Official CARC description: “Non-covered charge(s).” Here’s what it actually means, why it fires, and how to get the claim paid.
The PR twin of CO 96: excluded service, patient owes. The compliance question is whether the patient was warned — and for Medicare, whether a valid ABN exists.
Liability group: PR = Patient Responsibility — the amount can be billed to the patient (deductible, coinsurance, non-covered care) — but only after you verify the denial is correct. Mis-grouped PR denials are a common appeal win.
Also written: PR-96, PR96, “denial code 96”, “96 denial code” or “reason code 96” — same CARC, different ERA formatting.
Reason code 96 also appears under another group on the ERA. The number is the reason; the prefix decides who absorbs the money. This page covers PR 96 (Patient Responsibility). If your ERA shows a different prefix, use the matching page:
Check the exclusion against the actual plan document, not the EOB shorthand
Medicare: valid ABN on file? GA modifier billed? — that decides patient liability
No ABN where required: you may NOT bill the patient (CO 50-style medical-necessity cases)
Real exclusions with notice: statement with a plain-language explanation
Appeal mis-categorised exclusions (the plan covers it) exactly like CO 96. For Medicare, the ABN status — not the payer's grouping — determines whether the patient can be billed.
Fill in the denial facts — use placeholders, never real patient data (the letter keeps [PATIENT NAME]-style fields so you can merge real details privately). A payer-ready draft with an enclosure checklist comes back in ~20 seconds.
Your appeal letter draft will appear here.
The official CARC description for PR 96 is: “Non-covered charge(s).” In practice: The PR twin of CO 96: excluded service, patient owes. The compliance question is whether the patient was warned — and for Medicare, whether a valid ABN exists.
Denial code 96 under the PR group (Patient Responsibility) means: Non-covered charge(s). The number is the reason; the PR prefix decides who is liable — the amount can be billed to the patient (deductible, coinsurance, non-covered care) — but only after you verify the denial is correct. Mis-grouped PR denials are a common appeal win.
Yes. PR 96, PR-96, PR96 and “denial code 96” are the same CARC — clearinghouses, payer portals and PM systems just print it differently. Only the group prefix (CO, PR, OA or PI) changes the meaning, because it changes who has to absorb the amount.
PR stands for Patient Responsibility — the amount can be billed to the patient (deductible, coinsurance, non-covered care) — but only after you verify the denial is correct. Mis-grouped PR denials are a common appeal win.
Appeal mis-categorised exclusions (the plan covers it) exactly like CO 96. For Medicare, the ABN status — not the payer's grouping — determines whether the patient can be billed.
The number 96 is the same reason code in both — what changes is the liability group. CO 96 is Contractual Obligation. PR 96 is Patient Responsibility, so the amount can be billed to the patient (deductible, coinsurance, non-covered care). Check the prefix on the ERA before you write anything off or bill the patient — a mis-grouped 96 is one of the more winnable appeals.