CO-160: Benefit Exclusion: Injury from Excluded Activity

What Does CO-160 Mean?

With CO (Contractual Obligation), the CARC 160 denial for benefit exclusion: injury from excluded activity is the provider's contractual responsibility. The patient is not liable for this amount. However, the provider may appeal with supporting clinical or administrative documentation if the denial is believed to be in error.

CARC 160 indicates benefit exclusion: injury from excluded activity. The payer determined that the service or a portion of it does not meet coverage criteria under the patient's current plan benefits or the applicable coverage rules.

Common scenarios that trigger this adjustment include: the patient was injured while participating in an activity specifically excluded from coverage under their benefit plan, such as extreme sports, illegal activities, or self-inflicted harm; The payer determines the injury occurred during employment and should be covered by workers' compensation rather than the patient's health insurance; The payer incorrectly classified the cause of injury as resulting from an excluded activity when the actual circumstances do not meet the exclusion criteria. The group code paired with CARC 160 determines who bears the financial responsibility — CO places it on the provider as a contractual obligation, PR shifts it to the patient, OA indicates a coordination of benefits or other payer adjustment.

Common Causes

How to Resolve

1. Review the denial Examine the CO-160 denial and any RARC codes to understand the specific basis for the coverage determination.
2. Gather supporting documentation Collect medical records, clinical notes, authorization documents, or other evidence that supports the medical necessity or coverage of the denied service.
3. File the appeal Appeal with documentation showing the injury did not result from an excluded activity. Include medical records with the cause of injury, external cause codes, and a letter explaining the actual circumstances that led to the injury.
4. Track the appeal outcome Monitor the appeal status and follow up as needed. If denied again, consider further levels of appeal if available.

Common RARC Pairings

The RARC code tells you exactly what triggered the CO-160:

How to Prevent CO-160

• Document the cause and circumstances of all injuries thoroughly in the medical record
• Include appropriate external cause codes (ICD-10) on claims to specify the cause of injury
• Review patient insurance plans for benefit exclusions related to specific activities
• Verify whether work-related injuries should be billed to workers' compensation before submitting to health insurance
• Ask patients about the circumstances of their injury during intake to identify potential benefit exclusions early

Also Filed As

The same CARC 160 may appear with different Group Codes:

Related Denial Codes