Denial Code CO/PR 167 - Diagnosis Not Covered
Code 167 indicates that the diagnosis used in the claim is not covered by the payer. The remittance advice may include additional information in the 835 Healthcare Policy Identification Segment to clarify the specific policy exclusion.
Who Pays: Group Code Liability
For code 167, the group code could be CO or PR. CO applies if the non-coverage is due to a contractual agreement with the payer, meaning the provider must write off the amount. PR applies if the patient agreed to or was informed of the non-covered service, making it the patient's responsibility.
Why Claims Get Code 167
- The diagnosis code used is not included in the patient's insurance plan benefits.
- Incorrect diagnosis code entry that does not match the medical record.
- The diagnosis is considered experimental or investigational by the payer.
- Policy updates have excluded the diagnosis from coverage.
- The diagnosis does not meet the medical necessity criteria set by the payer.
How to Fix & Resubmit
- Review the 835 remittance advice for the Healthcare Policy Identification Segment in loop 2110 for policy details.
- Verify the diagnosis code against the payer's policy to ensure it is covered.
- Check the patient's insurance plan to confirm if the diagnosis is excluded from their benefits.
- If the diagnosis was entered incorrectly, correct the diagnosis code and resubmit the claim.
- If the diagnosis is non-covered but medically necessary, prepare to appeal with supporting documentation.
Corrected Claim or Appeal?
Submit a corrected claim if the diagnosis code was entered incorrectly. If the diagnosis is correct but denied, an appeal with documentation supporting medical necessity may be necessary. If the denial is due to a legitimate policy exclusion, no correction or appeal is warranted.
Preventing Future 167 Denials
- Ensure diagnosis codes used are covered under the patient's insurance plan before claim submission.
- Stay updated on payer policy changes regarding covered diagnoses.
- Train staff to verify diagnosis code accuracy against medical records prior to claim submission.
- Use eligibility verification tools to confirm coverage for specific diagnoses.