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CO-96
Recoverability: Low
Non-covered charge(s)
The plan does not cover this service, and the accompanying remark codes name the specific exclusion. Recovery depends on whether the exclusion actually applies to the facts, not on persuading the payer to change the plan.
Why this happens on dental claims
- Plan exclusions for adult fluoride, occlusal guards, implants, or services the plan deems cosmetic
- Missing tooth clause exclusions applied to bridges, implants, and dentures replacing teeth extracted before coverage began
- Miscoding that maps a covered service onto an excluded code
How to appeal CO-96
- Read the remark code and ask the payer to cite the specific plan exclusion being applied
- Verify the exclusion against the facts: missing tooth clauses often have exceptions, such as extractions that occurred under prior continuous coverage
- Correct any miscoding and resubmit if the wrong code triggered the exclusion
- If an alternate benefit applies, such as a partial denture allowance toward an implant case, request adjudication under the alternate benefit provision
- Bill the patient with documentation when the exclusion genuinely applies
How to prevent it
- Verify exclusions and missing tooth clauses during treatment planning for prosthetics and implants
- Present signed financial arrangements for commonly excluded services before treatment
Related codes
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