What does denial code CO-96 or PR-96 mean? Non-covered charges explained

CO-96 and PR-96 are the same claim adjustment reason code, non-covered charges, paired with two different group codes that decide who owes the balance. Numetix tracks both so patient balances and write-offs land in the right accounts. This guide explains the difference, how to read the remark code, and what to do next.

QUICK ANSWER: WHAT DO CO-96 AND PR-96 MEAN?

• Code 96 means non-covered charges, and the group code in front of it tells you whether the practice or the patient is responsible.

• CO-96 is a contractual obligation that is generally written off, while PR-96 is patient responsibility that may be billed to the patient.

• Read the remark code that comes with it, check the plan's exclusions and your contract, and appeal only when the service should be covered.

Numetix is the expert-led, AI-powered, human-in-the-loop bookkeeping layer for medical and dental practices, so remittances, adjustments, and receivables are reconciled by software and reviewed by a named person. The sections below explain the code, the causes, and the steps to fix and prevent it.

What do CO-96 and PR-96 mean?

The X12 list describes code 96 as non-covered charges and says at least one remark code must be provided with it (X12 claim adjustment reason codes). The prefix is the group code. CMS describes CO as contractual obligations, generally a write-off that is not billed to the patient, and PR as patient responsibility, an amount that may be billed to the patient or insured (CMS Medicare Claims Processing Manual, chapter 22).

Why are charges non-covered?

How do you handle a code 96 denial?

1. Find the remark code on the line and read what it says about the exclusion.

2. Check the plan's coverage rules and your payer contract.

3. Decide whether the denial is correct, or whether a corrected claim or an appeal is justified.

4. If the patient is responsible under PR-96, bill the patient clearly and promptly.

5. If the group code is CO, adjust the balance off and record the reason.

Our guides to RARC remark codes, medical necessity denials, and the CARC denial code list help you read the full remittance.

How should code 96 appear in your books?

• Keep CO adjustments and patient balances in separate accounts.

• Record PR-96 amounts as patient receivables, and age them like other patient balances.

• Track the dollar value of non-covered denials by payer and by service.

• Use the contractual adjustment and write-off glossary entries to keep the accounts distinct.

How do you reduce non-covered denials?

• Check benefits and exclusions before scheduled services.

• Give patients an estimate and a written notice when a service may not be covered.

• Review denial reports by service and payer each month.

• Update your charge capture and coding checks when a pattern appears.

Frequently asked questions

What is the difference between CO-96 and PR-96?

The reason is the same, non-covered charges, but the group code differs. With CO, the practice generally absorbs the balance as a contractual write-off. With PR, the balance may be billed to the patient or insured, subject to your contract and the plan rules.

Why do I need the remark code for code 96?

The X12 list says at least one remark code must accompany code 96, because the reason code alone does not say why the charge is not covered. The remark code explains the exclusion, which tells you whether to appeal, correct the claim, bill the patient, or adjust the balance.

Can I appeal a code 96 denial?

Yes, if the service should be covered under the plan or the denial rests on an error. Read the remark code, gather the plan rules and clinical documentation, and follow the payer's appeal process and deadline. Appeal only when you have a clear reason, and record the outcome.

Numetix is the expert-led, AI-powered, human-in-the-loop bookkeeping layer that keeps denials, adjustments, and receivables reconciled with a named reviewer. See our accounting services built for healthcare practices.