Learn what CO-96, PR-96, and OA-96 mean, how to find the exact reason for denial code 96, and how to choose the correct resolution.
A claim returns with denial code 96.
The basic description says:
But this description does not answer the questions that matter:
- Why did the payer consider the service non-covered?
- Who is responsible for the unpaid amount?
- Should you correct the claim, appeal, bill another payer, or adjust the balance?
To answer these questions, you must read the full remittance message—not code 96 alone.
Denial code 96 in 20 seconds
Claim Adjustment Reason Code 96 means the payer considers the billed service non-covered.
The payer may report code 96 with different group codes:
The group code tells you how the payer classified the balance.
Code 96 gives the general reason.
The Remittance Advice Remark Code, or RARC, gives the more specific reason.
Read denial code 96 as one message
Use this simple formula:
Each part has a different purpose:
- The group code shows how the payer classified the amount.
- CARC 96 tells you the charge is non-covered.
- The RARC explains why the payer considered it non-covered.
For example:
This combination means the payer classified the amount as a contractual obligation and considered the service non-covered in the reported place of service.
Now you know where to start: review the place of service.
Without the RARC, you know the service is non-covered, but you may not know why.
CO-96 denial code description
The CO-96 denial code means the payer considered the service non-covered and classified the adjustment as a Contractual Obligation.
This usually points toward provider responsibility.
However, do not post a write-off as soon as you see CO-96.
First, review the RARC and confirm the exact reason.
For example:
- CO-96 + N428 points to the place of service.
- CO-96 + N569 points to the diagnosis.
- CO-96 + N808 points to the provider type or specialty.
Each combination requires a different review.
If incorrect claim information caused the denial, correct the claim.
If the claim is correct but the payer applied the wrong policy, request reprocessing or submit an appeal.
If the denial is correct and the provider contract makes the provider responsible, post the correct adjustment.
PR-96 denial code description
The PR-96 denial code means the payer considered the service non-covered and classified the amount as Patient Responsibility.
However, PR-96 does not automatically mean you can bill the patient.
Before moving the balance to the patient, confirm:
- The service is not covered under the patient’s plan.
- The payer correctly applied the balance to the patient.
- The provider’s contract allows the patient to be billed.
- The patient received any required notice about the cost.
- There is no other insurance that should pay the claim.
The RARC provides the specific reason for the non-covered service. For example:
- PR-96 + N216 may mean the plan does not cover the service or the patient is not enrolled in that part of the benefit package.
- PR-96 + N174 means the service is not covered, and the patient’s liability is limited to the amount reported under PR.
For some Original Medicare services, an Advance Beneficiary Notice of Noncoverage, or ABN, may be required when the provider expects Medicare to deny payment.
A PR code on the ERA does not replace the need to review the notice, contract, benefit, and applicable billing rules.
OA-96 denial code description
OA means Other Adjustment.
The OA-96 denial code means the payer classified the non-covered amount under Other Adjustment instead of Contractual Obligation or Patient Responsibility.
OA-96 does not clearly tell you to:
- Write off the balance
- Bill the patient
- Bill another payer
It tells you that more review is needed.
Check the RARC, the complete ERA or EOB, and previous claim activity.
The RARC may explain why the service was considered non-covered. For example:
- OA-96 + N216 points to a benefit or enrollment issue.
- OA-96 + N428 points to the reported place of service.
- OA-96 + N569 points to the reported diagnosis.
OA-96 may appear in situations involving:
- Previous claim processing
- Corrected remittances
- Payment reversals
- Coordination of benefits
- Secondary payer processing
- Another payer-specific adjustment
Do not convert OA-96 to provider or patient responsibility based on an assumption.
If the reason is not clear, contact the payer and ask:
If the group code or explanation is wrong, ask the payer to send a corrected remittance.
Why the RARC matters
RARC stands for Remittance Advice Remark Code.
CARC 96 gives only the broad reason:
The RARC gives the detail needed to understand the denial and choose the next action.
A RARC may show that:
- The plan does not include the benefit.
- The payer does not cover the service in the reported setting.
- The diagnosis does not meet the coverage rule.
- The provider type is not eligible.
- The patient exceeded a frequency limit.
- Another coverage rule applies.
Think of CARC 96 as the headline and the RARC as the explanation.
Without the RARC, you may know what happened, but not why it happened.
