CARC 96: non-covered charge.

What X12 says CARC 96 means

Non-covered charge(s).

CARC 96 · Start 01/01/1995, last modified 07/01/2017.

X12 usage note: at least one remark code must be provided (either an NCPDP Reject Reason Code or a Remittance Advice Remark Code that is not an alert). Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

How it differs from the codes next to it

• CARC 50 says the payer does not see medical necessity. CARC 96 says the charge itself is not covered.
• CARC 167 says this diagnosis is not covered. CARC 96 is not tied to a diagnosis.
• CARC 204 says the service is not covered under the patient's current benefit plan, which is the plan-level version of the same idea.

Remark codes that usually explain a 96

The remark is the real reason. Two examples from the X12 remark list: N425, "Statutorily excluded service(s)", and N130, "Consult plan benefit documents/guidelines for information about restrictions for this service." X12 does not publish fixed CARC-to-RARC pairings, so read whichever remark your remittance shows and look it up in the CARC and RARC lookup.

Medicare exclusions in plain terms

For Original Medicare, 42 CFR 411.15 lists services excluded by regulation. A sample from that list: routine physical checkups (with listed preventive exceptions), eye examinations for prescribing glasses, hearing aids and exams to fit them, custodial care, and cosmetic surgery (with an exception for prompt repair of accidental injury). If the service is on that list, a correct claim is still denied and an appeal on medical necessity will not change it. Private plans write their own exclusions in the plan document.

What to check

• Read the remark code and the group code. CO generally means the provider writes the amount off; PR means it is the patient's responsibility.
• Confirm the patient's coverage and plan benefits for the date of service. A plan that changed or lapsed produces non-covered charges that no coding fix cures.
• Check that the procedure code, units, modifier and diagnosis are what was performed. A typo in a code can land on a non-covered service.
• For Medicare, check whether an Advance Beneficiary Notice was issued before the service. CMS describes the ABN as the form used where Medicare payment is expected to be denied, to transfer potential financial liability to the beneficiary.
• If the service is excluded, stop. If the code was wrong, correct it and resubmit as the payer directs.

Deadlines for Original Medicare

• Filing the claim: for services on or after January 1, 2010, no later than the close of the period ending 1 calendar year after the date of service (42 CFR 424.44(a)(1)), subject to the exceptions in that section.
• Redetermination: 120 calendar days from receipt of the initial determination, with receipt presumed 5 days after the notice date unless there is evidence to the contrary (42 CFR 405.942). Good cause can extend it.
• Reconsideration: 180 calendar days from receipt of the redetermination notice (405.962).
• ALJ hearing: 60 calendar days from receipt of the reconsideration notice, plus the amount-in-controversy requirement (405.1002).
• Reopening to fix an error: a party may ask the contractor to reopen within 1 year of the determination for any reason, or within 4 years for good cause (405.980(c)).

Medicare Advantage plans and commercial payers set their own deadlines. They are printed on the denial notice or in your contract, and they are often shorter. The calculator on this page covers Original Medicare only.

Worked example (hypothetical)

A claim for a hearing aid fitting comes back with CO-96 and remark N425. Original Medicare excludes hearing aids and exams to prescribe or fit them under 42 CFR 411.15(d), so the denial matches the regulation. An appeal would not succeed unless the claim described a different, covered service. In another case a covered service was billed with a code one digit off from the intended one, which landed on an excluded service: a corrected claim is the right response, not an appeal.

Sources

• X12: Claim Adjustment Reason Codes — code text, start and last-modified dates (list dated 10/30/2026, retrieved 2026-11-02)
• X12: Remittance Advice Remark Codes — remark text and dates (retrieved 2026-11-02)
• eCFR: 42 CFR 411.15 (particular services excluded from coverage) — regulation text as of the eCFR issue dated 2026-10-29, retrieved 2026-11-02
• eCFR: 42 CFR 405.942 — regulation text as of the eCFR issue dated 2026-10-29, retrieved 2026-11-02
• eCFR: 42 CFR 405.980 — regulation text as of the eCFR issue dated 2026-10-29, retrieved 2026-11-02
• CMS: Fee-for-Service ABN — what the Advance Beneficiary Notice of Noncoverage is for (page last modified 07/17/2026, retrieved 2026-11-02)

Every code description and rule above was retrieved from these pages on November 2, 2026. X12 code text is copyrighted by X12 and quoted only for the codes explained here; the complete lists are at x12.org. Payers revise code lists, contracts and policies, so confirm anything that affects a claim or a deadline with the payer.