Non-covered charge
The plan does not cover this service or item. A remark code should say why.
CO = Contractual Obligation. The provider owes the difference. The patient cannot be billed for this amount. The same reason code can appear with a different group code; the group decides who may be billed.
Usual causes
- Service excluded by the benefit plan (cosmetic, some vision, dental, hearing, routine foot care).
- Statutorily excluded by Medicare (N425).
- Service billed to the wrong plan (medical versus dental, vision, pharmacy or behavioral health carve-out).
- Provider not contracted for this benefit.
The fix
Read the remark code (N130, N425, N216 and others). If the service belongs to a carve-out plan, bill that plan. If it is a true exclusion, bill the patient if they were told in advance (Medicare: ABN with modifier GA, or GY for statutory exclusions). If the payer is wrong about the benefit, appeal with the plan document.
Appeal or corrected claim?
Depends on the remark code: redirect, bill the patient, or appeal with the benefit language.
Deadline to watch
Timely filing for a redirected claim; appeal window per payer.
Exact limits are in your payer contract or provider manual. When in doubt, send the correction or appeal this week.
CO-96 in short
What does CO-96 mean?
The plan does not cover this service or item. A remark code should say why. The official X12 text reads: "Non-covered charge(s). At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.) Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present."
What usually causes a CO-96 denial?
Service excluded by the benefit plan (cosmetic, some vision, dental, hearing, routine foot care). Statutorily excluded by Medicare (N425). Service billed to the wrong plan (medical versus dental, vision, pharmacy or behavioral health carve-out). Provider not contracted for this benefit.
How do I fix CO-96?
Read the remark code (N130, N425, N216 and others). If the service belongs to a carve-out plan, bill that plan. If it is a true exclusion, bill the patient if they were told in advance (Medicare: ABN with modifier GA, or GY for statutory exclusions). If the payer is wrong about the benefit, appeal with the plan document.
Should I appeal CO-96 or send a corrected claim?
Correct or appeal (see note). Depends on the remark code: redirect, bill the patient, or appeal with the benefit language.
What deadline applies to CO-96?
Timely filing for a redirected claim; appeal window per payer.