OA-96: Non-Covered Charges

What Does OA-96 Mean?

OA-96 is rare and appears in coordination of benefits situations where the non-covered charge from the primary payer may be covered by a secondary plan. The primary payer is flagging the charge as non-covered under their plan but leaving the door open for a secondary payer to adjudicate it.

CARC 96 is the payer's way of communicating that one or more charges on your claim fall outside the patient's coverage. This is a coverage-based denial, not a billing error or medical necessity dispute — although coding errors can trigger it when a covered service is submitted with the wrong code and gets reclassified as non-covered. The X12 standard requires at least one Remark Code to accompany CARC 96, so always check the RARC before taking any action.

The scope of non-covered charges is broad. It includes services explicitly excluded by the plan (cosmetic procedures, experimental treatments, alternative therapies), services that exceeded a plan-imposed limit (such as a cap on physical therapy visits per year), services from out-of-network providers without proper authorization, and services rendered after coverage has lapsed or been terminated. A service that is normally covered can also be adjudicated as non-covered if the submitted code set contains an excluded procedure code, a missing modifier, or an unsupported diagnosis.

The group code pairing is especially important with CARC 96. CO-96 assigns the non-covered charge to the provider as a contractual write-off — which means you cannot bill the patient unless you obtained an Advance Beneficiary Notice (ABN) before the service. Without a signed ABN on Medicare claims, the provider absorbs the cost entirely. PR-96 means the patient accepted financial responsibility, typically because they were informed the service was not covered and chose to proceed. Understanding this distinction is critical for correct financial posting and patient billing.

How to Resolve

Read the RARC to identify the specific reason for non-coverage, then either correct and resubmit, write off, or bill the patient based on the group code.

1. Submit to the secondary payer File the claim with the secondary payer, including the primary ERA showing the OA-96 adjustment. The secondary plan may cover what the primary plan excluded.
2. Process the secondary ERA Once the secondary payer adjudicates, follow their group code assignment for any remaining balance — either write off (CO) or bill the patient (PR).

Common RARC Pairings

The RARC code tells you exactly what triggered the OA-96:

How to Prevent OA-96

• Collect complete insurance information for all payers at registration and verify secondary coverage details
• Submit claims to the primary payer first and wait for their ERA before filing with secondary payers

Also Filed As

The same CARC 96 may appear with different Group Codes:

Related Denial Codes