Find a denial code by reason

Denial reasons

• Out of network

  Also: non-participating provider; provider not in network; no referral from the PCP; paid to the member instead of the provider

  • PR-242 Services were not provided by network providers
  • CO-243 Services were not authorized by the network or primary care provider
  • CO-256 The service is not payable under the managed care contract
  • OA-100 Payment was made to the patient instead of the provider

• No prior authorization

  Also: no auth on file; precertification missing; authorization denied; visits exceeded the authorization; no referral

  • CO-197 Precertification, authorization, or notification is absent
  • CO-39 Authorization was requested and refused
  • CO-198 The authorized limit for this service was exceeded
  • CO-243 Services were not authorized by the network or primary care provider

• Not medically necessary

  Also: does not meet medical necessity criteria; diagnosis does not support the service; experimental or investigational; wrong level of care; should have been outpatient

  • CO-50 Not deemed medically necessary by the payer
  • CO-11 The diagnosis does not support the procedure billed
  • CO-55 The service is considered experimental or investigational
  • CO-58 The payer considers the treatment setting inappropriate

• Service not covered

  Also: not a covered benefit; excluded service; plan exclusion; routine exam not covered; pre-existing condition

  • CO-96 Non-covered charge the provider absorbs
  • PR-96 Non-covered charges
  • PR-204 Service not covered under the patient's current benefit plan
  • PR-49 A routine or screening exam the plan does not cover
  • CO-167 The diagnosis is not covered by this plan
  • PR-51 A pre-existing condition exclusion was applied

• Bundled or not paid separately

  Also: included in another service; NCCI edit; procedure-to-procedure edit; mutually exclusive procedures; multiple procedure reduction; add-on code without its primary

  • CO-97 Service is bundled into another service already adjudicated
  • CO-236 Procedure combination is not compatible with another procedure
  • CO-231 Mutually exclusive procedures were billed for the same encounter
  • CO-234 This procedure is not paid separately
  • CO-59 Payment reduced under multiple or concurrent procedure rules
  • CO-107 The related or qualifying service was not identified on the claim

• Coding mismatch or invalid code

  Also: modifier inconsistent with the procedure; wrong place of service; procedure inconsistent with age; diagnosis does not support the procedure; invalid or deleted code

  • CO-4 The modifier does not match the procedure code billed
  • CO-5 The procedure does not match the place of service billed
  • CO-6 The procedure does not match the patient's age
  • CO-11 The diagnosis does not support the procedure billed
  • CO-146 The diagnosis was invalid for the date of service
  • CO-181 The procedure code was not valid on the date of service

• Patient not eligible or coverage ended

  Also: patient not eligible; coverage terminated; member not found; policy inactive; name and ID do not match; dependent not covered

  • CO-27 Expenses were incurred after coverage terminated
  • PR-26 Expenses were incurred before coverage began
  • PR-200 Expenses were incurred during a lapse in coverage
  • CO-31 The patient cannot be identified as an insured member
  • CO-140 The patient's identification number and name do not match
  • PR-33 The policy has no dependent coverage

• Another payer is responsible

  Also: other insurance is primary; COB; billed the wrong payer; workers' compensation; Medicare Advantage plan on file; secondary claim adjustment

  • CO-22 Care may be covered by another payer per coordination of benefits
  • OA-23 Impact of prior payer's adjudication
  • CO-109 Claim not covered by this payer or contractor
  • CO-19 The claim belongs to a work-related injury carrier
  • CO-24 Charges are covered under a capitation or managed care arrangement

• Missing information, duplicate, or late filing

  Also: missing or invalid information; duplicate claim; timely filing limit expired; medical records requested; attachment required

  • CO-16 Claim or service lacks required information
  • CO-252 An attachment or additional documentation is required
  • CO-226 Requested information was not received from the provider
  • CO-18 Exact duplicate claim or service
  • CO-29 The time limit for filing has expired

• Provider not eligible or not credentialed

  Also: provider not credentialed; rendering provider not enrolled; referring provider not enrolled; provider type not eligible; contract not loaded

  • CO-8 The procedure does not match the provider's type or specialty
  • CO-170 This provider type may not be paid for this service
  • CO-185 The rendering provider is not eligible to perform this service
  • CO-183 The referring provider is not eligible to refer this service
  • CO-147 The contracted rate has expired or is not on file

• Benefit or unit limit reached

  Also: benefit maximum reached; visit limit met; lifetime maximum; units exceed the limit; MUE; frequency limit

  • CO-119 The benefit maximum for this period has been reached
  • PR-35 The lifetime benefit maximum has been reached
  • CO-151 Payer deems the information does not support this many services
  • CO-198 The authorized limit for this service was exceeded
  • PI-222 The contracted maximum units for this period were exceeded

• Deductible, coinsurance, or copay

  Also: patient responsibility; applied to deductible; coinsurance amount; copay amount; PR adjustment

  • PR-1 Amount applied to the patient's deductible
  • PR-2 Amount applied to the patient's coinsurance
  • PR-3 Amount applied to the patient's copayment

• Paid less than billed

  Also: underpayment; contractual adjustment; write-off; multiple procedure reduction; indemnification adjustment

  • CO-45 Charge exceeds the contracted fee schedule amount
  • CO-59 Payment reduced under multiple or concurrent procedure rules
  • OA-23 Impact of prior payer's adjudication
  • OA-121 An indemnification adjustment was applied
  • PI-223 An adjustment required by federal, state, or local law

Frequently asked questions

How do I find a denial code if I only know the reason?

Start from the reason: find the problem in the list on this page, then compare the codes under it with the group and remark codes on your remittance. Each reason page explains what separates its codes, because one problem - an out-of-network provider, a missing authorization - is usually reported under several different codes.

Why do several denial codes cover the same reason?

Because payers report what specifically went wrong, not just the broad category. A missing authorization, a refused one, and an exceeded one are three different codes, and each needs different work. The group code in front of the number then says who owes the balance, which can differ even when the reason is the same.