CARC · CO group
CO-167
This diagnosis is not covered
Contractual obligation; provider write-off unless appealed
- What it means
- The plan excludes the diagnosis billed.
- Likely cause
- Adjustment or relational diagnoses on plans that only cover specified conditions.
- How to fix it
- Confirm the most clinically accurate covered diagnosis is sequenced first; do not upcode. If truly excluded, disclose self-pay in advance.
- Revenue impact
- Limited recovery; manage at intake with benefit verification.
- diagnosis
- exclusion
- benefits
Related codes
Early access
Seeing a lot of these?
Repeated CO-167 adjustments usually point to a step before submission. First Pass Paid is building pre-submission checks and a denial worklist to catch these earlier.
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