Common RARC codes used with non-covered services
The following examples show how a RARC can guide the review.
These are common examples. A payer may use other RARCs based on the claim and coverage rule.
How to read denial code 96
You can understand most code 96 adjustments by answering four questions.
Which service did the payer adjust?
Find the affected service line.
Confirm the procedure, date of service, billed amount, payment, and adjustment.
Code 96 may apply to one line rather than the full claim.
How did the payer classify the balance?
Check the group code:
- CO points toward contractual obligation.
- PR points toward patient responsibility.
- OA means the payer used another adjustment category.
The group code gives financial direction, but it does not explain the exact problem.
What does the RARC say?
The RARC is the strongest clue.
For example:
- N428: Review the place of service.
- N569: Review the diagnosis and coverage policy.
- N808: Review the provider type or specialty.
- N216: Review the patient’s benefit package.
The RARC helps you focus on the likely issue instead of reviewing every claim field.
Do the records support the payer’s decision?
Compare the RARC with:
- The original claim
- Medical records
- Patient benefits
- Payer policy
- Previous claim activity
The RARC tells you where to look.
The records tell you whether the payer is right.
Turn the denial into the right action
Once you know the exact reason, choose the correct path.
| WHAT YOU FIND | BEST NEXT ACTION |
|---|---|
| The claim contains incorrect information | Correct and resubmit |
| The claim is correct, but the payer processed it incorrectly | Request reprocessing |
| The service meets the payer’s coverage policy | Submit an appeal |
| Another payer or benefit administrator is responsible | Bill the correct payer |
| The service is a true non-covered benefit | Confirm financial responsibility |
| OA-96 does not clearly assign responsibility | Contact the payer or request a corrected remittance |
Correct and resubmit
Submit a corrected claim when incorrect claim information caused the denial.
For example:
- N428 may lead to a place-of-service correction.
- N569 may lead to a diagnosis review.
- N808 may lead to a provider-information correction.
The medical or administrative record must support every change.
Do not change information only to bypass a payer edit.
Request reprocessing
Request reprocessing when the original claim is correct but the payer:
- Used the wrong benefit
- Missed valid authorization
- Applied the wrong policy
- Used incorrect provider information
- Made another processing error
Keep the payer reference number and follow-up date.
Submit an appeal
Appeal when the claim and records support coverage.
Build the appeal around the RARC.
For example, if the payer reports N569, explain why the documented diagnosis meets the coverage policy.
If the payer reports N428, show why the billed place of service is correct and covered.
A focused appeal is stronger than a general request to reconsider the claim.
Bill the correct payer
A service may be non-covered under one benefit but covered by another payer or administrator.
Before rebilling, confirm:
- The correct payer
- Eligibility
- Payer order
- Filing limit
- Required documents
Do not assume that “non-covered” means the service is not covered anywhere.
Confirm financial responsibility
For CO-96, confirm whether the provider must accept the adjustment.
For PR-96, confirm whether the patient can be billed.
For OA-96, do not assign the balance until the payer clearly explains the adjustment.
Four examples that show why the RARC matters
A provider performed a service in the office, but the claim showed an outpatient hospital place of service.
The payer reported:
CO-96 + N428
N428 points to the place of service.
The records confirm that the service took place in the office.
The payer reported:
CO-96 + N569
N569 shows that the service was not covered for the reported diagnosis.
The medical record contains another documented diagnosis that may support coverage.
If the original diagnosis is correct and meets the payer’s policy, submit an appeal.
The payer reported:
PR-96 + N216
N216 shows that the plan does not offer the benefit or that the patient is not enrolled in that part of the plan.
PR-96 points toward patient responsibility, but the provider must still follow contract, notice, and legal requirements.
The payer had already paid the claim. Later, a new ERA reduced the payment and showed OA-96.
However, the RARC and adjustment details do not clearly explain whether the claim was corrected, reversed, or reprocessed.
Do not bill the patient or post a provider adjustment until responsibility is clear.
The biggest mistake with denial code 96
The biggest mistake is treating code 96 as the root cause.
It is not.
“Non-covered charge” is only a general description.
A useful root cause is specific:
- Incorrect place of service
- Diagnosis did not meet the coverage policy
- Benefit excluded under the plan
- Provider type not covered
- Frequency limit exceeded
- Another payer responsible
- Payer processing error
The RARC helps you move from the general denial to the specific reason.