835 Denial Combination

CO-96+N583

CO

Contractual Obligation · Claim-Level Adjustment

Contractual Non-Coverage

What This Combination Means

This combination indicates the auto insurance carrier denied the claim because the patient was not an occupant of the insured vehicle covered by the policy. The charges are not covered under this auto policy's terms, and the provider must write off the amount per contractual obligation. This typically occurs when the patient was a pedestrian, in another vehicle, or otherwise not an occupant of the policyholder's insured vehicle at the time of injury.

Financial Responsibility

provider writeoff

The provider must write off the full amount as the patient does not meet the auto insurance policy's eligibility criteria for coverage. The patient cannot be billed for this contractual adjustment.

N/A

Appeal Success

Immediate (write-off and alternate coverage pursuit)

Avg. Resolution

Easy

Difficulty

No

Appealable

Step-by-Step Resolution

Steps tailored specifically to this CO-96+N583 combination — not generic advice.

Not Appealable:This is a contractual exclusion based on the patient's ineligibility as a non-occupant of the insured vehicle, which is not disputable when patient status is accurately documented.
  1. 1

    Verify patient's relationship to the insured vehicle

    Confirm with the patient whether they were an occupant of the insured vehicle or had a different role (pedestrian, other vehicle occupant) at the time of the injury

  2. 2

    Write off the contractual adjustment amount

    Post the CO-96 adjustment as a contractual write-off in the billing system since the patient does not meet this auto policy's eligibility requirements

  3. 3

    Identify and bill the correct liable insurance coverage

    Submit claims to the appropriate auto insurance (at-fault driver's liability, patient's own auto medical payments coverage, or other applicable auto policy) or patient's health insurance if no auto coverage applies

Specialty Context

How CO-96+N583 typically presents across different practice types.

Dental

Applies to dental trauma or injury claims resulting from auto accidents where the patient was not occupying the insured vehicle, such as pedestrian struck by vehicle or occupant of another vehicle

Medical

Common in emergency department, orthopedic, and physical therapy settings for auto accident injuries where the patient's status as non-occupant of the insured vehicle excludes coverage under the specific auto policy billed

Behavioral Health

May apply to mental health or substance abuse treatment claims related to auto accident trauma where the patient was not an occupant of the insured vehicle at the time of incident

Individual Code References

View the standalone definition for each code in this combination.

CARC 96RARC N583

Medicare Contractor Guidance for CARC 96

FCSO + Noridian

This denial is received when 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.

How to Prevent CARC 96 Denials

  • ✓

    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.

Items & Services Not Covered Under MedicareStatutory exclusion from Medicare benefits - §1862(a)Noridian Medicare PortalCompetitive Bid HCPCS Lookup ToolCBA Zip Code Lookup ToolNMPModifier Lookup Tool

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Synthesized from official definitions — not from training data

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