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. 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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