CO-193: Original Payment Decision Maintained on Review
The appeal was denied. Escalate to the next appeal level with stronger documentation addressing the stated deficiencies.
What Does CO-193 Mean?
With CO (Contractual Obligation), the appeal was denied and the original contractual adjustment is maintained. The provider may escalate to the next appeal level with additional documentation. This is the most common scenario for CARC 193.
CARC 193 indicates that the provider submitted an appeal, reconsideration, or redetermination request, and after reviewing the case, the payer determined the original payment decision was correct. The appeal did not result in a change to the original determination.
This code does not mean the case is closed. In most situations, higher levels of appeal are available. For Medicare claims, the five-level appeal process includes redetermination (MAC), reconsideration (QIC), Administrative Law Judge (ALJ) hearing, Medicare Appeals Council review, and federal court review. Commercial payers also typically offer multiple appeal levels. The key is to identify why the appeal was denied and submit a stronger case at the next level.
Common Causes
| Cause | Frequency |
|---|---|
| Appeal or reconsideration denied — original decision upheld The provider submitted an appeal or reconsideration request, and after review, the payer determined the original payment decision was correct | Most Common |
| Redetermination request denied For Medicare claims, the first-level appeal (redetermination) was reviewed and the original determination was maintained | Most Common |
| Insufficient new evidence submitted with appeal The appeal did not include sufficient new information or documentation to warrant changing the original payment decision | Common |
| Clinical review confirmed original medical necessity determination A clinical review of the appeal upheld the original determination that the service was not medically necessary as billed | Common |
How to Resolve
- Review the denial reasons Identify the specific reasons the original decision was maintained.
- Gather additional evidence Compile new clinical documentation, evidence-based guidelines, or peer-reviewed literature that supports the claim.
- File the next-level appeal For Medicare: file QIC reconsideration within 180 days of the redetermination. Include new evidence and directly address the denial reasons.
- Consider external review If available, request an external or independent review of the case.
Escalate to the next level of appeal with additional or stronger documentation. For Medicare, after a redetermination denial, file a QIC reconsideration within 180 days. Include new evidence, clinical guidelines, and directly address the reasons the original decision was maintained.
Common RARC Pairings
The RARC code tells you exactly what triggered the CO-193:
| RARC | Description |
|---|---|
| N130 | You may need to review plan documents or guidelines Review the payer's appeal response for specific reasons the original decision was maintained → |
| N210 | Alert: You may appeal this decision Consider filing a higher-level appeal with additional supporting documentation → |
How to Prevent CO-193
- Submit comprehensive documentation with initial appeals to maximize the chance of a favorable decision
- Include all relevant medical records, clinical guidelines, and supporting evidence in the first appeal
- Address the specific denial reason directly in appeal letters
- Use evidence-based guidelines and peer-reviewed literature to support medical necessity arguments
- Consider consulting with a coding specialist or clinical reviewer before submitting appeals
Also Filed As
The same CARC 193 may appear with different Group Codes:
Related Denial Codes
Sources
- https://www.mdclarity.com/denial-code-carcs
- 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://docs.claim.md/docs/claim-adjustment-reason-codes
- Codes maintained by X12. Visit x12.org for official definitions.