What CO-96 means
The service is not covered under the patient's benefit plan. Sometimes a true benefit exclusion, but frequently a coverage determination that can be challenged with clinical documentation or a different code.
Common causes
- Service is explicitly excluded from the plan
- Routine or investigational service billed as a covered procedure
- Coding doesn't match the actual service rendered
How to appeal CO-96
Review the plan's benefit booklet for the specific exclusion language. If coverage may exist under a different code or a different benefit category, correct and resubmit. For discretionary exclusions (e.g., cosmetic vs. reconstructive), appeal with clinical documentation and relevant policy language.
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