272Denial Code (CARC)Active
CO 272 Denial Code - Coverage Guidelines Unmet
Code 272 means the claim was denied because the service did not meet the payer's coverage or program guidelines. This typically indicates that the service isn't covered under the patient's current policy terms or does not align with the payer's medical necessity criteria.
Who Pays: Group Code Liability
For code 272, the group code can be CO if the provider's contract specifies no billing to the patient for non-covered services. Alternatively, PR may apply if the policy allows the patient to be billed for these non-covered services.
Why Claims Get Code 272
- The service provided is not covered under the patient's specific insurance plan.
- The claim lacks necessary documentation to support medical necessity.
- The procedure requires prior authorization or referral, which was not obtained.
- The service is considered experimental or investigational by the payer.
- The service exceeds coverage limits such as frequency or dollar caps.
How to Fix & Resubmit
- Verify the specific coverage guidelines of the patient's insurance plan for the denied service.
- Check if any required documentation, such as medical records or prior authorization, was omitted from the claim.
- If prior authorization is needed, contact the payer to discuss retroactive authorization options.
- Submit a corrected claim with the necessary documentation if it is available and appropriate.
- If the denial is incorrect based on policy terms, prepare and submit an appeal with supporting evidence.
Corrected Claim or Appeal?
Submit a corrected claim if missing documentation or prior authorization is the issue. Appeal if the service should be covered under the patient's policy but was denied incorrectly.
Preventing Future 272 Denials
- Ensure that all services are verified against the patient's coverage guidelines before submission.
- Obtain prior authorization for services that routinely require it under the plan.
- Attach all necessary medical documentation to support medical necessity with the initial claim.
- Regularly update your billing team's knowledge of payer-specific coverage policies.