CO 96- Non Covered Charges Denial in medical billing

What are noncovered charges in medical billing?

CO 96- Non Covered Charges Denial – If the service billed on the claim doesn’t fall to the patient plan or Provider contract. Then it is considered to be a non-covered service. In some cases, billed service can deny as noncovered service when it is not billed under CMS guidelines or medical fee schedules.

Example for PR-96 noncovered charges per patients plan

Let us see an example for noncovered services. Mr. Patrick has a severe headache so he urgently went to a hospital nearby. Got an appointment to meet Ms.Tracy who is a Behavioral health physician. As per Tracy’s instruction in general Underwent medication for the headache and cured it. Now Patrick got his bill and shocked to see his claim denied as Non covered Charges.

Any answers? Any guesses? Comment below!

The Answer is As per the Patrick insurance plan Medical service claims are allowed but not behavioral claims. This is to say, Due to urgency, Patrick went to a behavioral health physician, not to medical services. The Diagnosis code billed on the claim is for behavioral not for medical claims. Consequently, the claim denied as a noncovered service under the patient’s contract.

Some Reason codes for Noncovered charges

N425  Statutorily excluded non-covered services.
N180/N56 This reason code shows Incorrect Dx code billed on the claim for the Procedure code Billed.
N115  This code shows the denial based on the LCD (Local Coverage Determination)submitted.
M114 The plan not contracted because the Beneficiary plan falls under the competitive bidding area(out of network).


CO 96- Non Covered Charges Denial (Not covered under Providers Contract)

When the billed Cpt/diagnosis code not listed under the provider’s contract then it called Non covered under the provider’s plan. if the claim is denied as Coding guidelines(LCD/NCD) not met. you can get the help of coding Because in some cases you can Correct /add the valid code for the claim to be processed.

Some of the reasons for CO-96 (Not covered under providers Contract)

  • Coding guidelines(LCD/NCD) not met.
  • When performed service is not related to Providers’ specialty.
  • Non-covered services listed by the carriers billed.
  • when the provider is not participating with the carrier.

Questionnaire flow chart  for the noncovered service

CO 96 claim denied as non covered services

Bonus tip

In short, Non covered services classified into two one is Co 96(Under providers plan) and PR 96(Under patients plan). Consequently, most of the PR-96  denial can be a valid one and it is the patient responsibility. As a result, you should just verify the secondary insurance of the patient. if, the patient has a secondary bill the secondary. Meanwhile, for Co 96 check for possible coding corrections (Dx/CPT/POS ). importantly,90% of claims are reimbursable after coding review if not follow the workflow.

Read more – What are Mutually Exclusive Procedures in Medical Billing?

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