CO 90 Denial Code - Ingredient Cost Adjustment Fix
CARC 90 indicates an adjustment to the claimed amount due to changes in the ingredient cost of a pharmaceutical product. This code specifically applies to the pricing of the drug component and not to any service fees or dispensing costs. When you see CARC 90, the payer has adjusted the reimbursement based on the ingredient cost of the medication involved in the claim.
Who Pays: Group Code Liability
For CARC 90, the adjustment typically falls under CO, meaning it's a contractual write-off and the patient cannot be billed for this difference. However, if the payer's policy specifies differently, it might be classified under OA, indicating a payer-initiated reduction that also should not be billed to the patient.
Why Claims Get Code 90
- Pharmaceutical pricing updates not reflected in the claim.
- Contracted rates for drug costs differ from billed amount.
- Incorrect NDC (National Drug Code) submitted with the claim.
- Bulk purchasing discounts not applied in the claim.
- Payer-specific drug cost policy changes after claim submission.
How to Fix & Resubmit
- Verify the NDC and ensure it matches the billed drug.
- Check the payer's pharmaceutical pricing policy to confirm the correct ingredient cost.
- Review the contract terms for drug pricing to ensure compliance.
- If incorrect, update the claim with the correct pricing or NDC and resubmit.
- Contact the payer for clarification if the adjustment seems incorrect.
Corrected Claim or Appeal?
Submit a corrected claim if the ingredient cost or NDC was incorrect. If the adjustment matches the contract terms, no appeal is needed. Appeal only if the payer's adjustment seems to deviate from agreed terms.
Preventing Future 90 Denials
- Regularly update and verify NDCs and pricing against payer policies.
- Ensure contract terms are current and accurately reflected in claims.
- Implement checks for bulk purchasing or volume discounts before claim submission.
- Stay informed on payer-specific drug pricing changes to adjust billing promptly.