What does CO-96 mean?
CARC code 96 means the service is not covered under the patient's benefit plan. This is a hard denial because if the service is truly excluded, there is no obligation to pay. However, check the RARC code for specifics. Sometimes the payer has incorrectly categorized the service, or the plan does cover it under a different benefit category. For behavioral health, the Mental Health Parity and Addiction Equity Act may apply if the same type of service would be covered for a medical/surgical condition. Overturn rate is approximately 20%.
How to appeal CO-96
Check the RARC code
The RARC (Remittance Advice Remark Code) on your ERA provides specific details about why the claim was denied. This tells you exactly what needs to be fixed.
Gather clinical documentation
Compile clinical notes, treatment plans, and any relevant guidelines that support the medical necessity of the service provided.
Submit a formal appeal letter
Write a detailed appeal letter that references clinical guidelines, payer policies, and includes supporting documentation. Submit via the payer's preferred method (fax, portal, or mail).
Key notes for behavioral health
Service excluded from plan. Check RARC for specifics. Low success unless plan interpretation is wrong.