Non-Covered Service Denials
CARC 96CARC 204The service is excluded from the patient's benefit plan — a coverage decision, not a data problem.
What it is
The pattern
A non-covered denial says the service is excluded or limited under the patient's benefit plan — cosmetic exclusions, experimental treatment, coverage limits, or services the plan simply does not include. Unlike a data or coding denial, there is nothing to correct on the claim.
Why it happens
Common causes
- The service was not verified against the patient's actual benefit coverage before rendering.
- A benefit limit (visits, units, dollars) was exceeded.
- The service was performed before the patient's coverage began.
- The CPT code maps to an exclusion the practice did not know about.
Prevention
Stop it before the claim goes out
- Check the benefit summary for exclusions and limits before scheduling high-cost or elective services.
- Get a documented benefit verification (and, where required, an authorization) before rendering.
- Have the patient acknowledge non-covered services in writing in advance.
When it happens
What to do
Confirm the exclusion in the plan document. If the service is truly excluded, bill the patient under the applicable patient-responsibility rules. If the exclusion is ambiguous or the payer applied the wrong plan, appeal with the benefit summary and the service description.
Deeper dive
The full denial guide
The service is not covered under the patient's benefit plan — an exclusion, a coverage limit, or a service the plan simply does not include.
Open the Non-Covered Services guide →