Official X12 description
“Non-covered charge(s).”
Source: X12 Claim Adjustment Reason Codes. The X12 External Code Lists are the single authoritative source for every CARC descriptor — always verify against the current release before building a claim-scrub rule.
What CARC 96 actually means
CARC 96 means the service is simply not a covered benefit under the patient's plan. This differs from CARC 50 (not medically necessary) — CARC 96 is a contractual exclusion regardless of clinical appropriateness. Common triggers include cosmetic procedures, experimental treatments, and services the plan categorically excludes. Verify the plan document; if the service is excluded, the patient is financially responsible (assuming ABN / advance notice was properly executed).
Common root causes
- Service is a plan-document exclusion (cosmetic, experimental, investigational).
- Service is outside the benefit category the patient elected (e.g., no vision or dental rider).
- Service is carved out to a separate benefit manager (behavioral health, chiropractic, PT/OT cap).
Prevention checklist
- Check benefits, not just eligibility — a 271 with active coverage does not guarantee this service is a covered benefit.
- Use payer-specific benefit-category checks (e.g., pre-authorization portals) before elective procedures.
- Have the patient sign an Advance Beneficiary Notice (ABN) for Medicare or a commercial-equivalent financial-responsibility form when you know the service will be non-covered.
Appeal strategy — step by step
Most CARC 96 denials clear faster with the right remediation than with a formal appeal. Work the steps in order and escalate only when a lower-effort path has been ruled out.
- 1If you believe the service should be covered under the plan's benefit categories, appeal with a citation to the specific section of the plan's certificate of coverage.
- 2If the service was experimental/investigational but later approved by FDA or NCCN guidelines, cite the updated evidence in the appeal.
- 3When the denial is correct, bill the patient with the executed ABN or financial-responsibility form; without that form, write-off may be required.
Sample appeal-letter language for CARC 96
[Provider letterhead]
Re: Appeal of CARC 96 — Claim #{claim_number}
Member: {member_name} · Member ID: {member_id}
Date(s) of Service: {dos}
On {remittance_date} this claim was adjusted with CARC 96:
"Non-covered charge(s)."
We respectfully request reconsideration. The X12 External Code List
definition of CARC 96 does not apply to this claim for the
following reasons:
1. [Cite the clinical / coding / policy fact that rebuts the adjustment]
2. [Cite the supporting documentation attached — op note, EOB,
LCD/NCD citation, NCCI edit indicator, modifier rationale]
3. [Cite the payer's own policy where applicable]
Attached: {list supporting documents}
Please process payment under the member's benefits. If additional
information is required, contact the billing office at
{provider_phone} or {provider_email}.
Sincerely,
{billing_manager_name}, {credentials}
Edit the bracketed fields before sending. This template is a starting point; a payer-specific appeal form may still be required — check the provider portal first.
Payer-specific notes
Payer-specific behavior for CARC 96 publishes here as the QuickIntell anonymized denial ETL ingests sufficient volume. In the meantime, consult the payer directory for the relevant provider manual and appeal form.
How common is CARC 96?
Search demand rank
#3
Out of 306 seeded CARCs, ranked by combined US monthly search volume for "CARC 96", "CO-96 denial", and "denial code 96".
Platform frequency
Pending ETL
Platform frequency ranks publish once the anonymized denial-rate pipeline reaches the publication threshold (strategy §12 Phase 2).
How QuickRCM prevents CARC 96
QuickRCM catches the root causes above before the 837 leaves the clearinghouse:
- Claim-scrub rules fire on every root cause listed above — the scrub references the same X12 CAS segment logic that drives the denial, so what the payer checks, QuickRCM checks first.
- When a denial lands, QuickRCM routes it to the correct worker with the documentation bundle already attached (op note, LCD citation, modifier rationale, EOB, primary 835).
- Appeal templates tuned to each CARC (including this one) pull the supporting facts from the claim and fill the bracketed fields automatically.
