CO-61: Second Surgical Opinion Not Obtained

What Does CO-61 Mean?

CO 61 places financial responsibility on the provider because the surgical claim was submitted without meeting the payer's second surgical opinion requirement. The provider cannot bill the patient for this adjustment. This typically indicates a process failure in the provider's scheduling or referral workflow — the surgical team did not verify or ensure compliance with the second opinion mandate before proceeding with the procedure. If the second opinion was obtained but not submitted, this is a straightforward documentation fix.

CARC 61 appears when a payer denies a surgical claim because the insurance plan required a second surgical opinion before the procedure was performed, and that requirement was not met. Second surgical opinion programs are designed to reduce unnecessary surgeries by having an independent physician confirm that the proposed procedure is medically necessary. While these programs were more common in earlier decades, many commercial plans and some self-insured employer plans still mandate second opinions for elective surgeries.

The denial can trigger for several reasons: the second opinion was never obtained, it was obtained from a provider not on the payer's approved list, the documentation was not submitted with the claim, or the second opinion did not support the surgical recommendation and the patient proceeded anyway. The last scenario is particularly challenging because some payers will deny coverage when the independent reviewer did not agree with the original surgical recommendation.

The group code determines the financial impact. CO 61 puts the burden on the provider, who should have ensured the second opinion requirement was met before scheduling the surgery. PR 61 puts the burden on the patient, who failed to comply with their plan's requirement. In either case, the first step is to determine whether the second opinion actually exists but was not documented on the claim — which is a fixable administrative issue — or whether it genuinely was never obtained.

Common Causes

How to Resolve

Determine whether a second surgical opinion was obtained, locate the documentation, and submit it with the claim or appeal. If no second opinion exists, explore retroactive options or write off the denial.

1. Search for existing documentation Check the patient's chart, referral tracking system, and correspondence records for a second surgical opinion that may have been obtained but not forwarded with the claim.
2. Resubmit with documentation If found, resubmit the claim with the second opinion consultation notes and any referral authorization documentation. File as a corrected claim or formal appeal.
3. Request retroactive review or write off If no second opinion exists, contact the payer about retroactive review options. If none are available, write off the denied amount and implement process improvements.

Common RARC Pairings

The RARC code tells you exactly what triggered the CO-61:

How to Prevent CO-61

• Build a second opinion verification step into the surgical scheduling workflow that prevents booking until the requirement is confirmed.
• Maintain a tracking system for second opinion referrals with automated reminders.
• Verify with the payer that the consulting physician meets their requirements before the consultation.
• Include second opinion documentation with the surgical claim as standard practice.

General Prevention

• Implement a surgical scheduling workflow that checks the patient's insurance plan for second opinion requirements before booking the procedure.
• Maintain a tracking system for second surgical opinion referrals to ensure they are completed and documented before the surgery date.
• Verify with the payer that the second opinion physician meets their requirements (approved provider, correct specialty) before the consultation.
• Include second opinion documentation with the surgical claim submission as a standard practice.
• Conduct regular staff training on payer-specific second opinion requirements.

Also Filed As

The same CARC 61 may appear with different Group Codes:

Related Denial Codes