Denial code · CARC 96
CARC 96 (CO-96 and PR-96): non-covered charges on BH claims
What CO-96 and PR-96 mean, why the remark code carries the real reason, behavioral-health examples such as telehealth, place of service, missed appointments and exclusions, and how to respond.
By the ClaimParrot editorial team · Who we are · Reviewed · 5 min read · 6 cited sources
Quick answer
CARC 96 means the plan treats the charge as not covered, and X12 requires a remark code with it that explains why. On behavioral-health claims that remark code often points to a telehealth or place-of-service rule, a missed appointment, a benefit exclusion or a statutory exclusion. The group code decides who pays: CO stays with the provider, PR can go to the patient.
| Item | Detail |
|---|---|
| Code | CARC 96 · Active on the X12 list; checked October 14, 2026 |
| Plain meaning | The plan treats the charge as not covered, and X12 requires a remark code with 96 to say why. |
| Group codes seen | CO (contractual obligation), PR (patient responsibility) |
| Common remark codes | N130, N216, N776, N428, N441 |
| Where it shows up in BH | Outpatient therapy, Psychiatry and medication management, ABA therapy, Residential mental health |
| Usual next step | Let the remark code decide: correct, appeal on plan language, or bill per PR rules |
| Related codes | CARC 50, CARC 167, CARC 119 |
What does CARC 96 mean?
CARC 96 is a coverage statement that says little on its own: X12 requires at least one remark code with it, and that code carries the actual reason. Read 96 as not covered as billed, then let the remark code tell you whether the issue is the plan, the setting or the service.
If the remark code points to clinical judgment, the dispute is really a medical-necessity one (CARC 50); if it points to the diagnosis, compare CARC 167.
What do CO-96 and PR-96 mean for who pays?
With 96 the group code matters more than usual. PR-96 means the plan says the patient owes it, for example a service the member agreed to pay for knowing it was not covered. CO-96 means the provider carries it, often because the contract bars billing members or a required notice was missing.
| Group + reason | What it signals | Who usually carries the balance |
|---|---|---|
| CO-96 | Not covered, and the provider may not bill the member | Provider |
| PR-96 | Not covered, and the plan assigns it to the member | Patient, subject to notice rules and your contract |
Which remark codes come with CARC 96?
A remark code is mandatory with 96 and tells you which kind of non-coverage applies.
| Remark code | What it adds | What to check |
|---|---|---|
| N130 | The plan's benefit documents limit this service; check them for the restriction that applied. | The plan's benefit documents for the specific restriction |
| N216 | The plan does not cover this kind of service, or the member is not enrolled in the part of the benefit package that covers it. | Enrollment in the benefit package that covers behavioral health |
| N776 | The service is not covered when delivered by telehealth. | The payer's telehealth list for the code and date |
| N428 | The service is not covered in the place of service billed. | Covered places of service, such as home or school |
| N441 | A missed or cancelled appointment is not a covered service. | Whether the plan and your contract allow a no-show charge to the patient |
Where does CARC 96 show up in behavioral health?
Behavioral-health CO-96 and PR-96 denials follow benefit design: telehealth codes or places of service a plan does not cover, missed-appointment charges, services outside the benefit package, and exclusions written into the plan. Each points to plan language, not to the clinical record, as the first thing to check.
| Care setting | Typical trigger | Check first |
|---|---|---|
| Outpatient therapy | Missed-appointment fee billed to the plan | Whether the plan or contract lets you charge the patient |
| Psychiatry and medication management | Visit by a telehealth modality the plan does not cover | The payer's telehealth rules for the date |
| ABA therapy | Sessions in a school or community setting the plan does not cover | Covered places of service in the benefit |
| Residential mental health | Level of care excluded in the plan document | The exclusion text, and parity questions if it is MH/SUD-only |
Corrected claim, reconsideration or appeal: which fits CARC 96?
Let the remark code decide. If it points to a billing choice, such as the wrong place of service or a modality the plan covers in another form, correct the claim. If it points to an exclusion, get the plan provision and appeal when the exclusion does not fit the facts or raises a parity question.
