Notes on payer behavior
CO-96 denial code: non-covered charge, and the remark code that explains why
Denial code CO-96 is the payer saying: "Non-covered charge(s)." What that means for your practice, and whether it's worth chasing, below.
What the payer is asserting
CO-96 is a category, not a reason. The payer is saying this charge isn't payable under the plan, and it's required to attach a remark code that says why. Without the remark code you can't work it. With it, CO-96 splits into a few very different denials, some of which are wrong.
The five reasons behind a CO-96
- Plan exclusion. The service is excluded under the patient's benefit plan. Cosmetic, experimental, a category the employer's plan doesn't buy. Remark codes in the N-range name the exclusion. Usually correct, usually patient responsibility if the contract allows it.
- Bundled by policy. The payer considers the charge part of another service. This is the CO-96 that overlaps with CO-97 and is worth checking against your contract, because payers apply bundling rules their contracts don't support.
- Non-covered by this provider type or setting. The service is covered, but not when billed by this provider or in this place of service. Sometimes a credentialing problem. Sometimes a claim that went out with the wrong POS code.
- Frequency or benefit limit. The plan covers a set number per year and this one is past it. Often correct. Sometimes the payer's count includes another provider's services or a prior year's.
- Missing a required modifier or code. A GY on Medicare, an S-code the commercial payer wanted instead of the CPT, a screening versus diagnostic distinction the claim didn't make. The care is covered; the claim didn't say so.
Which ones reverse
The last three regularly. Bundling that the contract doesn't allow is a reconsideration with the contract page. A provider-type or setting denial that stems from a claim error is a corrected claim. A frequency limit that counts wrong is a reconsideration with the service history. A missing modifier is a corrected claim. Only the first, the true plan exclusion, is generally final, and even then the question of who pays remains.
Who pays a true exclusion
The group code decides. CO-96 assigns the amount to you. PR-96 assigns it to the patient. Payers sometimes send CO-96 where the contract says the patient is responsible for excluded services, and that's a reconsideration to have the group code corrected so the patient can lawfully be billed. On Medicare, the patient can be billed for a statutorily excluded service without an ABN, but for a service that's usually covered and denied in this instance, only with one. The full group-code logic.
The pattern to watch
A CO-96 count that climbs from one payer without a plan change means a policy changed on their side. Payers publish policy updates; practices rarely read them. Find the policy behind the remark code, check the effective date against your contract, and if the contract doesn't allow it, dispute the set.
Questions people ask about CO-96
What does denial code CO-96 mean?
The payer says the charge is not covered. The attached remark code says why: a plan exclusion, a bundling rule, a provider or setting restriction, a frequency limit, or a missing modifier.
Can you appeal a CO-96 denial?
Depends on the reason. Bundling the contract doesn't allow, setting or provider errors on the claim, miscounted frequency limits, and missing modifiers reverse routinely. A genuine plan exclusion generally does not, though the group code may need correcting so the patient can be billed.
What's the difference between CO-96 and PR-96?
The group code. CO makes the non-covered amount your write-off. PR makes it the patient's responsibility. If the contract says excluded services are patient-pay and the payer sent CO, ask for the group code to be corrected.