CO-96 and PR-96 Denial Codes: Non-Covered Charges in Behavioral Health
CO-96 and PR-96 carry the same reason, a non-covered charge, with opposite outcomes. Under CO the practice writes it off. Under PR the patient may owe it. The remark code says why the service wasn't covered, and that decides whether the claim can be fixed.
Short answer
Reason code 96 means "Non-covered charge(s)." With group code CO, the provider is responsible and can't bill the patient, usually because the contract excludes the service or the provider type. With PR, the patient is responsible, usually because their plan excludes the service. Code 96 always comes with a remark code, such as N130 (plan restrictions), N95 (provider type), or N425 (statutorily excluded).
CO-96 vs. PR-96
| CO-96 | PR-96 | |
|---|---|---|
| Who owes it | The provider | The patient |
| Typical reason | The contract or payer policy excludes the service, or the provider type can't bill it | The member's plan excludes the service or benefit |
| Bill the patient? | No | Yes, subject to any advance-notice rules and your financial policy |
| First move | Check the remark code for a fixable cause | Confirm the exclusion, then bill the patient |
Behavioral health causes
- Couples counseling without a covered diagnosis. Relationship distress coded Z63.0 as primary is excluded by many plans. See 90846 and 90847.
- A service the plan doesn't cover. 90846 (family therapy without the patient), audio-only sessions, or out-of-network benefits the member doesn't have.
- A provider type the payer won't pay. Remark N95. Common with associates, peer specialists, or a payer that hasn't added a license type.
- Medicare statutory exclusions. Remark N425. Medicare pays only enrolled provider types. Marriage and family therapists and mental health counselors became enrollable on January 1, 2024; services before enrollment aren't covered.
- A code the payer stopped covering. For example, Ambetter stops covering 48 H codes on January 1, 2027.
What to do
- Read the remark code. N130 means check the plan documents. N95 is a provider-type problem you may be able to fix by billing under an eligible clinician where the payer allows it. N425 is a hard exclusion.
- Check the group code before billing the patient. Only PR amounts can go to the patient.
- Get agreement in advance. When a service may not be covered, a signed financial agreement before the session protects both sides. Medicare uses its own notice rules.
- Appeal only real coverage. If the plan documents show the service is covered, appeal with that language.
Related: CO-96 differs from CO-204 (not covered under the patient's current benefit plan) and from CO-50 (not medically necessary). See all behavioral health denial codes.
Code wording from the X12 Claim Adjustment Reason Code and Remittance Advice Remark Code lists, read October 19, 2026. X12 updates the lists several times a year, and each payer decides which codes it sends for which problem, so read the remark codes on your own remittance.
Frequently asked questions
What does denial code CO-96 mean?
The charge isn't covered, and the provider is responsible under its contract, so the patient can't be billed. A remark code explains why.
What does PR-96 mean?
The charge isn't covered under the patient's plan, and the patient is responsible for it. Practices can bill the patient, subject to their agreement and payer notice rules.
Can I bill the patient for CO-96?
No. Only amounts under the PR group code can be billed to the patient.
Is couples therapy covered by insurance?
Often not when relationship distress (Z63.0) is the primary diagnosis. It's coverable when one partner is the identified patient with a covered diagnosis and conjoint sessions treat it.
Non-covered services caught before the session.
Stable checks each patient's benefits and the payer's policy for the service, so non-covered charges are discussed up front, not written off later.
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