ModerateContractual Obligation (CO)Eligibility & Coverage
CO-242: Services not provided by network/primary care providers
The service was provided by a non-network or non-primary care provider. The patient's plan requires services to be rendered by in-network providers or requires a referral from a primary care provider.
Common Causes
- Provider is out-of-network for the patient's plan
- Patient has an HMO plan that requires a PCP referral which was not obtained
- Provider's network status changed and patient records were not updated
- Service performed at an out-of-network facility
How to Resolve CO-242
- 1Verify the provider's network status with the specific plan
- 2If in-network, appeal with proof of network participation
- 3If a referral is needed, obtain one and resubmit
- 4If out-of-network, check if the patient has out-of-network benefits
- 5Request a network exception or gap exception if no in-network provider is available
How to Prevent CO-242 Denials
- Verify network status for the patient's specific plan, not just the payer
- Check referral requirements for HMO and POS plans during scheduling
- Monitor provider credentialing and network participation status
Related Denial Codes
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