CO-96 — Noncovered / Statutorily Excluded Service

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.")

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.

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.

Resolution Workflow

• Confirm the CPT/HCPCS reported matches the service performed.
• Check the plan's benefit exclusions list or statutory exclusion basis (RARC N425).
• If the code was wrong, correct and resubmit (only if a different, accurate code applies).
• If genuinely excluded, confirm whether the patient was notified before the service (ABN/notice), which affects patient liability.
• Document the exclusion finding.
• Route to patient billing only when a proper pre-service notice was given or no notice is legally required for that exclusion category.

Department Most Likely Responsible

• Resolves current claim: Billing/Follow-Up. Prevents recurrence: Registration/Scheduling — benefit verification and patient notice workflow for known exclusion categories.

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.

Escalation Trigger

• 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.

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.

Resolution path at a glance

AI Search Terms / Synonyms

• CO96; CO-96; noncovered service; statutorily excluded; benefit exclusion; N425.

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.

Sources

• X12 CARC list; X12 RARC list