CO-39: Services Denied at Authorization/Pre-certification
Provider responsibility — gather documentation and appeal if the denial is in error. The patient is not liable for this amount.
What Does CO-39 Mean?
With CO (Contractual Obligation), the CARC 39 denial for services denied at authorization/pre-certification is the provider's contractual responsibility. The patient is not liable for this amount. However, the provider may appeal with supporting clinical or administrative documentation if the denial is believed to be in error.
CARC 39 relates to services denied at authorization/pre-certification. The payer requires specific authorization, certification, or referral for this service, and the claim was adjusted because that requirement was not satisfied.
Common scenarios that trigger this adjustment include: the payer denied the authorization request for the service before it was performed; The payer determined the service was not medically necessary during the pre-certification review; The authorization request lacked sufficient clinical information to justify the service. The group code paired with CARC 39 determines who bears the financial responsibility — CO places it on the provider as a contractual obligation, PR shifts it to the patient, OA indicates a coordination of benefits or other payer adjustment.
Common Causes
| Cause | Frequency |
|---|---|
| Prior authorization denied The payer denied the authorization request for the service before it was performed | Most Common |
| Service deemed not medically necessary The payer determined the service was not medically necessary during the pre-certification review | Common |
| Insufficient clinical documentation The authorization request lacked sufficient clinical information to justify the service | Common |
| Authorization request withdrawn The provider or patient withdrew the authorization request | Occasional |
How to Resolve
- Review the denial Examine the CO-39 denial and any RARC codes to understand the specific basis for the coverage determination.
- Gather supporting documentation Collect medical records, clinical notes, authorization documents, or other evidence that supports the medical necessity or coverage of the denied service.
- File the appeal Appeal with comprehensive clinical documentation including progress notes, test results, and a letter of medical necessity from the treating physician. Request a peer-to-peer review with the payer's medical director. Reference relevant clinical guidelines supporting the service.
- Track the appeal outcome Monitor the appeal status and follow up as needed. If denied again, consider further levels of appeal if available.
Appeal with comprehensive clinical documentation including progress notes, test results, and a letter of medical necessity from the treating physician. Request a peer-to-peer review with the payer's medical director. Reference relevant clinical guidelines supporting the service.
Common RARC Pairings
The RARC code tells you exactly what triggered the CO-39:
| RARC | Description |
|---|---|
| M62 | Missing/incomplete/invalid treatment authorization code Obtain proper authorization and resubmit → |
| N30 | Patient not eligible for this service Review authorization denial reason → |
| N362 | Missing/incomplete/invalid prior authorization Submit authorization documentation → |
| N473 | Missing/incomplete/invalid authorization number Provide the correct authorization number → |
How to Prevent CO-39
- Obtain authorization before performing services
- Track authorization status and expiration dates
- Submit complete clinical documentation with authorization requests
- Implement a pre-service authorization verification workflow
- Stay current on payer-specific authorization requirements
Also Filed As
The same CARC 39 may appear with different Group Codes:
Related Denial Codes
Sources
- https://x12.org/codes/claim-adjustment-reason-codes
- https://www.mdclarity.com/denial-code/39
- https://www.patientstudio.com/pr-39-denial
- Codes maintained by X12. Visit x12.org for official definitions.