CO-96 Denial Code: Non-Covered Charge(s)
CO-96 is a claim adjustment reason code meaning non-covered charge(s): the service is excluded from the patient's benefit plan. X12 requires at least one remark code with it explaining why. With group CO the practice absorbs the loss; with PR-96 and proper notice (like an ABN for Medicare) the patient can be billed.
- Group
- CO or PR (group code decides who eats it)
- Category
- Benefit exclusion / non-covered service
- Appealable?
- Sometimes; depends on why it is non-covered
- Typical fix
- Read the remark code, confirm the exclusion, rebill or bill patient
What does denial code CO-96 mean?
CO-96 means "non-covered charge(s)": the payer says this service is excluded from the patient's benefits. X12 requires at least one remittance advice remark code alongside it stating why, so a 96 never travels alone. The remark code is where the actionable information lives, N130 (benefit plan documents), N425 (statutorily excluded), M16, and dozens of others.
Example ERA line: CPT 97810 (acupuncture) billed $95.00, allowed $0.00, CO-96 $95.00, paid $0.00, remark N425. The patient's plan simply has no acupuncture benefit. Whether that $95.00 is your loss or the patient's bill depends entirely on the group code and what the patient signed before treatment.
Why did the claim get a CO-96?
- True benefit exclusion: the plan does not cover the service category at all (cosmetic, acupuncture on many plans, hearing aids, routine foot care).
- Statutory exclusion: Medicare never covers the service by law; these should be billed with modifier GY when you need the denial for a secondary.
- Coverage criteria not met: the service is covered only under specific conditions in the LCD or NCD or plan policy, and the claim did not demonstrate them.
- Benefit mapping error: the payer's system slotted the code into the wrong benefit bucket. Rare, but real, and fully appealable.
How do you fix a CO-96 denial?
- Read the remark code first; run it through the denial code lookup. "Non-covered" for plan-exclusion reasons and "non-covered" for criteria reasons are worked completely differently.
- Verify the exclusion against the patient's actual benefit document or the payer's medical policy, not just the ERA.
- If it is a criteria issue, check whether the claim told the whole story: diagnosis pointers, required modifiers, prior conservative treatment. Correct and resubmit if the record supports coverage.
- If it is a genuine exclusion and you obtained a signed notice (ABN for Medicare with modifier GA, or a commercial waiver), rebill or move the balance to the patient as the paperwork allows.
- If there was no notice and the group is CO, it is a write-off. Log it by service type so the pattern is visible.
How do you prevent CO-96 denials?
Verify benefits, not just eligibility, before scheduled services; an active policy can still exclude the procedure. For Medicare, check the NCD/LCD before furnishing services with frequency or condition limits, and get an ABN signed whenever coverage is doubtful. For commercial plans, use predetermination for high-dollar elective services. Confirming medical necessity criteria before the visit is far cheaper than arguing about them after.
Can you appeal a CO-96 denial?
Appeal when the denial contradicts the payer's own written policy: the service is listed as covered, the criteria were met, or the code was mapped to the wrong benefit. Quote the policy section verbatim and attach the clinical notes that satisfy each criterion; that structure wins these appeals. Skip the appeal for statutory and plan-document exclusions, which no letter can change. Check your window with the appeal deadline calculator and assemble the argument in the appeal letter generator.
Frequently asked questions
The payer classified the charge as non-covered under the patient's benefit plan. It is a coverage exclusion, not a coding error. X12 requires an accompanying remark code that states the specific reason, so the remark code, not the 96 itself, tells you what to do next.
The group code assigns liability. CO-96 means the provider absorbs the charge, usually because contract or notice requirements were not met. PR-96 means the patient owes it. For Medicare, having a valid ABN on file and billing modifier GA is what moves a non-covered denial to patient responsibility.
Yes, when the service actually is covered and the payer applied the wrong benefit category, or when coverage criteria in the policy were met. Appeal with the plan's own medical policy or the Medicare NCD/LCD text plus documentation. True statutory exclusions, like cosmetic procedures, are not winnable.
Sources & further reading
Reviewed by the ImmediCare Solutions RCM team
Certified billers and coders handling claims across 50+ specialties nationwide. This entry is reviewed against current payer policy and CMS rules. Last review: Jul 5, 2026.
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