PR 96 Denial Code | Everything You Need To Know

Are you struggling to find out why insurers are denying your claims with the PR 96 denial code? The full form of PR is Patient Responsibility. This category comprises those components of a medical bill that have to be paid by patients. This blog explores the common causes of this code’s denials.

Using advanced software and reimbursement recovery services helps prevent these issues. It’s crucial to adopt practical strategies that not only explore the root causes but also enhance the overall process.

PR 96 Denial Code Descriptions

PR 96 is a denial code used by insurance companies to deny reimbursement claims. By using this code, the company indicates that it simply does not cover the medical service provided. This is usually the reason behind the denied claims that contain the PR 96 code.

Insurers do not exactly explain their non-coverage of those specific medical services. Medicare usually uses the code but can cover other insurance companies as well. They can include copays, deductibles, and coinsurance amounts.

Common Reasons for the PR 96 Denial Code

There can be various reasons why insurers deny reimbursement claims with the PR 96 code. Since this code only indicates claim denials due to non-coverage, additional codes and details are needed to identify why payers do not cover the relevant services. Here are the general reasons for the PR 96 denial code:

• Statutory Exclusion

Certain services are legally excluded from coverage. These services are typically not essential from a medical standpoint. They may also be either considered routine or cosmetic. Some examples include regular health assessments. These assessments do not involve any medical symptoms or conditions.

There are some procedures performed as well that enhance appearance without medical necessity. Apart from this, certain medications can be purchased without a prescription. They are also not deemed medically necessary.

• Uncovered Service by Policy

Mislabeling a medical service can also lead to claim denials. The relevant insurance company may not be able to ascertain the coverage of that service. An example can be assigning codes to cosmetic procedures. These codes are typically recognized for a medically necessary procedure.

Some healthcare providers may display the medical necessity of procedures without proper documentation. Such cases are taken quite seriously and mostly denied coverage by insurers. The patients may also fail to include a doctor’s note or medical test results. Such notes and results are important for justifying the medical service.

There are some covered services that have limits on the frequency of their administration. Consider an example of an insurance policy that covers up to 10 physical therapy sessions per year. A reimbursement claim billed for an eleventh session would likely be denied. The PR 96 denials are also based on where certain services are performed.

The coverage for those claims similarly depends on the location. Insurance companies may cover an imaging test performed in a hospital setting. However, they may have a problem with a private clinic and, as such, may deny its claim.

• Benefit Plan Exclusions

Each insurance plan has specific exclusions listed in its benefit design. They can include certain types of care or procedures. Some insurance plans specifically exclude alternative therapies. These therapies usually comprise acupuncture or certain types of mental health care.

• Experimental or Investigational Treatments

There is a different category of treatments that are typically not covered. They are either considered experimental or have not been proven effective. An example would be a new cancer treatment still under clinical trials which may not be covered.

• Lack of Preauthorization

Certain treatments require preauthorization from the insurance provider. This preauthorization ensures that those treatments are medically necessary. Failure to obtain this authorization can lead to a denial. High-cost imaging tests or surgeries often require prior approval. If not obtained, those tests and surgeries likely result in non-coverage.

How to Avoid PR 96 Denial Code?

You can implement different strategies to avoid the PR 96 denial code in your reimbursement claims. They are based on two key stages of the medical billing process: before providing medical services and while processing claims. Take a look at them in detail below:

• Verify Insurance Coverage

The insurance coverage of patients has to be verified before they undergo the relevant medical treatments. You can use insurer-provided tools to verify specific coverage details. These tools primarily comprise online portals or customer service lines.

They help a lot in identifying any exclusions or special conditions. You should also keep track of any changes in the patient’s insurance policy. Insurance coverages tend to change annually or, in some cases, even more frequently.

• Understand Coverage Policies

Thoroughly review the insurance policy documents and online resources. It will help you understand the scope of coverage. You should primarily focus on any exclusions or limitations. This must be ideally done before providing medical services.

Ensure that all staff involved in patient care and billing are educated on the specifics of different insurance plans. They should especially know about the services that are frequently denied.

• Pre-Authorization

Secure pre-authorization for healthcare procedures that are known to require prior approval. You can do this by contacting the insurer directly. Conducting this step is crucial for expensive or less common procedures before they are implemented

Maintain records of all communications and approvals from insurance companies. The details regarding pre-authorizations should especially be documented. They will support your reimbursement claims whenever they are disputed.

• Accurate Coding

Use the latest coding manuals and software to ensure accuracy in generating bills. Regularly update coding resources and provide ongoing training for coding staff. Implement a double-check system as well where another qualified coder reviews the codes. The codes will be reviewed before claims submission to catch potential errors.

• Complete Documentation

Ensure that all necessary medical records are thorough. They should also justify the medical necessity of the services provided. This includes detailed notes from physicians and test results. There should also be a clear link between diagnosis and treatment.

Conduct internal audits of documentation practices as well. Such audits will ensure that your bills follow the insurance requirements.

• Modifiers

Apply the correct modifiers based on the setting, time, and the medical services provided. Modifiers can significantly impact reimbursement. They should be used accurately to describe the healthcare setting and circumstances.

Provide specific training sessions on the correct use of modifiers. These are common points of error as billers usually assign wrong modifiers.

• Continuous Education

Regular sessions to update staff on changes in insurance policies. You should especially do this for insurers that frequently update their coverage rules. Encourage regular participation in workshops and seminars for coding professionals. This way, they will stay updated on the best practices and changes in coding standards.

• Effective Communication with Insurers

Establish a routine for regular communication with insurers. You can use these meetings to discuss complex cases or unclear policy stipulations. Develop skills in negotiation and patient advocacy. Then, use those skills to address and resolve coverage issues before they lead to denials.

How Health Quest Billing Helps Prevent Claim Denials?

Health Quest Billing uses a combination of digital tools and expertise to prevent claim denials. We begin with an in-depth analysis of our previous billing data. This helps us identify patterns and common sources of denials. We use that data to adapt our strategies respectively.

This way, we are able to address specific billing challenges effectively. Our team also implements real-time eligibility checks and pre-authorization processes. They help us ensure that all services provided are covered under current insurance policies.

This is how we are able to significantly reduce the denials related to coverage issues. Additionally, we also use automated software to ensure accuracy in coding and documentation. Accuracy is one of the critical factors when it comes to claims approval.

We also provide targeted training to hospital billing departments. Our training sessions are largely about the latest changes in insurance policies. Apart from that, we also cover compliance requirements for healthcare providers.

This proactive approach greatly decreases the rate of claim denials for our hospital clients. It also improves the overall efficiency of their billing process. This is how we ensure that they receive maximum revenue retention.

The Bottom Line

Addressing the reasons behind PR 96 denials is crucial for healthcare providers. They can address them by verifying insurance coverage and securing pre-authorizations. You can also ensure accurate coding and maintain thorough documentation.

This is how you can easily manage insurance policies and prevent denials. This proactive approach will always improve your billing process. Contact Health Quest Billing to ensure that your patients receive the necessary care without any unexpected financial hurdles.