CAQH CORE code combinations for CARC 96
Under the CAQH CORE Payment and Remittance Uniform Use rule, health plans may pair CARC 96 only with the remark codes and group codes below for the defined business scenario 3 (Billed service not covered by the health plan). A combination outside this list on an 835 is itself a payer compliance issue worth raising.
| RARC | Remark description | Group code | Scenario |
|---|---|---|---|
| M1 | X-ray not taken within the past 12 months or near enough to the start of treatment. | CO, PI or PR | 3 |
| M2 | Not paid separately when the patient is an inpatient. | CO, PI or PR | 3 |
| M3 | Equipment is the same or similar to equipment already being used. | CO, PI or PR | 3 |
| M8 | We do not accept blood gas tests results when the test was conducted by a medical supplier or taken while the patient is on oxygen. | CO, PI or PR | 3 |
| M13 | Only one initial visit is covered per specialty per medical group. | CO, PI or PR | 3 |
| M18 | Certain services may be approved for home use. Neither a hospital nor a Skilled Nursing Facility (SNF) is considered to be a patient's home. | CO, PI or PR | 3 |
| M25 | The information furnished does not substantiate the need for this level of service. If you believe the service should have been fully covered as billed, or if you did not know and could not reasonably have been expected to know that we would not pay for this level of service, or if you notified the patient in writing in advance that we would not pay for this level of service and he/she agreed in writing to pay, ask us to review your claim within 120 days of the date of this notice. If you do not request an appeal, we will, upon application from the patient, reimburse him/her for the amount you have collected from him/her in excess of any deductible and coinsurance amounts. We will recover the reimbursement from you as an overpayment. | CO, PI or PR | 3 |
| M26 | The information furnished does not substantiate the need for this level of service. If you have collected any amount from the patient for this level of service /any amount that exceeds the limiting charge for the less extensive service, the law requires you to refund that amount to the patient within 30 days of receiving this notice. The requirements for refund are in 1824(I) of the Social Security Act and 42CFR411.408. The section specifies that physicians who knowingly and willfully fail to make appropriate refunds may be subject to civil monetary penalties and/or exclusion from the program. If you have any questions about this notice, please contact this office. | CO, PI or PR | 3 |
| M28 | This does not qualify for payment under Part B when Part A coverage is exhausted or not otherwise available. | CO, PI or PR | 3 |
| M37 | Not covered when the patient is under age 35. | CO, PI or PR | 3 |
| M41 | We do not pay for this as the patient has no legal obligation to pay for this. | CO or PI | 3 |
| M51 | Missing/incomplete/invalid procedure code(s). | CO, PI or PR | 3 |
| M55 | We do not pay for self-administered anti-emetic drugs that are not administered with a covered oral anti-cancer drug. | CO, PI or PR | 3 |
| M61 | We cannot pay for this as the approval period for the FDA clinical trial has expired. | CO, PI or PR | 3 |
| M64 | Missing/incomplete/invalid other diagnosis. | CO, PI or PR | 3 |
| M80 | Not covered when performed during the same session/date as a previously processed service for the patient. | CO, PI or PR | 3 |
| M82 | Service is not covered when patient is under age 50. | CO, PI or PR | 3 |
| M83 | Service is not covered unless the patient is classified as at high risk. | CO, PI or PR | 3 |
| M86 | Service denied because payment already made for same/similar procedure within set time frame. | CO, PI or PR | 3 |
| M87 | Claim/service(s) subjected to CFO-CAP prepayment review. | CO, PI or PR | 3 |
| M89 | Not covered more than once under age 40. | CO, PI or PR | 3 |
| M90 | Not covered more than once in a 12 month period. | CO, PI or PR | 3 |
| M97 | Not paid to practitioner when provided to patient in this place of service. Payment included in the reimbursement issued the facility. | CO, PI or PR | 3 |
| M100 | We do not pay for an oral anti-emetic drug that is not administered for use immediately before, at, or within 48 hours of administration of a covered chemotherapy drug. | CO, PI or PR | 3 |
