Code CO-95
Problem Description
Plan procedures not followed.
Actionable Fix — Solution Steps
Refer to CPT Code Set and P-Auth File: -Verify the P-AUTH reported is for the correct program, guarantor (Medi-Cal or County of Santa Clara), and service -Verify there is an open episode for the correct program -Verify client's financial eligibility demographics: Name DOB Address Coverage effective date Coverage end date CIN -Verify client has an admission Dx -Verify the Dx is supported -Verify the Dx is effective for the DOS of the claim
Related Codes in Contractual Obligation
The procedure code is inconsistent with the modifier used. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
The procedure code/type of bill is inconsistent with the place of service. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
Claim/service lacks information or has submission/billing error(s). Usage: Do not use this code for claims attachment(s)/other documentation. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.) Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
Exact duplicate claim/service (Use only with Group Code OA except where state workers' compensation regulations requires CO)
This directory provides reference information only and does not constitute official legal, medical, or financial billing advice. Always consult the payer's official remittance advice and current coding guidelines.