CO-292: Medical Plan Benefits Not Available - Forwarded to Pharmacy
CO-292 means the medical plan contractually denies the service and forwarded it to the pharmacy plan. Do not post as a contractual adjustment until the pharmacy plan has made its determination.
What Does CO-292 Mean?
When CARC 292 appears with CO, the medical plan is contractually denying the claim while forwarding it to the pharmacy plan. The provider cannot post as a contractual adjustment for the medical plan's denied amount while the pharmacy plan adjudicates the claim.
CARC 292 indicates the medical plan received the claim, determined the service falls under the pharmacy benefit rather than the medical benefit, and has forwarded the claim to the patient's pharmacy plan for processing. This is a routing code that signals the claim is being redirected, not permanently denied.
This code most commonly appears for injectable or infusible medications, specialty drugs, and certain pharmacy-related services that some plans manage through a pharmacy benefit manager (PBM) rather than through the medical benefit. The split between medical and pharmacy benefits varies significantly by payer and plan design. Some plans cover certain drugs under the medical benefit when administered in a provider's office, while others route all drug claims through the pharmacy benefit regardless of setting.
The distinction between CARC 292 and CARC 280 is important: CARC 292 confirms the claim was forwarded to the pharmacy plan, while CARC 280 indicates the medical plan denied the claim without forwarding it. Providers should track the forwarded claim with the pharmacy plan to ensure it does not fall through the cracks during the routing process.
Common Causes
| Cause | Frequency |
|---|---|
| Service classified as pharmacy benefit The medical plan determined the service or drug falls under the pharmacy benefit rather than the medical benefit plan | Most Common |
| Drug or pharmaceutical service not covered under medical plan The specific drug or pharmaceutical service is excluded from the medical plan and must be processed through the pharmacy benefit manager | Common |
| Coordination of benefits requires pharmacy plan processing The medical plan's COB rules direct the claim to the pharmacy plan for processing | Common |
| Incorrect plan routing for drug claims The claim for a pharmaceutical was incorrectly submitted to the medical plan instead of the pharmacy benefit plan | Occasional |
How to Resolve
- Track pharmacy plan adjudication Wait for the pharmacy plan to process the forwarded claim. Do not write off the balance until the pharmacy plan has completed adjudication.
- Reconcile after determination Post the appropriate payment or adjustment based on the pharmacy plan's determination.
CARC 292 indicates the medical plan has forwarded the claim to the patient's pharmacy plan. Follow up with the pharmacy plan rather than appealing the medical plan.
Common RARC Pairings
The RARC code tells you exactly what triggered the CO-292:
| RARC | Description |
|---|---|
| N590 | Alert: This claim has been forwarded to the patient's pharmacy plan for consideration. Follow up with the pharmacy plan to ensure the forwarded claim is being processed → |
How to Prevent CO-292
- Identify the correct benefit plan (medical vs. pharmacy) for drugs and infusion services before billing
- Contact the PBM for benefit verification before administering high-cost specialty medications
General Prevention
- Verify whether services should be billed to medical or pharmacy plan before submission
- Understand each plan's coverage parameters for pharmaceutical services
- Coordinate properly between medical and pharmacy plans for drug claims
- Stay current with plan changes affecting medical vs pharmacy benefit boundaries
- Train staff on proper claim routing for pharmaceutical services
Also Filed As
The same CARC 292 may appear with different Group Codes:
Related Denial Codes
Sources
- https://www.mdclarity.com/denial-code/292
- 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.