Denial code · group CO
CO-242: The plan pays only in-network clinicians for this member, and you are outside that network
Short answer
Denial code CO-242 means the member's plan pays only for care from its own network, or from the member's assigned primary care provider, and your claim came from outside it. HMO-style plans work this way. Look for an exception first, such as emergency or urgent care, or an approved out-of-network authorization. If none applies, the plan will not pay, and the group code puts the balance on your side.
Look up other codes in the denial code library.
Last reviewed by the Remitwright billing team. Editorial policy
Group CO means contractual obligation: the balance is written off, not billed to the patient. The number is the reason; the two-letter group says who carries the balance.
Remark codes that usually come with CO-242
- N130
- The plan's benefit documents limit this service; the rule applied is set out there
Common causes
An HMO member seen outside the network
Medicare.gov tells members of Medicare Advantage HMO plans that they generally have to get care from the plan's network, with exceptions for emergency care, urgent care when they are away from home and temporary out-of-area dialysis. A routine visit outside the network falls outside all three.
In network for one product, not for this one
The practice holds a contract with the carrier's PPO but not with its HMO or its Medicare Advantage product. The card carries the same logo, and the front desk reads it as in network.
The clinician was never loaded into the network
The group is contracted, but a new clinician has not been added as a participating provider for that product. Claims under that clinician's NPI look out of network until the plan updates its file.
Ancillary work sent to a non-network vendor
An in-network physician sends labs, imaging or equipment to a vendor outside the plan's network. The physician's claim pays and the vendor's claim denies.
Care from someone other than the assigned primary care provider
Some managed care plans pay primary care only to the provider the member chose or was assigned. A visit to another in-network primary care office can still deny on this basis.
How to fix it and resubmit
- 1
Confirm network status for the exact product and date
Check the plan name and product on the eligibility response, then the plan's directory or provider relations for your status in that product on the date of service. A contract with the carrier is not the same as a contract for every plan it sells.
- 2
Claim the exception when one applies
If the visit was an emergency, urgent care while the member was away from home, or out-of-area dialysis, appeal with the record showing it. Make sure the claim's place of service and diagnoses reflect the urgency, and send a corrected claim first if they do not.
- 3
Appeal with the authorization when the plan approved the visit
Plans can approve out-of-network care in advance. If an approval exists, send the claim back with the approval number and ask the plan to reprocess.
- 4
Fix the provider file when the error is the plan's
If you were in network on that date, send provider relations the participation letter or the directory listing and ask for reprocessing. For a clinician who was never loaded, finish the add and confirm the effective date before resubmitting.
How to prevent it
- Network status checked by plan product, not by carrier name, at scheduling
- A list of the carrier products the practice participates in, kept at the front desk and in the scheduling system
- New clinicians added to each plan's network, with confirmation, before they see that plan's members
- Lab, imaging and equipment referrals sent to vendors in the member's network
A visiting HMO member at an urgent care clinic
A Medicare Advantage HMO member visiting her daughter in another state goes to an urgent care clinic with a high fever and a cough. The clinic is not in her plan's network. The claim goes out with only a cough diagnosis and returns CO-242 with N130. The biller reads the note, which records the fever, low oxygen readings and a chest X-ray showing pneumonia, and files an appeal citing the plan's coverage of urgent care away from home. The plan reprocesses the visit at its out-of-network rate.
Official text: the X12 claim adjustment reason code list. The meaning above is our paraphrase for billers; the list is the authority.
FAQ
Questions about CO-242
Does an HMO ever pay an out-of-network provider?
The patient has a PPO. Why did I get CO-242?
Can I bill the patient after a CO-242?
How is CO-242 different from CO-288?
Next step
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