- 01Read the remark code and, for ERISA plans, the specific plan provision the notice must cite.
- 02Billing choice: correct and resubmit (place of service, modality, code).
- 03True exclusion: appeal if the facts fall outside it or it applies only to MH/SUD benefits; otherwise follow the PR or CO rules for the balance.
What evidence resolves a CARC 96?
For 96 the plan language is the main evidence: the benefit definition, the exclusion and any exception. Clinical records matter when you argue the service fits a covered benefit or an exception. For Medicare patient liability, the signed advance notice is what decides who pays.
- The plan provision or benefit summary cited
- The remark code and any policy reference
- Records showing the service fits a covered benefit
- A signed advance notice or financial agreement, if billing the patient
- Parity questions for MH/SUD-only exclusions
How do Medicare, Medicaid and commercial plans differ on CARC 96?
Medicare separates statutory exclusions from not-reasonable-and-necessary denials and uses notice rules to assign liability; Medicaid benefit packages are set by state plans and MCO contracts; employer plans define coverage in the plan document, subject to ERISA notice rules and federal parity requirements.
| Program | What differs |
|---|---|
| Medicare (Original) | For statutorily excluded services (remark N425) no ABN is required; a voluntary notice (modifier GX, with GY) informs the patient. Not-reasonable-and-necessary denials follow the mandatory ABN rules instead. |
| Medicaid | The state plan and MCO contract define the benefit package; remark N216 can mean the member is not enrolled in the part covering behavioral health. |
| Commercial and ERISA plans | Exclusions live in the plan document, and the denial must cite the provision. MH/SUD-only exclusions are a federal enforcement priority. |
PR-96 with N776 on audio-only sessions
A fictional practice held four audio-only follow-ups for a member whose plan covered video visits but not audio-only therapy. The plan reported PR-96 with N776 on each.
The member had agreed in writing to pay for audio-only sessions after being told they might not be covered, so the practice sent a statement and updated its scheduling rules for that plan.
Names, dates, payers and amounts are invented for illustration.
What a ClaimParrot packet does here
- When CARC 96 needs an appeal rather than a corrected claim, an appeal packet answers the payer's stated reason.
- A person checks every packet: $29, or $99 for level of care, and the first is free (pricing).
- No remittances, records or PHI are sent: just the reason and a de-identified summary (Trust & security).
Every draft is reviewed and approved by your team. ClaimParrot does not make medical-necessity determinations or give legal advice.
Frequently asked questions
Why does CARC 96 always come with a remark code?
Because 96 alone says only that the charge is not covered. X12 requires at least one remark code with it to give the reason, and that reason decides the next step.
Can we bill the patient for a PR-96?
PR assigns the amount to the patient. Bill only within the plan terms, your contract and any notice rules; in Medicare those rules differ between statutory exclusions and not-reasonable-and-necessary denials.
What should we do when CO-96 cites a plan exclusion for residential care?
Request the exact provision and ask how the plan treats comparable medical care, such as skilled nursing or rehabilitation facilities. An exclusion that applies only to MH/SUD benefits can raise a parity issue worth putting in the appeal.
Is CARC 96 used for missed appointments?
It can be, typically with remark code N441, which says a missed or cancelled appointment is not a covered service. Whether you may charge the patient depends on the plan, your contract and your no-show policy.
Primary sources and references
- Claim Adjustment Reason Codes (CARC) code list · X12 · checked
- Remittance Advice Remark Codes (RARC) code list · X12 · checked
- MLN006266, Medicare Advance Written Notices of Non-coverage (May 2025) · CMS Medicare Learning Network · checked
- 29 CFR 2560.503-1: ERISA claims procedure · eCFR · checked
- 29 CFR 2590.712: mental health parity, including criteria disclosure in paragraph (d) · eCFR · checked
- Summary of EBSA Field Assistance Bulletin 2026-03 on parity enforcement priorities (September 2026) · Proskauer · checked
General information, not legal or medical advice. Payer rules change; confirm deadlines and requirements in the notice and the plan documents. Read our editorial policy.
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