| M111 | We do not pay for chiropractic manipulative treatment when the patient refuses to have an x-ray taken. | CO, PI or PR | 3 |
| M114 | This service was processed in accordance with rules and guidelines under the DMEPOS Competitive Bidding Program or a Demonstration Project. For more information regarding these projects, contact your local contractor. | CO, PI or PR | 3 |
| M115 | This item is denied when provided to this patient by a non-contract or non-demonstration supplier. | CO, PI or PR | 3 |
| M116 | Processed under a demonstration project or program. Project or program is ending and additional services may not be paid under this project or program. | CO, PI or PR | 3 |
| M117 | Not covered unless submitted via electronic claim. | CO, PI or PR | 3 |
| M121 | We pay for this service only when performed with a covered cryosurgical ablation. | CO, PI or PR | 3 |
| M134 | Performed by a facility/supplier in which the provider has a financial interest. | CO, PI or PR | 3 |
| M138 | Patient identified as a demonstration participant but the patient was not enrolled in the demonstration at the time services were rendered. Coverage is limited to demonstration participants. | CO, PI or PR | 3 |
| M139 | Denied services exceed the coverage limit for the demonstration. | CO, PI or PR | 3 |
| MA20 | Skilled Nursing Facility (SNF) stay not covered when care is primarily related to the use of an urethral catheter for convenience or the control of incontinence. | CO, PI or PR | 3 |
| MA24 | Christian Science Sanitarium/ Skilled Nursing Facility (SNF) bill in the same benefit period. | CO, PI or PR | 3 |
| MA25 | A patient may not elect to change a hospice provider more than once in a benefit period. | CO, PI or PR | 3 |
| MA47 | Our records show you have opted out of Medicare, agreeing with the patient not to bill Medicare for services/tests/supplies furnished. As result, we cannot pay this claim. The patient is responsible for payment. | PR | 3 |
| MA54 | Physician certification or election consent for hospice care not received timely. | CO, PI or PR | 3 |
| MA55 | Not covered as patient received medical health care services, automatically revoking his/her election to receive religious non-medical health care services. | CO, PI or PR | 3 |
| MA56 | Our records show you have opted out of Medicare, agreeing with the patient not to bill Medicare for services/tests/supplies furnished. As result, we cannot pay this claim. The patient is responsible for payment, but under Federal law, you cannot charge the patient more than the limiting charge amount. | CO, PI or PR | 3 |
| MA57 | Patient submitted written request to revoke his/her election for religious non-medical health care services. | CO, PI or PR | 3 |
| MA73 | Informational remittance associated with a Medicare demonstration. No payment issued under fee-for-service Medicare as patient has elected managed care. | CO, PI or PR | 3 |
| MA84 | Patient identified as participating in the National Emphysema Treatment Trial but our records indicate that this patient is either not a participant, or has not yet been approved for this phase of the study. Contact Johns Hopkins University, the study coordinator, to resolve if there was a discrepancy. | CO, PI or PR | 3 |
| MA96 | Claim rejected. Coded as a Medicare Managed Care Demonstration but patient is not enrolled in a Medicare managed care plan. | CO, PI or PR | 3 |
| MA109 | Claim processed in accordance with ambulatory surgical guidelines. | CO, PI or PR | 3 |
| MA123 | Your center was not selected to participate in this study, therefore, we cannot pay for these services. | CO, PI or PR | 3 |
| MA126 | Pancreas transplant not covered unless kidney transplant performed. | CO, PI or PR | 3 |
| MA131 | Physician already paid for services in conjunction with this demonstration claim. You must have the physician withdraw that claim and refund the payment before we can process your claim. | CO, PI or PR | 3 |
| N6 | Under FEHB law (U.S.C. 8904(b)), we cannot pay more for covered care than the amount Medicare would have allowed if the patient were enrolled in Medicare Part A and/or Medicare Part B. | CO, PI or PR | 3 |
| N10 | Adjustment based on the findings of a review organization/professional consult/manual adjudication/medical advisor/dental advisor/peer review. | CO, PI or PR | 3 |
