was correct Appeal with documentation showing the authorization was obtained (if it exists but was omitted), or provide clinical documentation supporting medical necessity and evidence that the service was emergent or that retroactive authorization is warranted. Include the referring physician's information, clinical notes, and any communication with the payer regarding authorization.

Common RARC Pairings

The RARC code tells you exactly what triggered the CO-95:

How to Prevent CO-95

• Verify prior authorization requirements for all services before they are rendered
• Implement automated authorization verification in the scheduling workflow
• Confirm referral status for all specialist visits at the time of patient check-in
• Maintain a reference list of payer-specific authorization and referral requirements by service type
• Train front desk staff to verify plan procedure requirements during patient registration
• Set up real-time eligibility and authorization checks integrated with the practice management system

Also Filed As

The same CARC 95 may appear with different Group Codes:

Related Denial Codes