CARC 95: Plan procedures not followed
A required plan rule — like getting a referral or using a designated facility — wasn't followed before this service.
What this means for your claim
HMO and POS plans often require steps such as a primary care referral, using an in-network lab, or notifying the plan in advance. Skipping a required step can reduce or deny the benefit even when the service itself is covered.
What to do next
- 1
Ask your insurer exactly which plan procedure was not followed (referral, notification, designated provider, etc.).
- 2
If a referral was required and your PCP can provide one retroactively, request it and ask for the claim to be reprocessed.
- 3
If you reasonably relied on incorrect information from the plan or provider, document it and file an appeal.
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