Non-covered charge(s) (Updated for 2026)

Common Causes for 96

Denials with code 96 typically happen for the following specific reasons:

• The billed service is explicitly excluded from the patient's specific benefit plan design, such as cosmetic procedures, routine vision care, or infertility treatments.
• The procedure is classified as experimental, investigational, or cosmetic by the payer's clinical policy guidelines.
• The service exceeds plan-defined frequency limitations or age restrictions without a documented medical exception.
• The billed code requires a specific primary diagnosis to establish coverage, and the submitted diagnosis code did not match the payer's Local Coverage Determination (LCD) or National Coverage Determination (NCD) guidelines.

How to Prevent 96 Denials

To avoid receiving this denial in the future, implement these specific checks:

• Perform comprehensive real-time eligibility and benefits verification prior to rendering services to identify plan exclusions, limitations, and policy cap limits.
• Review CMS National Coverage Determinations (NCD) and Local Coverage Determinations (LCD) before billing to ensure the diagnosis supports the necessity of the service.
• Utilize Advance Beneficiary Notices (ABN) for Medicare beneficiaries, or commercial waiver forms for private plans, when a service is expected to be non-covered to enable patient billing.
• Establish a robust prior authorization workflow to secure written coverage confirmation for high-risk, specialized, or novel procedures before they are scheduled.

Appeal Letter Template for 96

If you believe this claim was denied incorrectly, you can use the following template to submit an appeal.

[Your Practice Header]
[Date]

[Payer Name]
[Appeals Department Address]

RE: Appeal for Claim [Claim Number]
Patient: [Patient Name]
ID: [Patient ID]
Date of Service: [Date]
Denial Code: 96 - Non-covered charge(s)

Dear Appeals Department,

I am writing to appeal the denial of the above-referenced claim, which was denied with code 96: "Non-covered charge(s)".

We are appealing the denial of this claim under denial code 96 (Non-covered charges) for the service rendered on [Date of Service]. While we understand the payer's guidelines regarding standard plan exclusions, the attached medical documentation demonstrates that this service was medically necessary and therapeutic, rather than elective, cosmetic, or investigational. In accordance with AMA CPT guidelines and peer-reviewed clinical standards, the patient's documented clinical indicators warranted this specific intervention as the primary standard of care. We request an independent clinical peer review of the enclosed progress notes, laboratory results, and treatment plan to override this denial and approve the claim for reimbursement.

Attached please find:
1. A copy of the original claim.
2. The relevant medical records supporting the service.
3. [Any other supporting documents].

We respectfully request that you reprocess this claim for payment.

Sincerely,

[Your Name]
[Title]
[Practice Name]