How do I fix a CO-242 denial?

Verify network status and referral rules during eligibility. Obtain a referral, or inform the patient of out-of-network costs before the visit.

Pricing

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Claim adjustment reason code · Contractual obligation

CO-242
Services not provided by network or primary care providers

Q: What does denial code CO-242 mean?

Services not provided by network or primary care providers. The plan only covers this service from in-network providers or the patient's assigned primary care provider.

What CO-242 means

The plan only covers this service from in-network providers or the patient's assigned primary care provider.

The CO group code means this amount is a contractual obligation: under most contracts you cannot bill it to the patient.

Common causes

Out-of-network provider
No referral from the assigned PCP

How to fix it

Verify network status and referral rules during eligibility
Obtain a referral, or inform the patient of out-of-network costs before the visit

Check the remark code (RARC) that came with the denial and the payer's own policy, since rules vary by payer and plan. This is a plain-English summary written by GetMax; the official code text is published by X12 at x12.org/codes.

Prevent it next time

Most denials are caused before the claim is sent. See 12 ways to reduce claim denials, or let our denial management team work them for you.

Other codes

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CO-242Services not provided by network or primary care providers