CARC 95 appeal letter template — Plan Procedures Not Followed

CARC 95 indicates the payer determined that required plan procedures (such as referral, authorization, notification, or network protocols) were not followed before or during service delivery. This template helps providers contest the denial when they believe applicable procedures were in fact met or when circumstances justify an exception.

When to appeal vs. correct & resubmit

Appeal when you have documentation showing the required plan procedure was actually followed (e.g., referral on file, authorization obtained, notification sent timely) or when the payer's own policy was unclear, inconsistently applied, or waived under urgent/emergent circumstances. If the procedure truly was not followed and no exception applies, it may be faster to correct internal workflows and, if allowed, request a retroactive authorization or submit a corrected claim rather than appeal.

Appeal letter template

Copy the template, replace every [bracketed] field with your details, and keep only the paragraph that fits your situation.

[Date]

[Payer Name]
Appeals Department
[Payer Address]

Re: Appeal of Claim Denial — CARC 95 (Plan Procedures Were Not Followed)
Patient Name: [Patient Name]
Member ID: [Member ID]
Claim #: [Claim #]
Date(s) of Service: [DOS]
Provider: [Provider Name, NPI]
CPT/HCPCS: [CPT/HCPCS]
Authorization #: [Authorization #]

Dear Appeals Reviewer,

This letter serves as a formal appeal of the above-referenced claim, which was denied under CARC 95, indicating that plan procedures were not followed. We respectfully disagree with this determination and ask that the claim be reprocessed for payment based on the information and documentation outlined below.

[Describe the specific plan procedure at issue — e.g., referral, prior authorization, notification timeline, network routing — and explain the steps taken to comply, including relevant dates and reference numbers.]

Enclosed is supporting documentation confirming that applicable plan procedures were followed, including [list specific evidence, e.g., referral confirmation, authorization approval, notification records, or correspondence with the plan]. If any step was delayed or varied from standard protocol, this occurred due to [explain circumstance, e.g., urgent/emergent need, plan instruction, administrative error], which we believe warrants reconsideration.

We request that [Payer Name] review the enclosed records and reverse the CARC 95 denial, issuing payment for the services rendered on [DOS]. Please contact our office with any questions or if additional documentation is needed to complete this review.

Thank you for your attention to this matter.

Sincerely,
[Provider Name, NPI]
[Practice/Facility Name]
[Phone]
[Email]

What to attach

• Explanation of Benefits (EOB) / Electronic Remittance Advice (ERA) showing the CARC 95 denial
• Proof of referral, authorization, or notification (confirmation number, fax log, portal screenshot, or approval letter)
• Relevant medical records supporting timing and medical necessity of the service
• Copy of the original claim submission
• Any written correspondence with the payer regarding plan procedure requirements

Frequently asked questions

More free billing tools: all appeal letters · denial codes · NCCI edits · Medicare fees

This template is for informational and administrative purposes only and does not constitute legal, billing, or coding advice. It does not guarantee any particular outcome, including claim reversal or payment. Always verify requirements against the specific payer's policies and consult a qualified billing or legal professional as needed.