CO-B1: Non-Covered Visits
CO-B1 means visits are not covered per the contract. Review the plan, verify coding, and appeal with medical necessity documentation if the visits should be covered.
What Does CO-B1 Mean?
When paired with Group Code CO, the non-covered visits are a contractual adjustment. The provider absorbs the cost and cannot transfer it to the patient. Appeal if the visits should be covered under the plan.
CARC B1 indicates that the billed visits or services are not covered by the patient's insurance plan. This is a broad non-coverage denial that can stem from multiple causes: the visit type may be explicitly excluded from the plan, the patient may have exhausted their allowed number of visits for the benefit period, required prior authorization was not obtained, the provider is out of network, or the payer determined the visits were not medically necessary.
The resolution path depends on the specific reason for non-coverage. If the visits are genuinely excluded from the plan, there is limited recourse. If the denial resulted from missing authorization, coding errors, or incorrect benefit tracking, correcting the issue and resubmitting or appealing is appropriate. If medical necessity is contested, a clinical appeal with physician documentation is the appropriate path.
Common Causes
| Cause | Frequency |
|---|---|
| Service not covered under the plan The visit type or service is explicitly excluded from coverage under the patient's insurance plan | Most Common |
| Benefit limit exceeded The patient has exhausted the allowed number of visits for the service type within the benefit period | Most Common |
| Missing pre-authorization Required prior authorization for the visit was not obtained before the service was rendered | Common |
| Out-of-network provider The provider is not in the patient's plan network and out-of-network visits are not covered | Common |
| Medical necessity not established The payer determined the visits were not medically necessary based on the documentation submitted | Common |
| Incorrect coding Visit codes or diagnosis codes do not support coverage for the billed visits | Common |
How to Resolve
- Review the plan's visit coverage Check whether the visit type is excluded from coverage.
- Verify coding Ensure correct visit and diagnosis codes were used.
- Check authorization Confirm whether prior authorization was required and obtained.
- Appeal if warranted Submit an appeal with medical necessity documentation if the visits should be covered.
- Accept if genuinely non-covered If the visits are excluded from the plan, accept the adjustment.
Appeal with documentation of medical necessity for the denied visits. Include physician notes, treatment plans, and relevant clinical guidelines. If visits were denied due to benefit limits, provide documentation showing the visits are for a different condition or service type. For Medicare, file within 120 days.
Common RARC Pairings
The RARC code tells you exactly what triggered the CO-B1:
| RARC | Description |
|---|---|
| N130 | Alert: You may need to review plan documents or guidelines. Review the patient's plan documents to confirm whether the visit type is excluded from coverage → |
| N381 | Alert: Consult your contractual agreement for restrictions, billing, and payment information. Check your payer contract for visit coverage limitations → |
How to Prevent CO-B1
- Verify insurance coverage and benefit limits before scheduling appointments
- Obtain required prior authorizations before rendering services
- Educate patients about their coverage limitations during registration
- Document medical necessity comprehensively in the patient's medical record
- Stay current with payer policy updates regarding covered visit types
Also Filed As
The same CARC B1 may appear with different Group Codes:
Related Denial Codes
Sources
- https://x12.org/codes/claim-adjustment-reason-codes
- https://www.mdclarity.com/denial-code/b1
- https://www.cms.gov/regulations-and-guidance/guidance/manuals
- Codes maintained by X12. Visit x12.org for official definitions.