Provider not certified or eligible to be paid for this service
On the date of service the provider was not enrolled, certified or eligible with the payer for this procedure.
CO = Contractual Obligation. The provider owes the difference. The patient cannot be billed for this amount. The same reason code can appear with a different group code; the group decides who may be billed.
Usual causes
- New provider whose enrollment effective date is after the date of service.
- Provider enrollment lapsed (revalidation missed, license expired in the payer file).
- Service requires a certification the provider lacks (for example CLIA for a lab test, see B23, or a mammography certification).
- Provider opted out of Medicare.
The fix
Check the enrollment effective date and status with the payer. If the claim has the wrong provider or date, correct it. If the provider was effective, appeal with the approval letter. If enrollment lapsed, revalidate and ask about retroactive dates. Otherwise the claim is not payable and the patient cannot be billed for a provider's enrollment problem.
Appeal or corrected claim?
Corrected claim for data errors; appeal with the effective date letter when the provider was eligible; enrollment work otherwise.
Deadline to watch
Timely filing limit; revalidation deadlines from the payer notice.
Exact limits are in your payer contract or provider manual. When in doubt, send the correction or appeal this week.
CO-B7 in short
What does CO-B7 mean?
On the date of service the provider was not enrolled, certified or eligible with the payer for this procedure. The official X12 text reads: "This provider was not certified/eligible to be paid for this procedure/service on this date of service. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present."
What usually causes a CO-B7 denial?
New provider whose enrollment effective date is after the date of service. Provider enrollment lapsed (revalidation missed, license expired in the payer file). Service requires a certification the provider lacks (for example CLIA for a lab test, see B23, or a mammography certification). Provider opted out of Medicare.
How do I fix CO-B7?
Check the enrollment effective date and status with the payer. If the claim has the wrong provider or date, correct it. If the provider was effective, appeal with the approval letter. If enrollment lapsed, revalidate and ask about retroactive dates. Otherwise the claim is not payable and the patient cannot be billed for a provider's enrollment problem.
Should I appeal CO-B7 or send a corrected claim?
Correct or appeal (see note). Corrected claim for data errors; appeal with the effective date letter when the provider was eligible; enrollment work otherwise.
What deadline applies to CO-B7?
Timely filing limit; revalidation deadlines from the payer notice.