CO-96 — Noncovered / Statutorily Excluded Service
The service billed simply is not a covered benefit under this patient's plan (or, for Medicare, is excluded by statute) — this is different from a medical-necessity denial, which concerns whether a covered bene…
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In plain language
The service billed simply is not a covered benefit under this patient's plan (or, for Medicare, is excluded by statute) — this is different from a medical-necessity denial, which concerns whether a covered benefit applies in this specific clinical situation.
Start here
Confirm the CPT/HCPCS reported matches the service performed.
Who resolves it
Billing/Follow-Up
Who prevents it
Registration/Scheduling — benefit verification and patient notice workflow for known exclusion categories.
Sources
- X12 CARC list; X12 RARC list
Validated ClaimetryX Source — Denial Management Knowledge Base, 2026 Research Edition
Research date August 18, 2026. CARC/RARC combinations and payer processes vary. Always check the specific remittance advice and the payer's current requirements before acting on any denial.
Published by ClaimetryX. Sources identify the code standards, agency guidance, and payer policies supporting this reference. How we use sources
How to resolve this denial, step by step
- 1
Confirm the CPT/HCPCS reported matches the service performed.
- 2
Check the plan's benefit exclusions list or statutory exclusion basis (RARC N425).
- 3
If the code was wrong, correct and resubmit (only if a different, accurate code applies).
- 4
If genuinely excluded, confirm whether the patient was notified before the service (ABN/notice), which affects patient liability.
- 5
Document the exclusion finding.
- 6
Route to patient billing only when a proper pre-service notice was given or no notice is legally required for that exclusion category.
Then choose the correct disposition
Corrected claim
only if the code itself was inaccurate.
Formal appeal
generally low likelihood of success for a true statutory/benefit exclusion; document why before filing.
Patient responsibility
appropriate when the exclusion is a true benefit-design limitation and required notice was properly given.
Stop and escalate when
- Pattern of a specific service being denied as excluded when the plan document suggests otherwise (potential payer processing error); compliance question about patient notice adequacy.
What Needs to Be corrected
- Claim correction: Rarely a claim-data issue; verify the code billed actually matches the service performed.
- Upstream correction: Registration/Scheduling should identify statutorily/benefit-excluded services before the appointment and issue the appropriate patient notice.
Do Not Do This
- Do not change the CPT/HCPCS code to a covered code that does not match the service performed.
- Do not bill the patient without confirming notice requirements were met where applicable.
Plain-Language Meaning
- The service billed simply is not a covered benefit under this patient's plan (or, for Medicare, is excluded by statute) — this is different from a medical-necessity denial, which concerns whether a covered benefit applies in this specific clinical situation.
Why the Claim Was Denied
- Benefit design: service category excluded from the specific plan (e.g., cosmetic, routine dental/vision, certain screening services)
- Coding: correct code billed, but that code maps to a category the plan never covers
- Registration: patient not informed of non-coverage before the service (relevant to patient- liability determination)
Information the Biller Must Review
- CPT/HCPCS billed, plan benefit summary/exclusions list, RARC identifying the specific exclusion basis, patient notice/consent documentation (ABN or plan-specific non-coverage notice) if obtained.
Sample Scenario
- Scenario: Cosmetic procedure claim denied CO-96/N425.
- Finding: Plan benefit document confirms the procedure category is excluded; no medical- necessity exception applies.
- Action: Patient billed per prior signed financial responsibility notice; no appeal filed given documented statutory/benefit exclusion.
Denial Identifier
- Primary CARC: CO-96 — "Non-covered charge(s). At least one Remark Code must be provided..." (X12)
- Common RARCs: N425 ("Statutorily excluded service(s)."), N130 ("Consult plan benefit documents/guidelines for information about restrictions for this service."), N356 ("Not covered when performed with, or subsequent to, a non-covered service.")
Prevention Control
- Benefit-category exclusion lookup at scheduling; standardized patient-notice process for known non-covered service lines; claim scrubber flag for high-exclusion-risk codes.
Department Most Likely Responsible
- Resolves current claim: Billing/Follow-Up. Prevents recurrence: Registration/Scheduling — benefit verification and patient notice workflow for known exclusion categories.
AI Answer Guardrail
- Confirm the plan's specific benefit-exclusion language and whether required patient notice was obtained before recommending patient billing or an appeal.
AI Search Terms / Synonyms
- CO96; CO-96; noncovered service; statutorily excluded; benefit exclusion; N425.
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