OwedAppeal

Denial codes

CO-96 / PR-96

Denied as a non-covered charge

A general "not covered" code. The remark code and the plan document decide what it really means.

Official meaning (X12 code 96): Non-covered charge(s).

Who pays

CO-96. Contractual obligation: the provider's contract with your plan makes this the provider's write-off. An in-network provider generally can't bill you for a CO amount.

PR-96. Patient responsibility: the plan says this part is yours to pay (deductible, copay, coinsurance, or a non-covered service).

What to do

  1. Ask the plan which plan provision excludes it.
  2. Read that provision: denials often stretch a definition.
  3. Check whether your state requires coverage for this service.

If you appeal

Ask for the plan document section the denial relies on. Denials often hinge on a definition that your situation fits better than the reviewer assumed. State mandates may also require coverage.

What the appeal asks for: Identify the specific plan provision relied on and reconsider, as the service falls within covered benefits.
Basis: 29 CFR §2560.503-1(g)(1)(ii)

Deadlines for the first appeal

employer plan
180 days from the notice
ACA Marketplace plan
180 days from the notice
Medicare Advantage plan
65 days from the notice
Original Medicare
120 days from the notice
Medicaid
60 days from the notice

The date printed on your notice controls. Urgent care can be appealed on an expedited (72-hour) basis.

What the data show

11.5%Only 11.5% of denied Medicare Advantage prior authorization requests were appealed in 2024. KFF, 2024 data
80.7%80.7% of appealed Medicare Advantage prior authorization denials were partially or fully overturned in 2024. KFF, 2024 data
<1% (262,982 appeals)Fewer than 1% of denied in-network marketplace claims were appealed in 2024 (at least 262,982 appeals). KFF, 2024 data
66% upheldInsurers upheld 66% of denials on internal appeal in 2024 (165,863 denials). KFF, 2024 data
13%13% of in-network marketplace denials were because the claim was for an excluded service. KFF, 2024 data

Averages across all denials; not a prediction for yours.

Appeal this denial

Upload your denial. We draft the appeal around this code, you approve it, and we fax it to your plan and mail a certified copy. Free check first, then $59.

Prepare my appealDecode my denial, free

General information, not legal or medical advice. Owed is a document-preparation and sending service, not a law firm.