CO-272: Coverage/Program Guidelines Were Not Met
CO-272 means the service did not meet the plan's program guidelines. Identify which guideline was not met and appeal with evidence of compliance.
What Does CO-272 Mean?
When paired with Group Code CO, the guideline non-compliance is considered a contractual matter. The provider absorbs the denied amount and cannot transfer it to the patient. Appeal with documentation if you believe the service met the guidelines.
CARC 272 indicates the payer denied the claim because the service did not satisfy the plan's coverage or program guidelines. This is a broad denial code that can encompass many types of guideline non-compliance: missing prior authorization, services not covered under the plan, exceeded benefit limits, insufficient medical necessity documentation, coding errors, or failure to follow plan-specific requirements like referral protocols or step therapy.
The key to resolving this denial is identifying which specific guideline was not met. The accompanying RARC codes may provide clues, but you may also need to review the payer's published program guidelines or contact the payer directly for clarification.
Once you identify the specific guideline issue, you can determine the appropriate resolution — correcting a coding error and resubmitting, obtaining a retroactive authorization, or filing a clinical appeal with documentation showing the service met or should be exempt from the guidelines.
Common Causes
| Cause | Frequency |
|---|---|
| Missing prior authorization The provider failed to obtain required pre-approval before rendering services, violating the plan's program guidelines | Most Common |
| Service not covered under plan guidelines The procedure or service is excluded from the patient's coverage per the plan's program guidelines | Common |
| Exceeded benefit limits The service frequency has surpassed the policy's allowed thresholds for this type of service | Common |
| Insufficient medical necessity documentation The clinical justification provided does not meet the plan's guidelines for medical necessity for the service | Common |
| Coding errors misaligning with program guidelines Incorrect procedure or diagnosis codes caused the service to not meet the plan's program guidelines | Occasional |
| Non-compliance with plan-specific requirements The provider failed to meet specific requirements outlined in the plan's program guidelines such as referral requirements or step therapy protocols | Occasional |
How to Resolve
- Review the plan's program guidelines Identify the specific guideline the payer says was not met.
- Verify claim information Check codes, modifiers, and authorization details for accuracy.
- Gather comprehensive documentation Compile medical records, authorization documents, and clinical justification.
- File a formal appeal Submit with documentation showing guideline compliance, including specific references to the plan requirements.
- Contact payer for guideline clarification If the requirement is unclear, contact the payer for specifics.
- Track deadlines and progress Monitor the appeal timeline and respond to requests promptly.
File a formal appeal with comprehensive documentation including medical records, authorization documentation, clinical justification for medical necessity, and specific references to the program guidelines that the service meets. Include a cover letter explaining how the service complies with the plan's requirements.
Common RARC Pairings
The RARC code tells you exactly what triggered the CO-272:
| RARC | Description |
|---|---|
| N381 | Alert: Consult your contractual agreement for restrictions, billing, and payment information. Review the plan's program guidelines to identify the specific requirement that was not met → |
| N657 | This should be billed with the appropriate modifier. Check whether a modifier is needed to comply with the plan's billing guidelines → |
How to Prevent CO-272
- Verify patient eligibility and program guidelines before service delivery
- Obtain prior authorization proactively for all services that require it
- Maintain detailed and accurate clinical documentation that demonstrates guideline compliance
- Monitor payer policy updates regularly to stay current with changing program guidelines
- Educate billing staff on specific coverage requirements and program guidelines for each payer
- Conduct internal audits to identify denial patterns related to guideline non-compliance
Also Filed As
The same CARC 272 may appear with different Group Codes:
Related Denial Codes
Sources
- https://www.mdclarity.com/denial-code/272
- https://resdac.org/sites/datadocumentation.resdac.org/files/Adjustment%20Reason%20Code%20Code%20Table%20(TAF%20Claims).txt
- https://x12.org/codes/claim-adjustment-reason-codes
- Codes maintained by X12. Visit x12.org for official definitions.