Non-Covered — Patient Responsibility

Non-covered charge(s) assigned to patient responsibility. The payer will not pay; the provider may bill the patient per plan rules and financial policy.

What This Means in Behavioral Health

PR-96 shifts financial responsibility to the patient when BH services are excluded from benefits—common when families assumed coverage for residential treatment that the plan limits to outpatient only, or when a carve-out denies SUD residential.

Root Causes

• Plan excludes the billed BH service category entirely
• Benefit rider for SUD or mental health residential not purchased
• Service deemed investigational or non-covered ancillary by plan
• Patient failed to obtain required referral from PCP
• Out-of-network non-covered benefit elected by patient

How to Appeal

Appeal similarly to CO-96 with benefit verification evidence. If appeal fails, update patient financial counseling and payment plans. Ensure compliant patient billing practices for non-covered services.

Prevention Tips

• Financial clearance at admission when VOB shows limited or excluded BH benefits
• Use written financial agreements for known non-covered portions
• Re-verify benefits when payer changes mid-treatment
• Document carve-out administrator contact for benefit exceptions before long RTC stays