CO 242: Out-of-Network Provider
The provider was out of network, or not the patient's assigned primary care provider.
Check whether the patient had a referral or an authorisation on file, or whether the care was urgent. Network denials are often won on one of those three.
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What CO 242 means
CO: Contractual obligation. The provider absorbs it and cannot bill the patient.
So the balance cannot move to the patient. Either the appeal recovers it or the practice absorbs it. That makes the appeal decision the whole decision on this line.
The same code, a different prefix. 242 also arrives as PR 242. The reason for the denial is the same. The prefix decides who pays for it, so the next step is not the same. If your remit says PR 242, read that page instead.
Is It Worth Appealing?
Usually recoverable. Appeal it. The money is usually there.
Why It Fires
In the order we see it.
No referral from the assigned primary care provider.
The provider is out of network for that specific plan product, though in network for others from the same payer.
Emergency or urgent care, where network rules are usually waived.
How to Appeal CO 242, Step by Step
Check whether the patient had a referral or an authorisation on file, or whether the care was urgent. Network denials are often won on one of those three.
- 1Step 1: Read the remark code. Find the remark code printed next to CO 242 on the 835 or EOB. It says what the payer wants back.
- 2Step 2: Find the cause. Match the denial to one of the 3 causes in Why It Fires above, and fix that one.
- 3Step 3: Take the first action. Check whether the patient had a referral or an authorisation on file, or whether the care was urgent. Network denials are often won on one of those three.
- 4Step 4: Attach the documentation. The referral or authorisation, with its date range. Documentation that the care was emergent, where that applies. The network participation record for that specific plan product.
- 5Step 5: Send the appeal before the deadline. Send it to the payer with the claim, the denial and the documentation, inside the payer's appeal window. See what an appeal letter must contain and the filing limits by payer.
The common mistake. Do not bill the patient before checking. Balance billing an out-of-network denial that was actually emergent is a compliance problem, not just a mistake.
Free: the Denial Code Appeal Playbook. 53 codes on one sheet: appeal, fix and resubmit, or let it go, and what to attach. Get the playbook
CO 242 description
The provider was out of network, or not the patient's assigned primary care provider.
The provider was out of network, or not the patient's assigned primary care provider. So the balance cannot move to the patient. Either the appeal recovers it or the practice absorbs it. That makes the appeal decision the whole decision on this line.
This is our plain-English wording, not the official X12 text. X12 asserts copyright over the published descriptions, so we write our own and say what it means for the money rather than restating the code.
Where this comes from. This is our own reading of the code, not the payer's and not a copy of the standards text. We classify it from how these denials actually resolve. Where we are unsure, we say so rather than guessing.
Related Codes
CO 185
The rendering provider is not eligible to perform the service billed.
Read the CO 185 pageCO 27
Coverage had ended on the date of service.
Read the CO 27 pageCO 26
Service fell before coverage started.
Read the CO 26 pageCO B7
The provider was not certified or eligible for this service on that date.
Read the CO B7 page
Your Questions Answered
What does CO 242 mean?
The provider was out of network, or not the patient's assigned primary care provider. Contractual obligation. The provider absorbs it and cannot bill the patient.
Can you appeal CO 242?
Usually recoverable. Check whether the patient had a referral or an authorisation on file, or whether the care was urgent. Network denials are often won on one of those three.
Why does CO 242 happen?
No referral from the assigned primary care provider. The provider is out of network for that specific plan product, though in network for others from the same payer. Emergency or urgent care, where network rules are usually waived.
What documentation wins a CO 242 appeal?
The referral or authorisation, with its date range. Documentation that the care was emergent, where that applies. The network participation record for that specific plan product.
How do I appeal a CO 242 denial?
Step 1: Read the remark code. Find the remark code printed next to CO 242 on the 835 or EOB. It says what the payer wants back. Step 2: Find the cause. Match the denial to one cause: No referral from the assigned primary care provider. The provider is out of network for that specific plan product, though in network for others from the same payer. Emergency or urgent care, where network rules are usually waived. Step 3: Take the first action. Check whether the patient had a referral or an authorisation on file, or whether the care was urgent. Network denials are often won on one of those three. Step 4: Attach the documentation. The referral or authorisation, with its date range. Documentation that the care was emergent, where that applies. The network participation record for that specific plan product. Step 5: Send the appeal before the deadline. Send it to the payer with the claim, the denial and the documentation, inside the payer's appeal window.
Most searched: CO 97 · CO 96 · OA 23 · PR 204 · CO 109 · CO 197 · CO 45 · CO 50
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