How do I fix or resolve code 96?

Locate the accompanying Remittance Advice Remark Code (RARC) on the ERA/EOB to determine the specific reason the charge is non-covered (e.g., N130 — service not covered under plan, N386 — non-covered service). Review the patient's benefit plan documents or contact the payer's provider relations to confirm whether the service is a covered benefit and under what conditions. If the service is non-covered under the plan, determine whether the patient signed an Advance Beneficiary Notice (ABN) or financial responsibility form acknowledging non-coverage; if so, bill the patient. If the service should be covered based on the plan documents or the payer's coverage policy, file an appeal with the benefit plan citation and supporting clinical documentation. If the non-covered status is correct and no ABN was obtained, write off the charge as a provider write-off unless the patient can be billed per the plan's non-covered provisions.

96Denial CodeGeneral Adjustment

Code 96

Problem Description

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.) Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

Root Cause

The charge is non-covered. At least one Remittance Advice Remark Code (RARC) must accompany this CARC to explain why the charge is non-covered — it may be a non-covered service under the plan, a service excluded by the patient's benefit plan, or a service that requires a specific condition to be covered. This differs from CO-50 (medical necessity) in that the service itself may be statutorily excluded or not a covered benefit under the patient's plan, regardless of medical necessity.

Resolution Steps

1Locate the accompanying Remittance Advice Remark Code (RARC) on the ERA/EOB to determine the specific reason the charge is non-covered (e.g., N130 — service not covered under plan, N386 — non-covered service).
2Review the patient's benefit plan documents or contact the payer's provider relations to confirm whether the service is a covered benefit and under what conditions.
3If the service is non-covered under the plan, determine whether the patient signed an Advance Beneficiary Notice (ABN) or financial responsibility form acknowledging non-coverage; if so, bill the patient.
4If the service should be covered based on the plan documents or the payer's coverage policy, file an appeal with the benefit plan citation and supporting clinical documentation.
5If the non-covered status is correct and no ABN was obtained, write off the charge as a provider write-off unless the patient can be billed per the plan's non-covered provisions.

EHR Documentation Note

Claim denied 96 — non-covered charge; identified accompanying RARC, verified plan coverage, billed patient if ABN signed, or filed appeal if service should be covered.

Preventative Action

Verify service coverage during pre-visit eligibility checks and obtain ABNs for services likely to be non-covered; maintain a list of commonly non-covered services for each major payer.

Related Codes in General Adjustment

Deductible Amount

Coinsurance Amount

Co-payment Amount

The procedure/revenue code is inconsistent with the patient's age. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

This directory provides reference information only and does not constitute official legal, medical, or financial billing advice. Always consult the payer's official remittance advice and current coding guidelines.