CARC 96
Non-covered charge
The payer does not cover this service — broad, and usually needing a remark code to interpret.
Why you actually get this
- The service is excluded from the patient's benefit plan.
- The service is covered but was billed in a way that put it outside the benefit.
- A statutory exclusion applies.
How to check whether it’s correct
- 01Read the accompanying remark code — like CARC 16, this one rarely explains itself.
- 02Confirm whether the exclusion is plan-specific or statutory.
- 03Establish whether the patient was notified in advance that this might not be covered.
Sometimes worth appealing
Depends entirely on why. A plan exclusion is not appealable; a coding or benefit-category error is. The remark code is what tells you which, so read it before deciding.
Often arrives with
Seeing a lot of these?
A single denial is a claim to work. A pattern of the same denial is a process to fix, and the two need completely different responses. A free panel reads ninety days of your claims data and shows which codes actually recur for you.
Claim Adjustment Reason Codes are maintained by X12 as External Code List 139. The official description of this code is theirs and is not reproduced here. Check the authoritative list for current wording and status.