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N216 Remark Code: Service Type Not in Member's Plan

N216 means either the payer does not offer coverage for this type of service at all, or the patient is not enrolled in the portion of the benefit package that covers it, such as a separate dental, vision, pharmacy, or behavioral health benefit.

Quick facts

Code
N216 (RARC N216)
Status
Active In use since April 1, 2004; last modified March 14, 2014.
Code set
Remittance Advice Remark Codes (RARC)
Group codes
  • PR (Patient Responsibility): If the patient simply lacks the benefit, the amount may be the patient's responsibility, subject to any advance notice requirements.
  • CO (Contractual Obligation): If the provider should have billed a different payer or carve-out vendor, the amount is written off or rebilled rather than charged to the patient.
Official description
We do not offer coverage for this type of service or the patient is not enrolled in this portion of our benefit package.
X12 Remittance Advice Remark Codes, retrieved September 25, 2026
Last verified
against the official X12 list.

What N216 means

Health coverage is often assembled from pieces: medical, pharmacy, dental, vision, behavioral health, sometimes each managed by a different company. N216 says one of two things: this payer does not offer the type of service billed, or it offers it but the patient did not enroll in that piece. It commonly accompanies CARC 96 or CARC 204.

The practical question is whether the service is covered somewhere else. N216 does not mean the patient has no coverage for it anywhere.

Common causes

  • A behavioral health service was billed to the medical plan when a carve-out vendor manages mental health benefits.
  • Routine vision or dental services were billed to a medical plan that does not include them.
  • The employer offers an optional rider, and the patient declined it.
  • The eligibility check confirmed active coverage but not the benefit for this service type.

How to fix it

  1. Run an eligibility inquiry for the specific service type, or call the payer and ask whether the benefit exists and who administers it.
  2. If a carve-out vendor or separate plan covers it, submit the claim to that entity.
  3. If no benefit exists, review whether the patient signed a financial responsibility notice and bill according to your policy and contract.
  4. If you believe the patient is enrolled in the benefit, ask the payer to review enrollment and reprocess.

For eligibility-driven denials in general, see eligibility and COB denials.

How to prevent it

Include benefit-level checks, not just active-coverage checks, in your pre-visit verification, and record which vendor administers carved-out benefits for each plan you see often. Tell patients before the visit when a service isn’t covered under their plan.

Codes that may appear with N216

  • CO-96 (Non-covered charge(s).): Non-covered charges; N216 explains the service type isn't part of the member's coverage.
  • PR-204 (This service/equipment/drug is not covered under the patient's current benefit plan): The service is not covered under the patient's current benefit plan.
  • CO-109 (Claim/service not covered by this payer/contractor.): Not covered by this payer; the service may belong with another payer or carve-out vendor.
  • N130 (Consult plan benefit documents/guidelines for information about restrictions for this service.): Consult plan benefit documents for restrictions on this service.
  • N30 (Patient ineligible for this service.): The patient is ineligible for this service.
  • N193 (Alert: Specific federal/state/local program may cover this service through another payer.): Alert that another program may cover the service through a different payer.

N216 FAQ

What is a carve-out benefit?

A benefit, such as behavioral health, vision, or pharmacy, that the health plan contracts out to a separate company. Claims for those services often go to the carve-out vendor, not the main plan.

Can I bill the patient after N216?

Only after confirming the service isn't covered by another benefit or vendor, and following any rules about advance notice. Check your contract with the payer too.

How do I find the right payer?

Look at the back of the member ID card, run an eligibility check for the specific service type, or call the plan and ask who administers that benefit.