What does denial code CO-167 mean?

CO-167 means the plan does not cover the diagnosis reported on the claim. The exclusion is on the condition itself, so services treating it are not payable no matter how well medical necessity is documented.

What is the difference between CO-167 and CO-11?

CO-11 means the diagnosis does not support the procedure - a linkage problem, often fixed by coding a condition already in the note. CO-167 means the diagnosis is excluded from the plan entirely, so the fix is either a different covered diagnosis, a different benefit, or advance notice to the patient.

CO-167: The diagnosis is not covered by this plan

CO-167 denies the condition rather than the service, which makes it a harder denial than most. Medical necessity arguments do not reach it: the plan has excluded the diagnosis, so proving the treatment was appropriate concedes the point. The productive question is whether the encounter also addressed a covered condition that was documented but never coded, and whether the exclusion is genuinely in the plan document or was applied more broadly than it should have been.

What it means: The plan excludes the condition itself from coverage, so services treating it are not payable regardless of medical necessity.
Who pays the balance: Contractual unless valid advance notice was obtained; some exclusions transfer to the patient with proper notice.
Group code CO: Contractual Obligation - the provider absorbs the balance and cannot bill the patient

Why CO-167 happens

The plan carries an explicit exclusion for the diagnosed condition, such as certain cosmetic, dental, or infertility categories.
The primary diagnosis submitted was the excluded one, while a covered condition also treated at the visit was never coded.
A screening or wellness diagnosis was reported under a plan that does not include that benefit.
The condition is covered under a separate benefit the patient carries elsewhere, such as a dental or vision plan.
The diagnosis lacked specificity and mapped to an excluded category when a more precise code would not have.

How to fix a CO-167 denial

1
Read the exclusion in the plan document, not just the remark code
Exclusions are written narrowly and applied broadly. Confirm the plan language actually covers this patient's specific condition before writing the balance off.
2
Look for a covered diagnosis already in the documentation
If the encounter also addressed a covered condition and that condition supports the service billed, adding it to a corrected claim can resolve the denial without any clinical change.
3
Redirect to the benefit that does cover it
Conditions excluded from a medical plan are often covered by a separate dental or vision benefit. That is a different payer and a different claim rather than an appeal.
4
Establish patient responsibility properly for continuing care
Where the exclusion is genuine and treatment continues, a signed advance notice before further services is what makes those balances collectible.

Preventing CO-167 denials

Check plan exclusions for the conditions your specialty treats most before scheduling elective care.
Code every condition the clinician addressed at the visit, not only the presenting one, so a covered diagnosis is on the claim.
Verify at registration whether a separate dental or vision benefit is the correct payer for the presenting complaint.

CO-167 frequently asked questions

What does denial code CO-167 mean?: CO-167 means the plan does not cover the diagnosis reported on the claim. The exclusion is on the condition itself, so services treating it are not payable no matter how well medical necessity is documented.
What is the difference between CO-167 and CO-11?: CO-11 means the diagnosis does not support the procedure - a linkage problem, often fixed by coding a condition already in the note. CO-167 means the diagnosis is excluded from the plan entirely, so the fix is either a different covered diagnosis, a different benefit, or advance notice to the patient.

Related denial codes

CO-11 CO-50 PR-204 CO-96 PR-51

Last reviewed August 5, 2026.

Denial code explanations are original plain-English summaries written for reference and are not the official X12 code descriptions. Payer handling of any code varies by contract - always verify against the remittance advice and your payer agreement before adjusting a claim.