Denial Code 96: Non-Covered Charges – Reasons, Call Flow & Best Resolution Steps
Denial Code 96 (Non-Covered Charges) is one of the most common denials in medical billing. It usually means the insurance is saying the service billed is not covered, either due to the patient’s plan benefits or the provider contract.
In this guide, we will explain:
• What Denial Code 96 means
• Main categories and reasons
• Simple call flow while speaking with insurance
• Best actions and next steps to resolve it
What is Denial Code 96?
Denial Code 96 = Non-Covered Charges
This denial occurs when the payer denies the claim because the charges are not payable under:
- Patient’s insurance plan, OR
- Provider contract
So first, always confirm:
✅ Is it patient plan non-coverage or provider contract non-coverage?
Categories of Denial Code 96
1) Non-Covered Charges as per Patient Plan
This denial happens when the service is not covered under the patient’s benefit plan.
Common reasons:
• Provider is out of network
• Diagnosis (DX / ICD-10) is non-covered
• CPT / Procedure code is non-covered
• Other plan restrictions or policy exclusions
2) Non-Covered Charges as per Provider Contract
This denial happens when the service is not covered under the contract agreement between the provider and payer.
Common reason:
• CPT code is not covered under the contract
Simple Insurance Call Flow for Denial Code 96 (Step-by-Step)
When you call insurance, use this call flow.
Step 1: Confirm the Denial Date
Ask:
“May I get the denial date?”
Step 2: Confirm Non-Covered Type
Ask:
“Is it non-covered as per the patient plan or provider contract?”
If Denial is Under Patient Plan (Category 1)
Ask:
“What is the reason for non-coverage?”
Then proceed based on the reason.
A) Provider is Out of Network
If payer says provider is out of network:
✅ Follow your Out-of-Network Scenario / Tool (as per process update)
Action
• Verify network status
• If OON, patient responsibility may apply
• Bill secondary payer if available
B) Diagnosis (DX / ICD-10) is Non-Covered
If payer says ICD-10 is non-covered:
✅ Action
- Send the denial to coding team
- Ask for alternative diagnosis code
If coding gives alternate ICD:
• Update claim
• Submit corrected claim
If no alternate ICD:
• Bill secondary payer (if available), OR
• Release to patient
C) CPT is Non-Covered Under Patient Policy
If CPT is not covered under policy:
Action
• Check if secondary payer exists
• Verify eligibility before billing secondary
• If no other payer → release to patient
D) Other Patient Plan Reasons
If payer gives other reason:
Action
• Bill secondary or consecutive payer if available
• If not available → patient responsibility
If Denial is Under Provider Contract (Category 2)
Ask:
“What is the reason for non-covered charges under the provider contract?”
Most often it will be:
✅ CPT non-covered under provider contract
Step 1: Check Payment History
Check if payer has paid for same CPT previously (same provider + same payer).
Ask insurance:
“Can you check if there was any prior payment for the same CPT?”
Scenario 1: Payment Exists for Same CPT (YES)
If payment exists previously:
Ask:
“Could you please send this claim back for reprocessing since payment was received for the same procedure earlier?”
If rep agrees:
Ask:
• “What is the TAT for reprocessing?”
• “May I have the claim number and call reference number?”
✅ Set follow-up based on TAT
If rep does not agree:
Ask:
• “What is the fax number or appeal mailing address?”
• “What is the appeal filing limit?”
• “May I have claim number and call reference number?”
✅ Submit appeal
Scenario 2: No Payment History Found (NO)
If no payment exists previously:
Action
• Follow client instructions:
Either:
• Submit appeal, OR
• Write-off
Ask:
• “What is the fax number or appeal mailing address?”
• “What is the appeal filing limit?”
• “May I have claim number and call reference number?”
Important Notes & Best Practices
Here are key points to remember for Denial Code 96:
✅ If denial is due to Out of Network, follow your OON scenario tool
✅ If denial is due to DX non-covered, route to coding team
✅ Always verify secondary payer eligibility before billing
✅ If no other payer active on DOS, release patient responsibility
✅ For provider contract denials:
• If payment was made before → request reprocess
• If rep refuses → appeal
• If no payment history → appeal or write off (per client rules)
Conclusion
Denial Code 96 (Non-Covered Charges) can be resolved quickly when you identify whether it is:
• Patient Plan Non-Covered, or
• Provider Contract Non-Covered
The key is to follow a structured call flow, document claim number and call reference numbers, and take the correct action:
• Corrected claim
• Billing secondary payer
• Appeal submission
• Patient responsibility
