What Is CARC 96?

What CARC 96 Means

CARC code 96 indicates a non-covered charge — the service billed is not a benefit under the patient's insurance plan. Unlike CARC 50, which challenges whether a covered service was medically appropriate, CARC 96 means the plan itself excludes this category of service. Common examples include cosmetic procedures, experimental treatments not approved by the payer, services requiring a plan rider the member did not purchase, and benefits exhausted for the plan year. The payer assigns CARC 96 and typically pairs it with a PR or CO group code depending on whether the provider may bill the patient.

Why CARC 96 Matters

Non-covered denials create financial risk for both providers and patients. Without a signed advance beneficiary notice or non-covered service waiver on file, the provider may be unable to collect from either the payer or the patient. CARC 96 denials account for approximately 6% of all claim denials, and many are preventable with eligibility verification and benefit checks before service delivery. When the denial is incorrect — the service is actually covered but coded or billed under the wrong benefit category — recovery requires a targeted appeal proving coverage under the member's plan document.

How CARC 96 Affects Your Claim

CARC 96 results in zero insurance payment on the affected line item. The payer's benefit engine matched the billed service against the member's plan summary and found no coverage. If the group code is PR, the patient may owe the full charge. If CO, the provider absorbs the loss under contract terms. CARC 96 sometimes appears alongside CARC 50 on the same claim when the payer applies both a benefit exclusion and a medical necessity denial — your appeal strategy must address the primary code driving the denial. Wrong-plan billing — submitting to a plan that does not cover the service category — is a frequent root cause that a corrected claim to the right payer resolves without appeal.

What to Do About CARC 96

Review the patient's plan summary of benefits and coverage document to confirm whether the service is truly excluded. Check if the service was billed to the correct payer and plan — Medicare versus commercial, or primary versus secondary. If coverage exists, appeal with the plan document section showing the benefit, the member's eligibility confirmation, and any prior authorization that was approved. If the service is genuinely non-covered, verify whether a signed ABN or non-covered waiver is on file before billing the patient. For recurring non-covered services, implement front-end eligibility checks to prevent future CARC 96 denials. Denial Appeal Pro analyzes CARC 96 denials and determines whether an appeal or patient billing is the correct path.

Frequently Asked Questions

What is the difference between CARC 96 and CARC 50?

CARC 96 means the service is excluded from the patient's plan benefits entirely. CARC 50 means the service type is covered but the payer determined it was not medically necessary for this patient.

Can I bill the patient for a CARC 96 denial?

Often yes, if the patient signed an advance beneficiary notice or non-covered service waiver before treatment. Without that documentation, billing the patient may violate payer contract terms or state balance billing laws.

Can CARC 96 denials be appealed?

Yes, when the service is actually covered under the plan and the payer misapplied a benefit exclusion. Appeals succeed when you prove the service falls under a covered benefit category or that the wrong plan was billed.

What services commonly receive CARC 96?

Cosmetic procedures, experimental treatments, services excluded by rider, dental services under medical plans, and wellness visits beyond plan limits are common CARC 96 triggers.