Denial Code CO 96 - Non-covered Charges Explained
Code 96 indicates that the charges in question are not covered by the payer. The accompanying remark code will provide specific reasons for the non-coverage, such as services not included in the benefit plan or experimental treatments.
Who Pays: Group Code Liability
For code 96, the group code can be CO if the non-covered service is due to a provider's contract with the payer, meaning it should be written off and not billed to the patient. If the non-coverage is due to patient-specific reasons, like benefit exclusions, PR applies and the patient may be billed.
Why Claims Get Code 96
- The service provided is excluded under the patient's health plan benefits.
- The procedure is considered experimental or investigational by the payer.
- A pre-authorization was not obtained when required by the payer.
- The patient has exceeded benefit limits for a specific service.
- The claim was submitted with an incorrect or outdated procedure code not covered by the payer.
How to Fix & Resubmit
- Review the accompanying remark code to understand the specific reason for non-coverage.
- Check the patient's benefit plan to verify if the service is indeed excluded.
- If the issue is related to pre-authorization, confirm if it was obtained and documented correctly.
- For coding issues, ensure that the correct and current procedure codes were used.
- Contact the payer for clarification if the reason for non-coverage is unclear or seems incorrect.
Corrected Claim or Appeal?
Submit a corrected claim if the issue was due to incorrect coding or missing authorization that can be rectified. If the denial is based on plan exclusions, a formal appeal may be necessary if you believe the service should be covered.
Preventing Future 96 Denials
- Ensure accurate procedure coding by regularly updating your coding resources.
- Verify patient benefits and coverage details prior to service to avoid non-covered charges.
- Implement a robust pre-authorization process to capture required approvals before service.
- Educate billing staff on common benefit exclusions to prevent unnecessary claim submissions.