The procedure does not match the provider type or specialty on file.
CO — Contractual obligation — the provider absorbs it and cannot bill the patient.
So the balance cannot move to the patient. Either the appeal recovers it or the practice absorbs it. That makes the appeal decision the whole decision on this line.
Fix and resubmit. This is a correction, not an appeal. Appealing burns the deadline.
In the order we see it.
The taxonomy code on the claim does not match the payer's record for that provider.
The service was billed under a provider not credentialed to perform it.
Compare the taxonomy code on the claim against the rendering provider's enrolment, then correct whichever is wrong.
The documentation, not the argument.
The correct taxonomy code, or the credentialing record for the rendering provider.
The common mistake. Do not resubmit unchanged. Nothing about the claim will look different to the payer's edit.
Where this comes from. This is our own reading of the code, not the payer's and not a copy of the standards text. We classify it from how these denials actually resolve. Where we are unsure, we say so rather than guessing.
Send your denial summary for the last ninety days. Four columns: payer, CARC code, count, billed amount. I will tell you which were winnable and what they were worth.
Send your denial summary No patient data. No BAA. No charge.
AppealHound