What is CO 96 Mean?
The CO 96 denial code stands for “Non-Covered Services.”
The CO 96 denial code means that the insurance company has denied payment because the service is not covered under the plan or contract. In simple words, it means the payer will not pay for the service because it is not included in the patient’s policy benefits or under the Provider’s Contract.
This denial can occur for various reasons — such as non-covered services, lack of medical necessity, experimental or investigational procedures, or services excluded from the plan.
Common Reasons for CO 96 Denials
The CO 96 denial can occur for multiple reasons, depending on the payer’s policy, the provider’s contract, or the services billed.
It’s always important to check the accompanying Remark Code (RARC) on the Explanation of Benefits (EOB) or ERA to identify the exact reason for the denial.
Below are some of the most common causes:
1. Service Not Covered by the Patient’s Plan
This is one of the most frequent reasons for a CO 96 denial. It occurs when the patient’s insurance policy does not include the billed service or procedure.
Example:
A patient’s plan does not cover chiropractic or infertility services, and the provider bills for them.
2. Service Not Covered Under the Provider’s Contract
Even if the service is covered under the patient’s plan, it may be excluded from the provider’s contract with the payer.
This usually happens when specific CPT codes are not listed or reimbursable under the provider’s agreement.
Example:
A certain CPT code is excluded from the provider’s fee schedule as per the contract with the insurance company.
3. Services Non-Covered as per Fee Schedule
In some cases, the denial happens because the billed service is not payable as per the payer’s fee schedule or reimbursement policy.
This means the payer has classified the procedure as non-compensable under their current plan terms.
Example:
The payer’s fee schedule excludes payment for a specific type of follow-up visit.
4. Out-of-Network Provider
If the patient’s plan only covers in-network services, and the provider is out of network, the payer will deny the claim as non-covered.
Example:
A patient visits a specialist who is not part of the plan’s network — resulting in a CO 96 denial.
5. Benefit Limitations or Frequency Exceeded
Many insurance plans restrict how often a particular service can be billed within a benefit period.
When these frequency or benefit limits are exceeded, the payer denies the claim as non-covered.
Example:
A plan covers one preventive exam per year — if a second exam is billed within the same year, it may be denied under CO 96.
On-Call Scenario: CO 96 – Non-Covered Charges
Here’s the On-Call Scenario for CO 96 Denial:
Rep:
The claim was denied as non-covered charges.
You:
Thank you. May I please have the denial date?
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Could you confirm if the denial is non-covered as per the patient’s plan or as per the provider’s contract?
If Non-Covered as per Patient Plan:
What is the reason for the non-covered denial?
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Provider out of network | Non-covered DX or ICD-10 | Other reason
If provider is out of network:
Please confirm the time frame to submit a corrected claim (if applicable).
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May I have the claim number and call reference number, please?If DX or ICD-10 is non-covered:
Can you confirm if an appeal can be submitted with supporting documentation?
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What is the fax number or mailing address to send the appeal?
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What is the appeal filing limit?
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May I have the claim number and call reference number, please?
If Non-Covered as per Provider Contract:
What is the reason for the non-covered denial?
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CPT not covered under provider contract | Other reasons
If CPT not covered under provider contract:
Let’s check the payment history to see if the same CPT has been paid previously for the same provider by the same insurance.
Yes | NoIf Yes:
Could you please send the claim back for reprocessing, since the same CPT was paid earlier?
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What is the turnaround time (TAT) for reprocessing?
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May I have the claim number and call reference number, please?If No:
What is the fax number or appeal address to send an appeal?
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How much is the appeal limit?
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May I have the claim number and call reference number, please?
If other reasons:
Please refer to the AR Scenarios for further steps.
Important Notes & Actions
Please take action as per your process update. The below steps may vary depending on your client’s specific process.
If the claim is denied as Non-Covered Charges under the Patient’s Plan:
If the provider is out of network:
→ Click on the link and follow the Out-of-Network Provider Scenario.If the denial is due to a non-covered DX or ICD-10 code:
→ Send the claim to the coding team to check for an alternative diagnosis code.
→ If the coding team provides a valid alternative code, update and resubmit a corrected claim.
→ If no alternative code is available, bill the claim to the secondary or consecutive payer, if applicable.
→ If no other payer is available, release the claim to the patient.If the denial is for other non-covered reasons:
→ Bill the claim to the secondary or consecutive payer if available.
→ If no other active coverage exists, release the claim to the patient.
Before Billing to a Secondary or Consecutive Payer:
Always verify the patient’s eligibility with the secondary or consecutive payer.
Check the payer’s website if access is available, or call the insurance to confirm coverage.
If no other active insurance exists for the Date of Service (DOS), release the claim to the patient.
If the Claim is Denied as Non-Covered Charges under the Provider Contract:
If payment is seen in the payment history and the representative agrees to reprocess the claim:
→ Set a follow-up for the TAT (Turnaround Time) provided by the representative.If payment is seen in the payment history but the representative refuses to reprocess and asks to send an appeal:
→ Submit an appeal to the insurance.If no payment is seen in the payment history:
→ Depending on your client’s instructions, either submit an appeal or adjust/write off the claim.
Additional Note:
A non-covered denial under the provider contract may not always relate to a CPT issue — reasons can differ.
→ Always refer to the Scenario Tool and follow the appropriate steps based on the denial reason.
Click here for more AR Scenarios and Denials.