What are noncovered charges in medical billing?

CO 96- Non Covered Charges Denial – If the service billed on the claim doesn’t fall into 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 the provider’s Contract)

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

For detailed noncovered services, you can check the below PDF.

https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnproducts/downloads/items-and-services-not-covered-under-medicare-booklet-icn906765.pdf

Some Non covered services are considered unnecessary services/supplies

Services that are related to the beneficiary’s home or a nursing home.
Maximum benefit Exceeding ie length of stay limitations.
When Evaluation and management services exceeded.
Using therapy visits/diagnostic procedures very often.
Tests like Screening, Examinations.
Services that are based on acupuncture and transcendental meditation.
Suicidal counsellings.
With some exceptions Preventive Services, Chronic Care Management, Transitional Care Management, and Advance Care Planning.

Important non-covered services categories that one should know

Custodial Care example Long term care.
Services are done Outside the United States.
Services and items are done as a Result of War or during the war.
Comfortable Items and Services for Personal use.
Routine services like Physical Checkups, Eye tests, Eyeglasses purchases, Lenses, Tests for Hearing Aids, and special Immunizations are not listed.
Not this important service – Cosmetic Surgery.
Services by the Beneficiary’s Relatives.
Dental care Services.
Inpatient I/p, Hospital O/p, or Skilled Nursing Facility (SNF) Services.
Special Foot Care Services, massages, treatments, and Supportive Devices for the Feet.
Service related to Investigational Devices.

Questionnaire flow chart for the noncovered service

Bonus tip

In short, Non covered services are classified into two Co 96(Under providers plan) and PR 96(Under patients plan). Consequently, most of the PR-96 denials can be valid ones 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.

CO 96- Non Covered Charges Denial in medical billing