CO-96 denial code: non-covered charges

Claim adjustment reason code 96 says: non-covered charge(s). The payer doesn't cover this service for this patient. CARC 96 always comes with at least one remittance advice remark code (RARC) that explains why.

It is one of the broadest codes on a remittance, so the remark code matters more than usual.

• CO-96: the practice is responsible and can't bill the patient. Typical when the patient wasn't told in advance that the service might not be covered.
• PR-96: the patient is responsible. Typical when the service is excluded from the plan, or when the patient signed a valid notice before the service.

• The service is excluded. Original Medicare doesn't cover routine physical exams (other than the initial preventive visit and the annual wellness visit), cosmetic surgery or most routine foot care.
• It isn't a benefit of the patient's plan. See also PR-204.
• It isn't covered for this diagnosis or circumstance, which is often a medical necessity question. See CO-50.
• It was billed to the wrong part of the plan, such as a pharmacy benefit.

1. Read the remark code to find the reason.
2. Check whether a covered code or benefit applies that was missed.
3. Appeal if the plan's own documents say the service is covered, or if a medical necessity requirement was met.
4. If it is excluded, bill the patient only if they were told and agreed in advance. For Medicare, an Advance Beneficiary Notice is required before billing the patient for a service expected to be denied as not reasonable and necessary.

• Check coverage for the specific service at booking, not just whether the plan is active.
• Know your common exclusions by payer.
• Give patients a written estimate and notice before services their plan may not cover, and keep the signed copy.

CO-96 is decided by the patient's coverage, so it is prevented at booking.

Claira Health's AI agents confirm coverage and the right payer before the visit, so this denial is stopped at the front desk instead of coming back weeks later. Your team sees only what needs a decision, and approves every step. On a 20-minute call, we’ll walk through it using one of your own denials.

Book a 20-minute call and bring a CO-96 with its remark code.