CO-216: Based on Findings of a Review Organization
A review organization denied the claim. Appeal with clinical evidence addressing their specific findings.
What Does CO-216 Mean?
With CO (Contractual Obligation), the review organization's findings result in a contractual denial. Appeal with comprehensive clinical documentation addressing the specific findings.
CARC 216 indicates that an external or internal review organization evaluated the claim and determined that the service was not payable as billed. The review organization may have concluded that the service was not medically necessary, was not provided at the appropriate level of care, or did not meet the clinical criteria for coverage.
Review organizations include Quality Improvement Organizations (QIOs) for Medicare, independent review entities for commercial payers, and state-mandated review bodies. Their findings carry significant weight in the appeals process and typically reflect a clinical assessment of the medical records.
Common Causes
| Cause | Frequency |
|---|---|
| Utilization review determined service was not medically necessary A review organization or the payer's utilization review department determined that the service was not medically necessary based on clinical criteria | Most Common |
| Independent medical review upheld the denial An independent review organization (IRO) reviewed the claim and upheld the payer's original denial decision | Common |
| Peer review found documentation insufficient A peer-to-peer or clinical review found that the clinical documentation did not support the level of service billed | Common |
| Quality review identified care concerns A quality review organization identified issues with the appropriateness of the care provided | Occasional |
| Workers compensation utilization review denial A workers compensation utilization review organization denied the treatment based on evidence-based guidelines | Occasional |
How to Resolve
- Review the findings Obtain and analyze the review organization's determination.
- Gather additional evidence Compile clinical documentation, guidelines, and literature supporting the service.
- Appeal to the next level Submit a detailed appeal addressing each finding point with supporting evidence.
- Request peer-to-peer review Request a clinical discussion with the review organization's medical director.
Appeal with comprehensive clinical documentation that addresses the specific findings of the review organization. Include physician narrative letters, relevant peer-reviewed literature, clinical guidelines supporting the service, and detailed operative or treatment notes. Request a peer-to-peer review with the payer's medical director. If internal appeals fail, request an external review by an independent review organization.
Common RARC Pairings
The RARC code tells you exactly what triggered the CO-216:
| RARC | Description |
|---|---|
| N386 | This decision was based on a National Coverage Determination (NCD) or Local Coverage Determination (LCD). Review the specific NCD or LCD cited in the review organization's findings → |
| N130 | Consult plan benefit documents/guidelines for coverage of this service. Review plan benefit guidelines referenced by the review organization → |
How to Prevent CO-216
- Maintain thorough clinical documentation that supports medical necessity from the outset
- Respond promptly to review organization requests for additional information
- Train clinical staff on documentation requirements for external review processes
General Prevention
- Ensure thorough clinical documentation supporting the medical necessity of all services before submission
- Follow evidence-based clinical guidelines and payer-specific criteria for service authorization
- Participate in peer-to-peer reviews proactively when authorization requests are questioned
- Maintain awareness of the review criteria used by contracted review organizations
- Document the clinical rationale for services that may be subject to utilization review
Also Filed As
The same CARC 216 may appear with different Group Codes:
Related Denial Codes
Sources
- 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.aapc.com/resources/claim-adjustment-reason-codes
- Codes maintained by X12. Visit x12.org for official definitions.