Denial Reason Codes and Solutions

Denial Reason Codes is standard messages, which are used to describe or provide information to the Medical provider or patient by insurances regarding why the claim was denied. This standard format is followed by all the insurances in order to relieve the burden of the Medical provider.

Denial Reason codes and Solutions

CO 4 Denial Code – The procedure code is inconsistent with the modifier used or a required modifier is missing

CO 11 Denial Code – The diagnosis is inconsistent with the procedure

CO 16 Denial Code – Claim or Service Lacks Information which is needed for adjudication

CO 18 Denial Code – Duplicate Claim or Service

CO 22 Denial Code – This care may be covered by another payer per coordination of benefits

CO 24 Denial Code – Charges are covered under a capitation agreement or managed care plan

CO 27 Denial Code – Expenses incurred after coverage terminated

CO 29 Denial Code – The time limit for filing has expired

CO 50 Denial Code – These are non-covered services because this is not deemed medical necessity by the payer

CO 96 Denial Code – Non-Covered Charges

CO 97 Denial Code – The benefit for this service is included in the payment or allowance for another service or procedure that has already been adjudicated

CO 109 Denial Code – Claim or Service not covered by this payer or contractor, you must send the claim or service to the correct payer or contractor

These are some of the important Denial reason codes which we come across regularly and it’s been explained with solutions.

You can find complete list of denial codes here: Medicare Denial Reason Codes.

Once the claim has been adjudicated from the insurance company, they will send the remittance or EOB to Medical provider/Patient/Medical Billing Company. If suppose the claim is denied, the EOB or remittance contains denial reason codes which explains how claim was processed.

Provider or Medical Billing Company identifies the exact reason of the denied claim from the Denial reason code which is displayed on the Explanation of Benefits (EOB) or remittance issued from the insurance company, and then find the solutions to reimburse the claims towards payment. Sometimes Provider or Medical billing company may probably contact claims department for more information on the denial reason codes or to know the exact reason of the denial to take necessary actions.

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