AGAR Guide

Non-Covered Services

AR Guide Knowledge

Benefit exclusions, coverage limits, and services not covered under the patient's plan.

Denial Decoder

Run this denial through the decoder

Enter the codes from your ERA/EOB and get this workflow with the exact CARC/RARC on your line.

Open Denial Decoder

Check first

Check these before anything else

  • Benefit plan document for the specific service
  • Remark code explaining the exclusion
  • ABN or waiver on file
  • Benefit limits or maximums against utilization
  • Plan type (dental vs. medical vs. pharmacy)
  • CARC 96 / 204 and the accompanying remark code

Verify payer-specific rules: Heads up

Coverage and exclusions are defined by each plan document. Pull the actual benefit language for the patient's plan and confirm the exclusion against it before billing or appealing — a general appeal without plan evidence rarely succeeds.

AR Guide knowledge

What it means

The plan does not provide coverage for the service, or the benefit was exhausted. A remark code usually explains the specific reason. Before appealing, confirm the exclusion actually applies and check whether an advance beneficiary notice or waiver would have applied.

AR Guide knowledge

Common causes

  • Benefit exclusion applies to the service
  • Service not covered under the patient's plan design
  • Coverage limits or benefit maximums exhausted
  • Service classified as routine, preventive, or personal convenience by the plan
  • Service not covered by this plan type (e.g., dental vs. medical)

AR Guide knowledge

What AR should verify

  • Read the accompanying remark code for the specific reason
  • Review the patient's benefit plan document for the service
  • Check whether a rider or amendment covers the service
  • Confirm whether an ABN or waiver would have applied
  • Check benefit utilization against the plan limits

Recommended workflow

What to do next

  1. If the exclusion applies, bill the patient per plan rules where allowed
  2. If the service should be covered, appeal with the benefit document and policy evidence
  3. If the benefit was exhausted, bill the patient per plan rules once the limit is reached
  4. Consider whether the service belongs under a different benefit plan

Don’t assume

Avoid these shortcuts

  • The service is never covered — check the specific plan document
  • The remark code alone tells you the benefit rule
  • A non-covered denial can be appealed without benefit evidence
  • The patient was notified (ABN) just because billing happened
  • All plans exclude the same services

AR Guide knowledge

Documentation

  • The relevant benefit plan language
  • The remark code and payer correspondence
  • Utilization records showing benefit limits
  • Any ABN or waiver documentation

AR Guide knowledge

Escalation

  • Eligibility: confirm the benefit design and coverage details
  • Client: when the patient's plan was described differently at sale
  • Appeals: when the payer's application of the exclusion appears incorrect

QA checkpoint

Confirm before closing

  • Verify benefit coverage before rendering non-routine services
  • Track benefit maximums on accounts approaching their limits
  • Document ABN delivery where applicable

AR Guide knowledge

Related guides

Eligibility & CoveragePatient ResponsibilityMedical Necessity

Reference

Related codes

CARCs

Source & review

References

AR Guide editorial research · Last reviewed Aug 15, 2026 · Reviewed. General practice guidance — not official payer or standards documentation. Payer-specific requirements must be verified with the payer.

About this guidance: Note

AR Guide knowledge is general reference content written by our team — it is not payer-specific policy and never replaces the payer’s documentation or your contract. Always confirm specifics with the payer.