CO-96: Non-covered charge(s)

CO-96 is a coverage denial. The plan is saying the service is not covered under your benefits. Whether that is true depends on your plan document, not the plan's initial assessment.

What your letter emphasized

• The specific plan provision (section number in your SPD or Certificate of Coverage) that covers this type of service
• Any exception that applies to your situation
• The regulatory requirement that a denial identify the plan provision on which it is based (29 CFR 2560.503-1(g)(1)(ii) for ERISA)
• If the plan document is ambiguous, the general rule that ambiguities in plan documents are construed against the drafter

What the insurer's likely response is

Reversal. If your plan document does clearly cover the service and the plan applied the wrong exclusion, they will often reverse.

Detailed citation. The plan writes back citing a specific exclusion provision. Read it carefully. Sometimes the plan is right and the service is genuinely not covered. Sometimes the plan is stretching the exclusion beyond its plain meaning.

Upheld with the same one-line reason. Weak response. Push back on procedural grounds; the plan is required to identify the specific plan provision, not just cite the same CO-96 code.

Request for more information. Rare on CO-96 but possible if the plan wants clarification on what the service was.

How to handle each outcome

Reversal: confirm reprocessing and payment.

Detailed citation: read the exclusion provision. If it clearly excludes your service, you may be out of options for this appeal. If it does not clearly apply, respond in a second-level appeal explaining why.

Upheld with one-liner: file a second-level appeal citing the plan's failure to identify a specific plan provision. Under 29 CFR 2560.503-1(g)(1)(ii), the plan must cite the specific plan provision. A bare CO-96 citation does not meet that standard.

Reading your plan document

Every non-grandfathered plan has to make its plan document available. Ask for:

• The Summary Plan Description (SPD) for ERISA plans
• The Certificate of Coverage for insured plans
• The Evidence of Coverage for Medicare Advantage

Read the table of contents. Look for the section on "Covered Services" and the section on "Exclusions." Compare the plan's citation to the actual text.

Common CO-96 scenarios that are appealable

• Preventive services. ACA-covered preventive services (annual physicals, screenings, immunizations for the recommended population) must be covered without cost sharing on non-grandfathered plans. If the plan denied a preventive service as CO-96, cite 42 USC 300gg-13 and 45 CFR 147.130.
• Mental health parity. If the denial applies a stricter standard than would apply to a comparable medical service, the Mental Health Parity and Addiction Equity Act (MHPAEA) protection applies. Cite 42 USC 300gg-26.
• Emergency services. Plans generally cannot deny coverage for care received in a genuine emergency. Cite ACA 42 USC 300gg-19a for emergency-service protections.
• Services covered by the plan document but administered differently than the plan is applying. Read the plan carefully.

Common CO-96 scenarios that are not appealable

• Cosmetic procedures that are truly cosmetic
• Weight-loss services on plans that explicitly exclude them
• Services delivered by providers your plan does not credential

What to gather

• Your SPD or Certificate of Coverage
• The plan's denial letter
• The provider's chart notes showing what service was rendered
• The plan's own online medical policy on the service, if one exists

When to escalate

Second-level appeal, then external review if the denial involved medical judgment. For pure coverage disputes without a medical-judgment component, external review may not apply, but a state DOI complaint often does.