| N12 | Policy provides coverage supplemental to Medicare. As the member does not appear to be enrolled in the applicable part of Medicare, the member is responsible for payment of the portion of the charge that would have been covered by Medicare. | CO, PI or PR | 3 |
| N15 | Services for a newborn must be billed separately. | CO, PI or PR | 3 |
| N20 | Service not payable with other service rendered on the same date. | CO, PI or PR | 3 |
| N30 | Patient ineligible for this service. | CO, PI or PR | 3 |
| N32 | Claim must be submitted by the provider who rendered the service. | CO, PI or PR | 3 |
| N33 | No record of health check prior to initiation of treatment. | CO, PI or PR | 3 |
| N35 | Program integrity/utilization review decision. | CO, PI or PR | 3 |
| N39 | Procedure code is not compatible with tooth number/letter. | CO, PI or PR | 3 |
| N43 | Bed hold or leave days exceeded. | CO, PI or PR | 3 |
| N52 | Patient not enrolled in the billing provider's managed care plan on the date of service. | CO, PI or PR | 3 |
| N54 | Claim information is inconsistent with pre-certified/authorized services. | CO, PI or PR | 3 |
| N55 | Procedures for billing with group/referring/performing providers were not followed. | CO, PI or PR | 3 |
| N56 | Procedure code billed is not correct/valid for the services billed or the date of service billed. | CO, PI or PR | 3 |
| N61 | Rebill services on separate claims. | CO, PI or PR | 3 |
| N67 | Professional provider services not paid separately. Included in facility payment under a demonstration project. Apply to that facility for payment, or resubmit your claim if: the facility notifies you the patient was excluded from this demonstration; or if you furnished these services in another location on the date of the patient's admission or discharge from a demonstration hospital. If services were furnished in a facility not involved in the demonstration on the same date the patient was discharged from or admitted to a demonstration facility, you must report the provider ID number for the non-demonstration facility on the new claim. | CO, PI or PR | 3 |
| N68 | Prior payment being cancelled as we were subsequently notified this patient was covered by a demonstration project in this site of service. Professional services were included in the payment made to the facility. You must contact the facility for your payment. Prior payment made to you by the patient or another insurer for this claim must be refunded to the payer within 30 days. | CO, PI or PR | 3 |
| N79 | Service billed is not compatible with patient location information. | CO, PI or PR | 3 |
| N81 | Procedure billed is not compatible with tooth surface code. | CO, PI or PR | 3 |
| N83 | No appeal rights. Adjudicative decision based on the provisions of a demonstration project. | CO, PI or PR | 3 |
| N86 | A failed trial of pelvic muscle exercise training is required in order for biofeedback training for the treatment of urinary incontinence to be covered. | CO, PI or PR | 3 |
| N87 | Home use of biofeedback therapy is not covered. | CO, PI or PR | 3 |
| N90 | Covered only when performed by the attending physician. | CO, PI or PR | 3 |
| N92 | This facility is not certified for digital mammography. | CO, PI or PR | 3 |
| N95 | This provider type/provider specialty may not bill this service. | CO, PI or PR | 3 |
| N96 | Patient must be refractory to conventional therapy (documented behavioral, pharmacologic and/or surgical corrective therapy) and be an appropriate surgical candidate such that implantation with anesthesia can occur. | CO, PI or PR | 3 |
| N103 | Records indicate this patient was a prisoner or in custody of a Federal, State, or local authority when the service was rendered. This payer does not cover items and services furnished to an individual while he or she is in custody under a penal statute or rule, unless under State or local law, the individual is personally liable for the cost of his or her health care while in custody and the State or local government pursues the collection of such debt in the same way and with the same vigor as the collection of its other debts. The provider can collect from the Federal/State/ Local Authority as appropriate. | CO, PI or PR | 3 |
