CARC Code 95
The plan's procedures were not followed.
What this denial means
When you see CARC code 95 on your Explanation of Benefits (EOB), it means your insurer has denied the claim with the following reason: the plan's procedures were not followed.
This code is one of the most common denial reasons in the CARC system and appears across both employer-sponsored and ACA marketplace plans. How you respond depends on whether the denial is a patient-side or provider-side issue.
Can you appeal this?
Yes — this denial is patient-appealable. Identify which plan procedure was allegedly not followed and whether adequate published notice of that requirement was provided. Plans cannot enforce procedural requirements that are ambiguously stated or not reasonably accessible. Argue the requirement was satisfied or was insufficiently disclosed.
Applicable federal regulations:
ERISA plans (employer-sponsored)
- ERISA § 503
- 29 CFR § 2560.503-1(g)
- 29 CFR § 2560.503-1(h)
ACA plans (marketplace / individual)
- PHS Act § 2719
- 45 CFR § 147.136(b)
Your insurer's legal team is bound by these regulations. An appeal letter that cites them directly demands a specific, documented response.
What to include in your appeal
Gather as many of these supporting documents as apply to your denial:
- –Explanation of Benefits (EOB)
- –Doctor's letter of medical necessity
- –Clinical notes and records from your provider
- –Prior authorization record (if applicable)
- –Summary of Benefits and Coverage (SBC)
See our submission guide for full instructions on each document and how to submit your appeal.
Related reading
Not legal or medical advice. Rebuttal is a document drafting tool, not a law firm. Review your letter before submitting and consult a licensed professional for legal questions specific to your plan.