Non-Covered Charge(s)

The payer considers the service non-covered under the patient's plan. Payment is denied in full unless contractual rules allow patient billing for the specific non-covered benefit.

What This Means in Behavioral Health

In behavioral health billing, CO-96 appears when SUD or mental health benefits are carved out, exhausted, or excluded for the billed setting—common on detox room-and-board lines, family therapy, or services outside the patient's behavioral health rider. Facilities often admit patients assuming medical benefit coverage when SUD services route to a separate administrator with different network and benefit limits.

Root Causes

• Patient's plan excludes residential SUD or mental health treatment in the billed setting
• Benefit maximum or day limit exhausted before claim processed
• Service billed to wrong payer or benefit (medical vs behavioral carve-out)
• Experimental or non-covered ancillary service bundled into program billing
• Out-of-network benefit not active or not applicable to BH program

How to Appeal

Appeal with plan documents, VOB screenshots, and benefit summaries showing coverage for the specific LOC and HCPCS/CPT billed. If the payer misapplied a carve-out, include routing instructions from the eligibility response. Some CO-96 denials require a benefit exception or single-case agreement request instead of a standard clinical appeal.

Prevention Tips

• Verify SUD and mental health benefit administrators—not just medical eligibility—before admission
• Document carve-out routing and day limits in the admission financial summary
• Confirm network status for the billing entity and facility location on each plan
• Flag exhausted benefits on census before billing additional program days