| N104 | This claim/service is not payable under our claims jurisdiction area. You can identify the correct Medicare contractor to process this claim/service through the CMS website at www.cms.gov. | CO, PI or PR | 3 |
| N110 | This facility is not certified for film mammography. | CO, PI or PR | 3 |
| N113 | Only one initial visit is covered per physician, group practice or provider. | CO, PI or PR | 3 |
| N115 | This decision was based on a Local Coverage Determination (LCD). An LCD provides a guide to assist in determining whether a particular item or service is covered. A copy of this policy is available at www.cms.gov/mcd, or if you do not have web access, you may contact the contractor to request a copy of the LCD. | CO, PI or PR | 3 |
| N117 | This service is paid only once in a patient's lifetime. | CO, PI or PR | 3 |
| N118 | This service is not paid if billed more than once every 28 days. | CO, PI or PR | 3 |
| N120 | Payment is subject to home health prospective payment system partial episode payment adjustment. Patient was transferred/discharged/readmitted during payment episode. | CO, PI or PR | 3 |
| N121 | Medicare Part B does not pay for items or services provided by this type of practitioner for beneficiaries in a Medicare Part A covered Skilled Nursing Facility (SNF) stay. | CO, PI or PR | 3 |
| N124 | Payment has been denied for the/made only for a less extensive service/item because the information furnished does not substantiate the need for the (more extensive) service/item. The patient is liable for the charges for this service/item as you informed the patient in writing before the service/item was furnished that we would not pay for it, and the patient agreed to pay. | CO, PI or PR | 3 |
| N125 | Payment has been (denied for the/made only for a less extensive) service/item because the information furnished does not substantiate the need for the (more extensive) service/item. If you have collected any amount from the patient, you must refund that amount to the patient within 30 days of receiving this notice. The requirements for a refund are in §1834(a)(18) of the Social Security Act (and in §§1834(j)(4) and 1879(h) by cross-reference to §1834(a)(18)). Section 1834(a)(18)(B) specifies that suppliers which knowingly and willfully fail to make appropriate refunds may be subject to civil money penalties and/or exclusion from the Medicare program. If you have any questions about this notice, please contact this office. | CO, PI or PR | 3 |
| N126 | Social Security Records indicate that this individual has been deported. This payer does not cover items and services furnished to individuals who have been deported. | CO, PI or PR | 3 |
| N129 | Not eligible due to the patient's age. | CO, PI or PR | 3 |
| N130 | Consult plan benefit documents/guidelines for information about restrictions for this service. | CO, PI or PR | 3 |
| N141 | The patient was not residing in a long-term care facility during all or part of the service dates billed. | CO, PI or PR | 3 |
| N143 | The patient was not in a hospice program during all or part of the service dates billed. | CO, PI or PR | 3 |
| N157 | Transportation to/from this destination is not covered. | CO, PI or PR | 3 |
| N158 | Transportation in a vehicle other than an ambulance is not covered. | CO, PI or PR | 3 |
| N159 | Payment denied/reduced because mileage is not covered when the patient is not in the ambulance. | CO, PI or PR | 3 |
| N161 | This drug/service/supply is covered only when the associated service is covered. | CO, PI or PR | 3 |
| N163 | Medical record does not support code billed per the code definition. | CO, PI or PR | 3 |
| N167 | Charges exceed the post‐transplant coverage limit. | CO, PI or PR | 3 |
| N171 | Payment for repair or replacement is not covered or has exceeded the purchase price. | CO, PI or PR | 3 |
| N174 | This is not a covered service/procedure/ equipment/bed, however patient liability is limited to amounts shown in the adjustments under group 'PR'. | CO, PI or PR | 3 |
| N176 | Services provided aboard a ship are covered only when the ship is of United States registry and is in United States waters. In addition, a doctor licensed to practice in the United States must provide the service. | CO, PI or PR | 3 |
