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Claim adjustment reason code

CO-96: Non-covered charges

CO-96 means: 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.) The plan does not cover this service at all. Distinct from medical necessity, which is an argument about evidence.

Read the group code before you act on this

96 is the claim adjustment reason code. The CO in front of it is the group code — a separate field the payer sets on the remittance. The same reason code arrives under different group codes depending on the payer and the situation, and the group code, not the reason code, decides who owes the money.

CO — contractual obligation. You write it off. You may not bill the patient.
PR — patient responsibility. Billable to the patient.
OA — other adjustment, and PI — payer initiated reduction. Neither is patient responsibility.

What causes it

The service is genuinely excluded from the plan — cosmetic, experimental, or outside the benefit
The service is covered but was billed under a code the plan excludes
A carved-out benefit administered by a different organization entirely
Statutory exclusion under Medicare, which no appeal will overturn

How to work it

Read the RARC. CO-96 alone does not distinguish an exclusion from a coding problem, and those have opposite remedies
Confirm whether an Advance Beneficiary Notice was obtained. Without one you generally cannot bill a Medicare patient for a statutorily excluded service
If it is a carve-out, find the administering organization and rebill there — this is often behavioral health, dental or vision
Read the GROUP code before doing anything with the balance. PR-96 is patient responsibility and billable; CO-96 is a contractual write-off and is not. The same CARC arrives under either group depending on the payer and the reason

How to stop it recurring

Eligibility verification that records the plan type, not merely that coverage is active, catches most of these before the visit.

Who does this work

A eligibility & benefits verification seat at $1,700 per seat per month works this queue full time, during your business hours, inside your own system. Every call is logged with the payer reference number and the outcome, and every Friday you get it in writing.

What that seat does →

Codes worked the same way

CO-96 is appealed with clinical documentation. So are these, which is why a queue sorted by recovery route moves faster than one sorted by code number — the same person, in the same system, with the same evidence to hand, clears all of them in one pass.

CO-50 — Not deemed medically necessary
CO-151 — Too many services billed
CO-170 — Provider type not paid
CO-234 — Not paid separately
CO-236 — Modifier combination not allowed
CO-231 — Mutually exclusive procedures

Specialties that name this among their costliest

These are specialties whose own worst denials include one of this kind. The line under each is the denial they name, quoted from their page so you can see what the link is based on.

Pain Management
RFA denied because the chart does not carry percent relief and duration from both diagnostic blocks
Orthopedics
Implant and hardware charges denied for missing invoice documentation
Behavioral Health
Time-based psychotherapy codes not supported by documented duration
Cardiology
Stress tests denied for medical necessity documentation
Podiatry
At-risk foot care documentation not naming the treating physician for the systemic condition
Physical Therapy
Timed code units not supported by documented treatment minutes

What leaving it costs

Working a denied claim costs $57.23 per denied claim in administrative time. Source. At 100 denials a month — an illustration, not a measurement of your practice — that is $5,723 a month, or $68,676 a year, in labour alone.

The figure that makes it worth spending: about 90% of initially denied claims are eventually paid. Source. The reason a denial sits is almost never that nobody knows how to work it — it is that nobody has the hours.

Questions

What does denial code CO-96 mean?

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.) In plain terms: The plan does not cover this service at all. Distinct from medical necessity, which is an argument about evidence.

What causes CO-96?

The service is genuinely excluded from the plan — cosmetic, experimental, or outside the benefit. The service is covered but was billed under a code the plan excludes. A carved-out benefit administered by a different organization entirely. Statutory exclusion under Medicare, which no appeal will overturn.

How do you fix a CO-96 denial?

Read the RARC. CO-96 alone does not distinguish an exclusion from a coding problem, and those have opposite remedies. Confirm whether an Advance Beneficiary Notice was obtained. Without one you generally cannot bill a Medicare patient for a statutorily excluded service. If it is a carve-out, find the administering organization and rebill there — this is often behavioral health, dental or vision. Read the GROUP code before doing anything with the balance. PR-96 is patient responsibility and billable; CO-96 is a contractual write-off and is not. The same CARC arrives under either group depending on the payer and the reason.

Can CO-96 be prevented?

Eligibility verification that records the plan type, not merely that coverage is active, catches most of these before the visit.

Is CO-96 the same as PR-96?

Same reason, different group code. The number 96 is the reason: The plan does not cover this service at all. Distinct from medical necessity, which is an argument about evidence. The prefix says who carries the amount. CO means contractual obligation — the payer says the amount is not billable to anybody, and it is written off unless the denial itself is overturned. PR-96 is the same reason assigned to patient responsibility — the payer says the amount is owed by the patient, and it is billed to them. Read the prefix before the number: it decides whether you appeal, write off, or bill the patient.

What is the difference between CO-96 and CO-97?

CO-96: The plan does not cover this service at all. Distinct from medical necessity, which is an argument about evidence. CO-97: The payer is bundling this code into another one on the same claim. Sometimes that is correct and sometimes it is not. They are different reasons that happen to sit next to each other in the list, and they are worked differently — CO-96 is appealed with clinical documentation; CO-97 is checked against the contract before any work is done.

Code descriptions are the standard X12 claim adjustment reason and remittance advice remark code text. Payer policies differ, and the payer’s own coverage policy governs any individual claim. This page is working guidance, not legal or clinical advice.

Last updated 2026-09-12. This is operational guidance drawn from payer remittance practice, not legal, coding or reimbursement advice. Payer-specific rules vary and change; confirm against the payer’s own policy before acting on a specific claim.

Written by Ibtesam Asif · Last reviewed 2026-09-12

Code descriptions are the standard published text. Everything after them is operational guidance from our own work, and payer policy governs any individual claim.

Other denial codes

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