CO-61: Failure to Obtain Second Surgical Opinion

What Does CO-61 Mean?

With CO (Contractual Obligation), the CARC 61 denial for failure to obtain second surgical opinion 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 61 relates to failure to obtain second surgical opinion. 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 patient's plan requires a second surgical opinion before certain procedures and it was not obtained; A second opinion was obtained but documentation was not submitted with the claim; Specific payers or plan types mandate a second opinion for elective surgeries. The group code paired with CARC 61 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

How to Resolve

1. Review the denial Examine the CO-61 denial and any RARC codes to understand the specific basis for the coverage determination.
2. Gather supporting documentation Collect medical records, clinical notes, authorization documents, or other evidence that supports the medical necessity or coverage of the denied service.
3. File the appeal If a second opinion was obtained, appeal with the documentation. If the surgery was emergent, appeal with emergency documentation showing a second opinion was not feasible. If the plan does not actually require a second opinion for this procedure, appeal citing the plan terms.
4. Track the appeal outcome Monitor the appeal status and follow up as needed. If denied again, consider further levels of appeal if available.

Common RARC Pairings

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

How to Prevent CO-61

• Check plan requirements for second surgical opinions before scheduling surgery
• Facilitate second opinion referrals for patients when required
• Document and retain second opinion results for claim submission
• Track second opinion requirements by payer

Also Filed As

The same CARC 61 may appear with different Group Codes:

Related Denial Codes