| N180 | This item or service does not meet the criteria for the category under which it was billed. | CO, PI or PR | 3 |
| N188 | The approved level of care does not match the procedure code submitted. | CO, PI or PR | 3 |
| N194 | Technical component not paid if provider does not own the equipment used. | CO, PI or PR | 3 |
| N198 | Rendering provider must be affiliated with the pay-to provider. | CO, PI or PR | 3 |
| N216 | We do not offer coverage for this type of service or the patient is not enrolled in this portion of our benefit package. | CO, PI or PR | 3 |
| N301 | Missing/incomplete/invalid procedure date(s). | CO, PI or PR | 3 |
| N348 | You chose that this service/supply/drug would be rendered/supplied and billed by a different practitioner/supplier. | CO, PI or PR | 3 |
| N351 | Service date outside of the approved treatment plan service dates. | CO, PI or PR | 3 |
| N356 | Not covered when performed with, or subsequent to, a non‐covered service. | CO, PI or PR | 3 |
| N357 | Time frame requirements between this service/procedure/supply and a related service/procedure/supply have not been met. | CO, PI or PR | 3 |
| N362 | The number of Days or Units of Service exceeds our acceptable maximum. | CO, PI or PR | 3 |
| N370 | Billing exceeds the rental months covered/approved by the payer. | CO, PI or PR | 3 |
| N372 | Only reasonable and necessary maintenance/service charges are covered. | CO, PI or PR | 3 |
| N376 | Subscriber/patient is assigned to active military duty, therefore primary coverage may be TRICARE. | CO, PI or PR | 3 |
| N383 | Not covered when deemed cosmetic. | CO, PI or PR | 3 |
| N384 | Records indicate that the referenced body part/tooth has been removed in a previous procedure. | CO, PI or PR | 3 |
| N386 | This decision was based on a National Coverage Determination (NCD). An NCD provides a coverage determination as to whether a particular item or service is covered. A copy of this policy is available at www.cms.gov/mcd/search.asp. If you do not have web access, you may contact the contractor to request a copy of the NCD. | CO, PI or PR | 3 |
| N405 | This service is only covered when the donor's insurer(s) do not provide coverage for the service. | CO, PI or PR | 3 |
| N406 | This service is only covered when the recipient's insurer(s) do not provide coverage for the service. | CO, PI or PR | 3 |
| N408 | This payer does not cover deductibles assessed by a previous payer. | CO, PI or PR | 3 |
| N409 | This service is related to an accidental injury and is not covered unless provided within a specific time frame from the date of the accident. | CO, PI or PR | 3 |
| N410 | Not covered unless the prescription changes. | CO, PI or PR | 3 |
| N414 | This service is allowed 4 times in a 12-month period. | CO, PI or PR | 3 |
| N416 | This service is allowed 1 time in a 3-year period. | CO, PI or PR | 3 |
| N424 | Patient does not reside in the geographic area required for this type of payment. | CO, PI or PR | 3 |
| N425 | Statutorily excluded service(s). | CO, PI or PR | 3 |
| N426 | No coverage when self‐administered. | CO, PI or PR | 3 |
| N427 | Payment for eyeglasses or contact lenses can be made only after cataract surgery. | CO, PI or PR | 3 |
| N428 | Not covered when performed in this place of service. | CO, PI or PR | 3 |
| N429 | Not covered when considered routine. | CO, PI or PR | 3 |
| N431 | Not covered with this procedure. | CO, PI or PR | 3 |
| N435 | Exceeds number/frequency approved /allowed within time period without support documentation. | CO, PI or PR | 3 |
| N441 | This missed/cancelled appointment is not covered. | CO, PI or PR | 3 |
| N448 | This drug/service/supply is not included in the fee schedule or contracted/legislated fee arrangement. | CO, PI or PR | 3 |
| N450 | Covered only when performed by the primary treating physician or the designee. | CO, PI or PR | 3 |
| N507 | Plan distance requirements have not been met. | CO, PI or PR | 3 |
| N525 | These services are not covered when performed within the global period of another service. | CO, PI or PR | 3 |
| N528 | Patient is entitled to benefits for Institutional Services only. | CO, PI or PR | 3 |
| N529 | Patient is entitled to benefits for Professional Services only. | CO, PI or PR | 3 |
| N538 | A facility is responsible for payment to outside providers who furnish these services/supplies/drugs to its patients/residents. | CO, PI or PR | 3 |
