The provider was not certified or eligible for this service on that date.
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.
Usually recoverable. Appeal it. The money is usually there.
In the order we see it.
The provider was not enrolled or credentialed with this payer on the date of service.
Enrolment lapsed or a revalidation was missed.
Usually an enrolment or credentialing gap. Fix the enrolment and appeal for the back period.
The documentation, not the argument.
The effective date of enrolment, once corrected.
An appeal covering the retroactive period the payer allows.
The common mistake. Do not treat this as a coding problem. It is an enrolment problem, and fixing the enrolment often recovers every claim in the gap.
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