PI 96 – Non-Covered Charge(s)

The PI-96 denial code indicates that the payer denied or adjusted the claim because the billed service, procedure, or item is considered a non-covered benefit under the patient's health plan. The PI (Payer Initiated) group code identifies an adjustment initiated by the insurance payer based on plan coverage rules or reimbursement policies.

Providers should verify the patient's benefits and review payer coverage policies before determining whether a corrected claim or appeal is appropriate.

Quick Facts

Denial Code
PI-96

Group Code
PI (Payer Initiated)

Category
Non-Covered Services

Meaning
The billed service is not covered under the patient's health plan

Common Payers
Medicare, Medicaid, and Commercial Insurance

Next Step
Review the patient's benefits, payer policies, and supporting documentation before resubmitting or appealing the claim

What Does PI-96 Mean?

The PI-96 denial code indicates that the payer determined the submitted service is not a covered benefit under the patient's insurance plan.

Coverage exclusions vary by payer and health plan. Providers should review the patient's benefit information and any accompanying RARC codes to better understand the adjustment.

Common Causes

Providers may receive the PI-96 denial code when:

• The service is excluded from the patient's benefit plan.

• The procedure is considered non-covered.

• Benefit limitations apply.

• Coverage requirements were not met.

• An incorrect insurance plan was billed.

How To Resolve PI-96

If you receive the PI-96 denial code:

• Review the patient's benefit plan.

• Verify eligibility and coverage.

• Review payer coverage policies.

• Confirm the service was billed correctly.

• Submit an appeal if documentation supports coverage.

Common Billing Mistakes

Common issues associated with PI-96 include:

• Performing services without verifying benefits.

• Billing non-covered procedures.

• Using outdated insurance information.

• Misinterpreting payer coverage policies.

• Not obtaining required prior authorization.

Frequently Asked Questions

Does PI-96 always mean the patient owes the balance?

Not necessarily. Patient responsibility depends on the provider contract, payer policies, and applicable billing regulations.

Can providers appeal a PI-96 denial?

Yes. If documentation supports coverage or the denial was issued in error, an appeal may be appropriate.

How can providers reduce PI-96 denials?

Verify benefits, review coverage policies, and obtain any required prior authorizations before services are performed.

Should providers review the associated RARC code?

Yes. RARC codes often provide additional information that helps explain why the payer considered the service non-covered.

Related PI Codes

You may also encounter:

• PI-204 Denial Code

• PI-16 Denial Code

• PI-22 Denial Code

• PI-197 Denial Code

Quick Summary

The PI-96 denial code indicates that the payer considers the billed service a non-covered benefit under the patient's health plan. Reviewing coverage policies, verifying benefits, and examining the associated RARC code can help determine the appropriate next steps.