278Denial Code (CARC)Active
CO/PI 278 Denial Code - Resolve & Prevent Adjustments
Code 278 indicates that the claim was adjusted because the provider did not meet certain performance program proficiency requirements. This adjustment reflects the payer's determination that specific quality or performance metrics were not satisfied.
Who Pays: Group Code Liability
With group code CO, the adjustment is a contractual write-off, and the patient cannot be billed for the amount. When group code PI is used, it's a payer-initiated reduction that also does not allow billing the patient for the adjusted amount.
Why Claims Get Code 278
- The provider did not meet specific proficiency metrics required by a payer's performance program.
- Required documentation proving proficiency was not submitted with the claim.
- The performance data reported was incomplete or incorrect.
- The provider's participation in a performance program was not properly updated in the payer's system.
How to Fix & Resubmit
- Verify if the proficiency requirements and related metrics were met for the service date in question.
- Check if all necessary documentation proving compliance with the performance program was submitted.
- Contact the payer to confirm the specific proficiency metrics not met and what documentation, if any, is missing.
- If metrics were met and documentation was complete, prepare to appeal by gathering supporting evidence of compliance.
- Submit a formal appeal with the evidence, or if corrections are required, submit a corrected claim if allowed.
Corrected Claim or Appeal?
A formal appeal is appropriate if the metrics were met and you have evidence to prove compliance. If documentation or data was incomplete, correct and resubmit the claim if the payer allows.
Preventing Future 278 Denials
- Regularly review and understand the proficiency requirements for each performance program you participate in.
- Ensure timely and complete submission of all required documentation proving proficiency.
- Maintain up-to-date records of performance metrics and compliance with program requirements.
- Communicate regularly with payers to stay informed about any changes to performance program requirements.