CO-288: Referral absent

Why it fires

• The patient's plan, typically an HMO, requires a PCP referral before seeing a specialist or receiving certain services
• The referral was obtained but not submitted with the claim or not on file with the payer
• The referral existed but expired, or was for a different provider or specialty than what was billed

Corrective actions, ranked

1. 1

   Search for the referral

   Check whether a referral exists under a different reference number, provider, or date range before assuming none was issued.

2. 2

   Obtain a retroactive referral

   Contact the PCP's office to issue a referral covering this date of service if the care was appropriate and simply not documented at the time.

3. 3

   Fix the front-desk verification process

   Add a scheduling or registration check confirming an active referral is on file before HMO patients are seen.

Is it worth appealing

Appeal when a valid referral did exist, or can be obtained retroactively, and documentation shows the referral requirement was substantively met, just not linked to the claim.

Other denial codes to check

Codes that share a remark code with this one, or that are reported under the same group code.

• CO-45Charge exceeds fee schedule/maximum allowable or contracted/legislated fee arrangement.
• CO-97The benefit for this service is included in the payment/allowance for another service/procedure that has already been adjudicated.
• CO-16Claim/service lacks information or has submission/billing error(s).
• CO-11The diagnosis is inconsistent with the procedure.
• OA-18Exact duplicate claim/service (Use only with Group Code OA except where state workers' compensation regulations requires CO)
• CO-29The time limit for filing has expired.

See every CARC in the dataset