CO-96 Denial Code: Non-Covered Charges

What Does CO-96 Mean?

Code 96 means the service isn't covered — excluded by the plan, not a benefit, or non-covered in this circumstance. Critically, it arrives as either CO-96 or PR-96, and that prefix decides everything: CO-96 means the provider absorbs it; PR-96 means the patient can be billed. The accompanying remark code explains the specific exclusion.

Code group: CO / PR (liability depends on notice) · Appealable: Yes when the exclusion is misapplied or a benefit category was wrong; liability reassignment when valid notice exists. True exclusions without notice are write-offs.

Why CO-96 Happens

True plan exclusions: cosmetic procedures, most adult dental on medical plans, experimental/investigational services, or benefits the employer's plan simply didn't purchase.
Category confusion: the service is covered — but under a different benefit (pharmacy vs medical for drugs, vision carve-out for eye care, behavioral carve-out for therapy).
Statutory exclusions for Medicare: services Medicare never covers by law, which have their own billing and notice rules.
Missing notice: the service could have been patient liability, but no ABN (Medicare) or financial waiver (commercial) was obtained — so liability lands on the provider as CO-96.

How to Fix a CO-96 Denial — Step by Step

Read the remark code first — it distinguishes 'never covered' from 'not covered like this' from 'wrong benefit category.'

If it's a benefit-category problem, redirect: pharmacy benefit drugs go through the PBM, carve-out services go to the carve-out administrator. The service is payable — the route was wrong.

If a valid ABN or waiver exists, the liability should be PR — contact the payer with the notice documentation and have liability reassigned, then bill the patient.

If it's a genuine exclusion with no notice on file, it's a provider write-off — and a process lesson.

Verify the exclusion is real: payers misapply exclusion edits, and a claim denied 96 for a service the policy documents as covered deserves a documented appeal.

CO-96 Appeal Letter Template

Adapt this wording to your claim — replace the bracketed fields and attach the documentation it references:

Claim [number] was denied code 96 as non-covered. Per the member's benefit document [section], [service/CPT] is a covered benefit when [criteria], and the attached documentation demonstrates those criteria are met. We request adjudication under the correct benefit provision. [If notice exists: A signed beneficiary notice dated before the service is attached; we request liability reassignment to the member.]

How to Prevent CO-96

Verify benefits for the specific service before delivering it — 'has insurance' is not 'has this benefit.'
Use ABNs and commercial financial waivers systematically for services with exclusion risk.
Keep a per-payer map of carve-outs and benefit categories for your common services.

Related Denial Codes

CO-50 — Not medically necessary CO-204 — Not covered under plan CO-109 — Wrong payer CO-119 — Benefit maximum reached

Related: the same reason code with the opposite liability is PR-96 — patient responsibility, billable only if you obtained valid advance notice first.

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Reviewed by the LegitMedBilling denial management team. This guide is general billing information, not legal or payer-specific advice — always verify against your payer contract and current policy.

Frequently Asked Questions

What's the difference between CO-96 and PR-96?

The liability. PR-96 means the patient can be billed for the non-covered service; CO-96 means the provider absorbs it — usually because required notice (like a Medicare ABN) wasn't obtained. Same exclusion, opposite financial outcome, decided entirely by your paperwork before the service.

How is 96 different from CO-50?

CO-50 says the service could be covered but wasn't medically necessary per policy — an argument you can win with documentation. Code 96 says the benefit doesn't exist for this service or circumstance — an argument you win only by showing the benefit actually does exist or the claim belongs elsewhere.

A drug we administered denied as non-covered. Now what?

Check the benefit category first: many drugs are covered under the pharmacy benefit, not the medical benefit — meaning the claim belongs at the PBM or the drug should have been dispensed through specialty pharmacy. Site-of-care and buy-and-bill policies drive these denials, and the fix is routing, not appealing.