245Denial Code (CARC)Active
CO 245 Denial Code - Understand and Fix Provider Withhold
Code 245 indicates a withhold from your reimbursement due to a provider performance program. This means the payer has retained a portion of your payment, typically as part of a value-based care or performance incentive program.
Who Pays: Group Code Liability
The adjustment under code 245 usually falls under the CO group code, meaning it's a contractual adjustment and the patient cannot be billed.
Why Claims Get Code 245
- Participation in a value-based care program with performance metrics tied to reimbursement.
- Failure to meet specific performance targets set by the payer.
- Payer's periodic evaluation of performance metrics affecting payment.
- Incorrect contract terms interpretation leading to unexpected withholdings.
How to Fix & Resubmit
- Review the contract terms related to the performance program to understand the withhold criteria.
- Verify recent performance reports from the payer to identify areas not meeting targets.
- Contact the payer for clarification on specific metrics affecting this payment.
- If a misunderstanding or error is identified, negotiate or appeal with supporting performance data.
- If justified after review, write off the amount as a contractual adjustment.
Corrected Claim or Appeal?
Submit a formal appeal if you find an error in the performance data or misunderstanding of contract terms. A corrected claim does not apply here since it's a contractual withhold.
Preventing Future 245 Denials
- Regularly review and understand contract terms related to performance programs.
- Monitor performance metrics closely to ensure targets are met.
- Communicate with payer representatives to clarify performance expectations.
- Implement internal reviews of performance data before payer evaluations.