| N564 | Patient did not meet the inclusion criteria for the demonstration project or pilot program. | CO, PI or PR | 3 |
| N567 | Not covered when considered preventative. | CO, PI or PR | 3 |
| N569 | Not covered when performed for the reported diagnosis. | CO, PI or PR | 3 |
| N576 | Services not related to the specific incident/claim/accident/loss being reported. | CO, PI or PR | 3 |
| N578 | Coverages do not apply to this loss. | CO, PI or PR | 3 |
| N584 | Not covered based on the insured's noncompliance with policy or statutory conditions. | CO, PI or PR | 3 |
| N587 | Policy benefits have been exhausted. | CO, PI or PR | 3 |
| N588 | The patient has instructed that medical claims/bills are not to be paid. | CO, PI or PR | 3 |
| N589 | Coverage is excluded to any person injured as a result of operating a motor vehicle while in an intoxicated condition or while the ability to operate such a vehicle is impaired by the use of a drug. | CO, PI or PR | 3 |
| N590 | Missing independent medical exam detailing the cause of injuries sustained and medical necessity of services rendered. | CO, PI or PR | 3 |
| N592 | Adjusted because this is not the initial prescription or exceeds the amount allowed for the initial prescription. | CO, PI or PR | 3 |
| N593 | Not covered based on failure to attend a scheduled Independent Medical Exam (IME). | CO, PI or PR | 3 |
| N607 | Service provided for non-compensable condition(s). | CO, PI or PR | 3 |
| N621 | Charges for Jurisdiction required forms, reports, or chart notes are not payable. | CO, PI or PR | 3 |
| N622 | Not covered based on the date of injury/accident. | CO, PI or PR | 3 |
| N623 | Not covered when deemed unscientific/unproven/outmoded/experimental/excessive/inappropriate. | CO, PI or PR | 3 |
| N624 | The associated Workers' Compensation claim has been withdrawn. | CO, PI or PR | 3 |
| N626 | New or established patient E/M codes are not payable with chiropractic care codes. | CO, PI or PR | 3 |
| N628 | Out-patient follow up visits on the same date of service as a scheduled test or treatment is disallowed. | CO, PI or PR | 3 |
| N630 | Referral not authorized by attending physician). | CO, PI or PR | 3 |
| N633 | Additional anesthesia time units are not allowed. | CO, PI or PR | 3 |
| N636 | Adjusted because this is reimbursable only once per injury. | CO, PI or PR | 3 |
| N637 | Consultations are not allowed once treatment has been rendered by the same provider. | CO, PI or PR | 3 |
| N640 | Exceeds number/frequency approved/allowed within time period. | CO, PI or PR | 3 |
| N643 | The services billed are considered Not Covered or Non-Covered (NC) in the applicable state fee schedule. | CO, PI or PR | 3 |
| N647 | Adjusted based on diagnosis-related group (DRG). | CO, PI or PR | 3 |
| N651 | No Personal Injury Protection/Medical Payments Coverage on the policy at the time of the loss. | CO, PI or PR | 3 |
| N652 | The date of service is before the date of loss. | CO, PI or PR | 3 |
| N653 | The date of injury does not match the reported date of loss. | CO, PI or PR | 3 |
| N658 | The billed service(s) are not considered medical expenses. | CO, PI or PR | 3 |
| N665 | Services by an unlicensed provider are not reimbursable. | CO, PI or PR | 3 |
| N666 | Only one evaluation and management code at this service level is covered during the course of care. | CO, PI or PR | 3 |
| N676 | Service does not qualify for payment under the Outpatient Facility Fee Schedule. | CO, PI or PR | 3 |
| N682 | Missing/Incomplete/Invalid history of prior periodontal therapy/maintenance. | CO, PI or PR | 3 |
| N721 | This service is only covered when performed as part of a clinical trial. | CO, PI or PR | 3 |
| N722 | Patient must use Workers' Compensation Set-Aside (WCSA) funds to pay for the medical service or item. | CO, PI or PR | 3 |
| N726 | A conditional payment is not allowed. | CO, PI or PR | 3 |
| N732 | Services performed at an unlicensed facility are not reimbursable. | CO, PI or PR | 3 |
| N734 | The patient is eligible for these medical services only when unable to work or perform normal activities due to an illness or injury. | CO, PI or PR | 3 |
| N744 | Adjusted because the services may be related to an auto/other accident. | CO, PI or PR | 3 |
