CARC · CO group
CO-50
Non-covered service, not deemed a medical necessity
Contractual obligation; provider write-off unless appealed
- What it means
- The payer's medical-necessity criteria were not met by the information on the claim.
- Likely cause
- Session frequency beyond plan limits, diagnosis that does not support the level of service, or missing authorization details.
- How to fix it
- Appeal with the treatment plan and progress notes. If the plan explicitly excludes the service, move it to self-pay under a signed agreement.
- Revenue impact
- Partially recoverable with a documented appeal packet.
- medical necessity
- appeal
- authorization
Related codes
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