CO-183: Referring Provider Not Eligible to Refer
Verify the referring provider's enrollment and NPI. Correct errors and resubmit, or appeal with enrollment proof.
What Does CO-183 Mean?
With CO (Contractual Obligation), the ineligible referring provider is the provider's responsibility to resolve. Verify the referring provider's enrollment status, correct any NPI errors, and resubmit. If the referring provider is genuinely eligible, appeal with enrollment documentation.
CARC 183 indicates that the referring provider listed on the claim does not meet the payer's requirements for making referrals. This could mean the referring provider is not enrolled with the payer, their NPI is invalid or inactive, their specialty is not authorized to make referrals for the billed service, or they have been excluded from federal healthcare programs.
This code is common for services that require a physician referral, such as specialist consultations, physical therapy, and certain diagnostic tests. The payer validates the referring provider's status during claim processing and rejects the claim if the referral source is not eligible. Resolving this requires verifying and correcting the referring provider's information.
Common Causes
| Cause | Frequency |
|---|---|
| Referring provider not enrolled with the payer The provider who made the referral is not enrolled or credentialed with the payer, making their referral invalid for claim processing | Most Common |
| Referring provider's NPI is invalid or inactive The NPI listed as the referring provider on the claim is either invalid, inactive, or not found in the payer's system | Most Common |
| Referring provider's specialty not authorized to make referrals for this service The referring provider's specialty or provider type is not among those authorized by the payer to make referrals for the specific service billed | Common |
| Self-referral for services requiring an external referral The rendering provider listed themselves as the referring provider for a service that requires a referral from a different provider | Common |
| Referring provider has been excluded or sanctioned The referring provider has been excluded from federal healthcare programs or sanctioned, making their referrals ineligible | Occasional |
How to Resolve
- Check the referring provider's status Verify the referring provider's NPI, enrollment, and credentialing status with the payer.
- Correct NPI errors If the NPI was entered incorrectly, fix it and resubmit the claim.
- Obtain a new referral if needed If the referring provider is not enrolled, get a referral from an enrolled, eligible provider.
- Appeal with enrollment documentation If the provider is eligible, submit NPI verification, enrollment confirmation, and credential records with the appeal.
- Check exclusion status Verify the referring provider has not been excluded from federal healthcare programs via the OIG exclusion list.
Appeal with documentation proving the referring provider is enrolled, credentialed, and eligible to make referrals, including the provider's NPI verification, enrollment confirmation, and credential records.
Common RARC Pairings
The RARC code tells you exactly what triggered the CO-183:
| RARC | Description |
|---|---|
| N95 | This provider type/provider specialty may not refer this service Verify the referring provider's specialty and enrollment status are valid for making referrals → |
| N130 | You may need to review plan documents or guidelines Review the payer's referral requirements and referring provider eligibility criteria → |
How to Prevent CO-183
- Verify the referring provider's enrollment status with the payer before processing referrals
- Maintain accurate referring provider NPI records in the billing system
- Check referring provider eligibility before submitting claims that require referrals
- Ensure referring providers are aware of enrollment requirements for the payers they refer to
- Monitor the OIG exclusion list and SAM.gov for any referring providers who may have been sanctioned
Also Filed As
The same CARC 183 may appear with different Group Codes:
Related Denial Codes
Sources
- https://www.mdclarity.com/denial-code/183
- https://x12.org/codes/claim-adjustment-reason-codes
- https://portal.ct.gov/-/media/ohs/health-it-advisory-council/apcd-advisory-group/data-submission-guide-workgroup/meeting-materials/6-30-22/carc-codes_final.pdf
- https://www.cms.gov/regulations-and-guidance/guidance/transmittals/downloads/R743CP.PDF
- Codes maintained by X12. Visit x12.org for official definitions.