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Denial code CO-167: what it means and what to do

Denial code CO-167 on your Explanation of Benefits: The diagnosis on the claim is not covered.

What CO-167 means

The diagnosis on the claim is not covered.

CO means contractual obligation: under its contract, the provider is usually responsible for this amount, so an in-network provider generally should not bill you for it.

What to do

Ask for the exact plan language and compare it with your Summary of Benefits and Coverage.

If the service fits a covered benefit, quote it in your appeal.

Your deadline

Most plans give you 180 days from the denial notice to file an internal appeal. Original Medicare gives 120 days from the Medicare Summary Notice, and Medicare Advantage plans 65 days from their decision. Check the date printed on your letter.

More on this reason: Not covered by your plan.

Other denial codes

• CO-50
• CO-197
• CO-198
• CO-15
• CO-16
• CO-18
• CO-97
• CO-4
• CO-11
• CO-29
• CO-96
• CO-204
• CO-119
• CO-55
• CO-242
• CO-22
• CO-109
• CO-27
• CO-26
• CO-31
• CO-45
• PR-1
• PR-2
• PR-3

Sources

1. HealthCare.gov: Internal appeals
2. 29 CFR 2560.503-1, claims procedure for employer health plans