CARC 96 means the service is not covered. The group code decides who pays. With CO-96, the provider absorbs it. With PR-96, the patient can be billed. The remark code that comes with it tells you why the service is not covered.
1. What CARC 96 means
CARC 96 is "non-covered charge(s)". The service falls outside what the plan pays for: an excluded benefit, a service Medicare never covers by law, or something outside the patient's plan design. Payers must send at least one remark code with it, and may point to a specific policy on the 835.
2. CO-96 vs PR-96
| Code | Who pays | Common reasons |
|---|---|---|
| CO-96 | Provider (write-off or appeal) | Your contract bars billing the patient, or required patient notice was not given. |
| PR-96 | Patient | The service is excluded from the plan and the patient is responsible, for example a statutorily excluded Medicare service billed with the GY modifier. |
For Original Medicare, the GY modifier tells Medicare the item or service is statutorily excluded or does not meet the definition of a Medicare benefit. Those claims deny, and the patient is usually responsible. This is different from a medical necessity denial (CO-50), where an ABN decides liability.
3. Remark codes that come with 96
| Remark code | What it points to |
|---|---|
| N130 | Consult plan benefit documents or guidelines for restrictions on this service. |
| N425 | Statutorily excluded service. |
| N30 | Patient ineligible for this service. |
4. How to fix a 96 denial
- Read the remark code and any policy reference to learn why the service is excluded.
- Check the coding. A covered service billed with the wrong code can look like an excluded one. If so, send a corrected claim.
- Check the plan. Was the right plan billed? Coverage may differ between the patient's old and new plan.
- If it is CO-96 and you believe the service is covered, appeal with the plan language and documentation.
- If it is PR-96, bill the patient, following any notice or financial agreement rules in your contract.
5. Payer-by-payer: fixing a 96
| Payer | What to know |
|---|---|
| Medicare | Statutorily excluded services (routine physicals, most dental, hearing aids, cosmetic surgery) usually come back with remark code N425. Append the GY modifier so the line denies as patient responsibility. An ABN is not required for excluded services, but a voluntary notice sets expectations. Do not use GY for services denied as not reasonable and necessary; that is the GA/GZ and ABN process (see CO-50). |
| Medicare Advantage | MA plans cover everything Original Medicare does and may add extra benefits. If a service is denied as non-covered, check the plan's Evidence of Coverage. For planned services, ask for a pre-service organization determination. |
| Medicaid | Covered services differ by state. Billing the patient for a non-covered Medicaid service is restricted. Most states require the patient's written agreement before the service, so check your state's rules first. |
| Commercial plans | Check the plan's exclusions in the Summary of Benefits and Coverage. With CO-96 the provider contract usually bars billing the patient. With PR-96 you can, ideally with a signed financial waiver collected before the visit. |
6. How to prevent it
- Check benefits for the specific service, not just active coverage, before the visit. See our eligibility verification guide.
- Have patients sign a financial agreement for services you know a plan excludes, where your contract allows it.
- Use the right Medicare modifier: GY for statutorily excluded services, GA or GZ for medical necessity cases.
Related: PR-204, CO-45, and the full CARC and RARC codes list.
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