Diagnosis not covered
The plan does not cover services for the diagnosis on the claim.
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
- Excluded conditions under the plan (some cosmetic, infertility, or weight-related diagnoses).
- Diagnosis that belongs to another coverage (work injury, auto accident, dental).
- The primary diagnosis is a symptom or screening code where the payer wants the confirmed condition.
The fix
Check the note. If a documented, covered diagnosis explains the visit, correct the claim. If the plan truly excludes the condition, bill the patient if they were told, or bill the responsible coverage. Appeal with the plan language when the payer applied the exclusion wrongly.
Appeal or corrected claim?
Corrected claim when coding was incomplete; otherwise appeal or patient responsibility.
Deadline to watch
Timely filing for corrections; appeal window per payer.
Exact limits are in your payer contract or provider manual. When in doubt, send the correction or appeal this week.
CO-167 in short
What does CO-167 mean?
The plan does not cover services for the diagnosis on the claim. The official X12 text reads: "This (these) diagnosis(es) is (are) not covered. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present."
What usually causes a CO-167 denial?
Excluded conditions under the plan (some cosmetic, infertility, or weight-related diagnoses). Diagnosis that belongs to another coverage (work injury, auto accident, dental). The primary diagnosis is a symptom or screening code where the payer wants the confirmed condition.
How do I fix CO-167?
Check the note. If a documented, covered diagnosis explains the visit, correct the claim. If the plan truly excludes the condition, bill the patient if they were told, or bill the responsible coverage. Appeal with the plan language when the payer applied the exclusion wrongly.
Should I appeal CO-167 or send a corrected claim?
Correct or appeal (see note). Corrected claim when coding was incomplete; otherwise appeal or patient responsibility.
What deadline applies to CO-167?
Timely filing for corrections; appeal window per payer.