CO-167: Diagnosis Not Covered by This Payer
CO (Contractual Obligation)What is CO-167?
CO-167 is a Contractual Obligation code indicating the diagnosis submitted with the claim is not covered under the patient's benefit plan or the payer's coverage policies. This differs from CO-11 (medical necessity) in that CO-167 means the diagnosis itself is excluded, not that it fails to support the procedure.
Why Does CO-167 Occur?
- Diagnosis excluded from plan coverage. Certain ICD-10 codes are explicitly excluded in the patient's benefit plan (e.g., cosmetic conditions, self-inflicted injuries in some plans).
- Workers compensation or auto insurance should be primary. The diagnosis code indicates an injury that should be covered by WC or auto liability, not the health plan.
- Pre-existing condition limitation (rare, mostly grandfathered plans). The diagnosis relates to a pre-existing condition that the plan excludes.
How to Fix CO-167 Denials
- Review the EOB to identify why the diagnosis is not covered. The RARC code will specify the exclusion reason.
- If the diagnosis is truly excluded from the plan, check for an alternative ICD-10 code that is more clinically accurate and covered.
- If the denial is because another payer should be primary (WC, auto), redirect the claim to the correct payer.
- Appeal with clinical documentation if the payer's exclusion is incorrect or if the diagnosis falls within a coverage exception.
CO-167 by Payer
| Payer | Common RARC | Appeal Deadline | Notes |
|---|---|---|---|
| UnitedHealthcare | N/A | 60 days from remittance | Check UHC plan documents for diagnosis-specific exclusions. |
| Anthem | N/A | 365 days from denial notice | Anthem's coverage varies by state. Verify the exclusion against your region. |
| Aetna | N/A | 180 days from denial | Review Aetna's excluded diagnosis list for the patient's plan. |
| Cigna | N/A | 180 days from denial | Contact Cigna to confirm the diagnosis exclusion is correct for the plan. |
| Medicare | N/A | 120 days (redetermination at MAC) | Medicare rarely excludes diagnoses. Verify the claim was not miscoded. |
Related CARC Codes
If you are seeing CO-167, check these related codes: CO-11 (medical necessity), CO-50 (non-covered service), CO-15 (workers compensation).
Common Questions About CO-167
What is the difference between CO-167 and CO-11?
CO-167 means the diagnosis itself is not covered by the plan. CO-11 means the diagnosis does not support the medical necessity of the procedure billed. CO-167 is a coverage exclusion; CO-11 is a medical necessity failure.
Can the patient be billed for a CO-167 denial?
Possibly. If the patient was informed before the service that the diagnosis may not be covered and signed a waiver (ABN for Medicare), the balance may be transferred to the patient.
Altair catches CO-167 denials before submission with coverage eligibility checking. See how pre-submit claim scoring works.