| N765 | This payer does not cover coinsurance assessed by a previous payer. | PR | 3 |
| N766 | This payer does not cover co-payment assessed by a previous payer. | PR | 3 |
| N776 | This service is not a covered Telehealth service. | CO, PI or PR | 3 |
| N789 | Clinical Trial is not a covered benefit. | CO, PI or PR | 3 |
| N808 | Not covered for this provider type / provider specialty. | CO, PI or PR | 3 |
| N819 | Patient not enrolled in Electronic Visit Verification System. | CO, PI or PR | 3 |
| N821 | Electronic Visit Verification System visit not found. | CO, PI or PR | 3 |
| N840 | Worker's compensation claim filed with a different state. | CO, PI or PR | 3 |
| N844 | This claim, or a portion of this claim, was processed in accordance with the Nebraska Legislative LB997 July 24, 2020 - Out of Network Emergency Medical Care Act. | CO, PI or PR | 3 |
| N849 | Missing Tooth Clause: Tooth missing prior to the member effective date. | CO, PI or PR | 3 |
| N853 | The number of modalities performed per session exceeds our acceptable maximum. | CO, PI or PR | 3 |
| N881 | Client Obligation, patient responsibility for Home & Community Based Services | CO, PI or PR | 3 |
| N890 | Electronic Visit Verification Data Element Requirements were not met. | CO, PI or PR | 3 |
| N905 | Our records show you have opted out of Medicare, agreeing with the patient not to bill Medicare for services/tests/supplies furnished. As a result, we cannot pay this claim. The patient is not responsible for payment. | CO or PI | 3 |
| N906 | Service is not covered when a patient is under age 45. | CO, PI or PR | 3 |
| N912 | Our records indicate that this beneficiary did not elect hospice. | CO, PI or PR | 3 |
Source: CAQH CORE-required Code Combinations v3.10.0 (2026-02).
The rule behind CARC 96
CARC 96 (non-covered charge) often traces to an NCD exclusion or a service outside the benefit category. The coverage reference lists each NCD's limitations and the contractor LCDs that apply in your state.
Frequently asked questions — CARC 96
What does CARC 96 mean?
CARC 96 is an X12 Claim Adjustment Reason Code. The official definition is: "Non-covered charge(s)." In plain English, the payer is telling you cARC 96 means the service is simply not a covered benefit under the patient's plan. This differs from CARC 50 (not medically necessary) — CARC 96 is a contractual exclusion regardless of clinical appropriateness. Common triggers include cosmetic procedures, experimental treatments, and services the plan categorically excludes. Verify the plan document; if the service is excluded, the patient is financially responsible (assuming ABN / advance notice was properly executed).
How do I resolve a CARC 96 (CO-96) denial?
Start with the most common root cause: Service is a plan-document exclusion (cosmetic, experimental, investigational). First step: If you believe the service should be covered under the plan's benefit categories, appeal with a citation to the specific section of the plan's certificate of coverage. See the full remediation and appeal checklist on this page before filing a formal appeal.
Is CARC 96 patient responsibility?
No — CARC 96 is typically carried under CO (Contractual Obligation) or OA (Other Adjustment), which means it is the provider's responsibility, not the patient's. Do not bill the patient unless the 835 CAS group code is PR.
What does CARC 96 look like on an EOB or 835 remittance?
On the 835 ERA, CARC 96 appears in Loop 2110 CAS segment as "CAS*CO*96*{amount}". On a paper EOB the same code prints in the Adjustment/Denial Reason column with the X12 description: "Non-covered charge(s)." — usually paired with one or more RARC remark codes in the same remittance line for additional context.
Which RARC is paired with CARC 96?
CARC 96 is commonly observed with RARC N115, N130, N362. The RARC narrows the reason — for example, pointing at a missing modifier, an LCD citation, or a specific policy. Fix the underlying CARC first; the RARC usually clears with the corrected claim.
Disclaimer
This page is operational reference for medical-billing professionals. It is not legal, clinical, or contractual advice. X12 code descriptors are maintained by the X12 External Code Lists; always verify against the current X12 release and the payer's own published policy before submitting or appealing a claim.