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Last Modified: 11/11/2022 Location: FL, PR, USVI Business: Part B

Denial reason code PR 96 FAQ

Q: We received a denial with claim adjustment reason code (CARC) PR 96. What steps can we take to avoid this denial?
PR 96 – Non-covered charge(s).
M16 – Alert: Please see our website, mailings, or bulletins for more details concerning this policy/procedure/decision.
N425 – Statutorily excluded service(s).
A: The denial was received because the service billed is statutorily excluded from coverage under the Medicare program. Payment cannot be made for the service under Part A or Part B.
Review the service billed to ensure the correct code was submitted.
If the claim is being submitted for statutorily excluded services, you can append a GY modifier to the line item. The GY modifier indicates that the item or service is statutorily excluded or does not meet the definition of a Medicare benefit.
If an error was made, make the necessary correction, and resubmit your claim.
If a payable diagnosis is indicated in the patient's medical record, correct the diagnosis, and resubmit the claim.
If a covered service was coded incorrectly, correct the code, and resubmit the claim.
Prevent a duplicate denial: Submit corrected line item(s) only.
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