Non-covered charge(s). At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.) Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
Current X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.
Back to HubCurrent X12 Claim Adjustment Reason Code. Read the full ERA/EOB, group code, and accompanying RARCs before deciding whether to correct, appeal, rebill, move patient responsibility, or adjust.
Same standard code · different claim context
How PI-96 can be investigated across specialties
CARCs and RARCs are not separate code sets for radiology, gastro, hospital, or professional billing. The code meaning stays standardized; the claim fields, documentation, payer rules, and next checks change by setting.
Professional / Office
Check CMS-1500/837P fields, rendering/billing NPI, diagnosis, modifier, place of service, authorization, and payer policy.
Hospital / Facility
Check UB-04/837I bill type, revenue code, status, inpatient/outpatient rules, authorization, and line-level ERA detail.
Radiology
Check 26/TC component billing, imaging authorization, medical necessity, site of service, same-day edits, and referring provider data.
Gastroenterology
Check procedure relationships, screening vs diagnostic context, modifiers, pathology/anesthesia relationships, authorization, and payer edits.
Behavioral Health
Check provider credential, behavioral-health carve-out, authorization, units/time, telehealth, place of service, and plan-specific rules.
Therapy / Rehab
Check therapy modifiers, timed units, benefit limits, authorization, plan of care/documentation, and NCCI/payer edits.
DME / Supplies
Check HCPCS, modifiers, same/similar equipment, medical necessity, proof of delivery, authorization, and supplier enrollment.
Lab / Pathology
Check CLIA, ordering/referring data, diagnosis support, frequency, panel bundling, specimen/documentation, and payer medical policy.
Status
Review Payer PolicyRecommended Action
Should This Go to Coding?
Do not send every denial to Coding. Coding is appropriate only when the resolution requires coding judgment rather than an administrative or payer follow-up action.
Send to Coding When
Do Not Send to Coding When
Simple rule: If you would have to choose, change, or defend a CPT/HCPCS, ICD-10, modifier, code pair, NCCI edit, or documentation-to-code decision, Coding should review it.
Corrected Claim, Reconsideration, Appeal, or Something Else?
Use the ERA/EOB, RARC, payer portal, policy, claim history, and internal workflow to decide between corrected claim, reconsideration, appeal, coding review, payer follow-up, patient responsibility, or adjustment.
Should I Adjust This Balance?
Treat the balance as recoverable until research shows otherwise. The goal of insurance collections is to resolve the denial and obtain payment when a valid recovery path exists.
Collections rule: A denial code by itself does not automatically mean write-off. Work the claim for payment first when a valid recovery path exists.
What Should My Account Note Say?
4-Part Note Formula
WHAT HAPPENED + WHAT YOU REVIEWED/DID + WHY THAT ACTION WAS CORRECT + WHAT HAPPENS NEXT
General Denial Note
REVIEWED ERA/EOB FOR PI-96. PAYER PROCESSED/DENIED $[AMOUNT] DUE TO [DENIAL REASON + CARC/RARC]. VERIFIED [PORTAL/ELIGIBILITY/CLAIM HISTORY/POLICY/CODING/AUTHORIZATION]. [ACTION TAKEN] BECAUSE [WHY THIS ACTION IS SUPPORTED]. REMAINING BALANCE $[BALANCE]. WILL FOLLOW UP IN [TIMEFRAME] OR NO FURTHER PAYER ACTION REQUIRED.
Adjustment Note
REVIEWED ERA/EOB FOR PI-96. PAYER APPLIED $[AMOUNT] AS [CONTRACTUAL/NONPAYABLE REASON]. VERIFIED FINAL ADJUDICATION, [CONTRACT/POLICY/CODING REVIEW], AND NO ADDITIONAL RECOVERY PATH. ADJUSTED/REQUESTED ADJUSTMENT OF $[AMOUNT] PER ORGANIZATIONAL WORKFLOW. REMAINING BALANCE $[BALANCE]. [FOLLOW-UP OR RESOLVED].
Current decision: DO NOT ADJUST YET. Do not document an action you did not actually perform. Do not say a payment was posted unless you personally posted it.
How to Investigate
Investigation Checklist
Step-by-Step Workflow
Hospital & Professional Workflows
Hospital / Facility AR Workflow
Professional Billing Workflow
Research Steps
When NOT to Appeal, Rebill, or Adjust
Do NOT Appeal
- Do not appeal until you have reviewed all line-level CARCs and every RARC — PI-96 alone is not actionable.
- Do not appeal if a remark confirms the service is genuinely non-covered and no new documentation exists.
- Do not appeal based on the group code alone without identifying the specific reason.
Do NOT Rebill
- Do not rebill a duplicate — use a corrected claim or void-and-rebill per payer rules.
- Do not rebill to another payer without confirming correct coordination of benefits.
Do NOT Adjust
- Do not adjust the balance to the patient without confirming an ABN or advance notice is on file.
- Do not write off until the root cause is confirmed from the EOB and remark codes.
Real World Account Examples
De-identified scenarios contributed from live hospital and professional accounts.
An inpatient claim line returned PI-96 on the remittance with no accompanying RARC printed on the EOB. The account balance was pending with no clear next step.
- Pulled the full EOB and confirmed no RARC was printed on the denied line.
- Checked the Medicare Advantage payer portal and found a pending remark referencing a non-covered service.
- Confirmed an ABN was on file for the non-covered service from registration.
- Reviewed claim history — no prior corrected claim had been submitted for this DOS.
Posted the balance to the patient after confirming the ABN was on file and the portal remark confirmed non-coverage.
PI-96 with no printed remark is not actionable from the EOB alone — the payer portal held the actual reason. Always check the portal before acting on a bare group code.