Quick Explanation
Denial code CO-96 indicates that the billed service is considered a non-covered charge under the patient’s insurance plan or provider contract, meaning the payer has determined the service is excluded from reimbursement regardless of medical necessity or documentation. This differs from other denial codes such as CO-167 (specific procedure exclusion) or PR-96 (patient responsibility), as CO-96 reflects a contractual obligation where the provider cannot bill the patient and must absorb the loss unless the denial is successfully appealed based on coverage policy or medical necessity.
Common Causes for 96
Denials with code 96 typically happen for the following specific reasons:
- The billed service is explicitly excluded in the patient’s insurance policy (e.g., cosmetic procedures, routine screenings, or non-medically necessary services).
- The service was provided when the patient’s insurance was inactive, lapsed, or not in effect on the date of service.
- Incorrect coding or modifier usage led to the service being categorized as non-covered (e.g., missing KX, GY, or GA modifiers for Medicare).
- The item or service does not meet the payer’s criteria for the billed category (e.g., durable medical equipment billed under the wrong HCPCS code).
- The service is statutorily excluded by the payer (e.g., certain preventive exams or transportation services not covered by Medicare).
How to Prevent 96 Denials
To avoid receiving this denial in the future, implement these specific checks:
- Verify patient insurance eligibility and active coverage status prior to service delivery.
- Review payer-specific coverage policies and exclusions for the planned service or procedure.
- Ensure accurate coding and appropriate use of modifiers (e.g., KX, GY, GA) to reflect coverage requirements.
- Confirm that the diagnosis and procedure codes align to demonstrate medical necessity as required by the payer.
- Educate staff on common non-covered services and regularly update billing protocols based on payer updates.
Appeal Letter Template for 96
If you believe this claim was denied incorrectly, you can use the following template to submit an appeal.
[Your Practice Header]
[Date]
[Payer Name]
[Appeals Department Address]
RE: Appeal for Claim [Claim Number]
Patient: [Patient Name]
ID: [Patient ID]
Date of Service: [Date]
Denial Code: 96 - Non-Covered Charge
Dear Appeals Department,
I am writing to appeal the denial of the above-referenced claim, which was denied with code 96: "Non-Covered Charge".
The service in question was medically necessary and performed in accordance with accepted clinical guidelines for the patient’s documented condition. The submitted documentation, including the diagnosis (ICD-10) and procedure (CPT) codes, supports the medical necessity and appropriateness of the service. The payer’s denial under CO-96 appears to be based on a policy interpretation that may not reflect the clinical context or the specific circumstances of this case. We request reconsideration of coverage based on the clinical evidence provided and reference to the payer’s own medical policy, which allows for exceptions when services are deemed medically necessary and supported by documentation. If applicable, we also note that the service was performed during a period of active patient coverage and meets all contractual and regulatory requirements for reimbursement.
Attached please find:
1. A copy of the original claim.
2. The relevant medical records supporting the service.
3. [Any other supporting documents].
We respectfully request that you reprocess this claim for payment.
Sincerely,
[Your Name]
[Title]
[Practice Name]
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