ModerateContractual Obligation (CO)Eligibility & Coverage
CO-167: Diagnosis/procedure not covered by this payer for this plan
This diagnosis code or procedure code is not a covered benefit for the patient's specific insurance plan. While the payer may cover this service on other plans, it is excluded or not included in the patient's particular plan type.
Common Causes
- Procedure is not included in the patient's specific plan tier
- Plan has limited benefits that exclude this service category
- High-deductible or catastrophic plan with limited covered services
- Marketplace plan with narrow covered service list
How to Resolve CO-167
- 1Verify the patient's specific plan benefits for this service
- 2Check if an alternative procedure code is covered under the plan
- 3If covered but denied incorrectly, appeal with plan benefit documentation
- 4Inform the patient of their financial responsibility for non-covered services
How to Prevent CO-167 Denials
- Verify specific service coverage, not just eligibility, before scheduling
- Maintain awareness of plan-level benefit variations within the same payer
- Inform patients of potential non-coverage before rendering services
Related Denial Codes
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