Medigami Benchmarks: what medical bills and denials actually look like

Public federal and state data, decoded. Every number is reproducible from the cited source files.

Denial codes

• CO-4: procedure code inconsistent with modifier / missing modifier
• CO-11: diagnosis inconsistent with procedure
• CO-15: authorization number missing or invalid
• CO-16: claim lacks information / submission error
• CO-18: duplicate claim or service
• CO-22: care may be covered by another payer per COB
• CO-29: time limit for filing has expired
• CO-45: charge exceeds fee schedule/allowed/contracted amount
• CO-50: non-covered because not deemed medically necessary
• CO-55: procedure/treatment deemed experimental/investigational
• CO-56: procedure/treatment not proven effective
• CO-58: treatment was in an inappropriate/incorrect place of service
• CO-59: processed based on multiple/concurrent procedure rules
• CO-96: non-covered charge(s)
• CO-97: benefit included/bundled in another service already adjudicated
• CO-109: claim not covered by this payer/contractor
• CO-119: benefit maximum for time period/occurrence reached
• CO-151: payer deems the information does not support this many services
• CO-167: diagnosis/diagnoses not covered
• CO-197: precertification/authorization/notification absent
• CO-198: precertification/authorization exceeded
• CO-204: service/equipment/drug not covered under the plan
• CO-B7: provider not certified/eligible to be paid for this procedure/service on this date
• CO-B15: requires a qualifying service/procedure not received/adjudicated
• PR-1: deductible amount (patient responsibility)
• PR-2: coinsurance amount (patient responsibility)
• PR-3: copayment amount (patient responsibility)
• PR-96: non-covered charge (patient responsibility)
• PR-204: not covered under plan (patient responsibility)
• OA-23: impact of prior payer(s) adjudication
• N130: consult plan benefit documents for coverage/limitations
• N386: decision based on a National/Local Coverage Determination
• CO-5: procedure or bill type doesn't match the place of service billed; usually a billing-office coding fix — ask the provider to correct and resubmit
• CO-6: billed procedure/revenue code doesn't fit the patient's age on file; often a data or coding error — ask the provider to verify and rebill
• CO-7: billed procedure/revenue code doesn't fit the patient's recorded gender; usually a records or coding error to correct and resubmit
• CO-8: procedure doesn't match the billing provider's registered type/specialty; a provider-side coding/enrollment fix
• CO-9: diagnosis doesn't fit the patient's age; typically a coding error the provider can correct and resubmit
• CO-10: diagnosis doesn't fit the patient's recorded gender; usually correctable coding or a records error
• CO-12: diagnosis doesn't match the provider type that billed; provider-side coding fix
• CO-13: insurer's records show a date of death before the service date; almost always a records error — contact the insurer (and SSA/Medicare if applicable) to fix the record
• CO-23: amount reflects what a prior insurer already paid or adjusted (coordination of benefits math), not a new denial
• CO-24: insurer says this care is covered under a capitated/managed-care arrangement (e.g. billed to original Medicare while enrolled in Medicare Advantage); claim usually needs resubmitting to the right plan
• PR-26: service date is before the coverage start date; verify the actual effective date — if the insurer's date is wrong, ask them to correct it
• PR-27: service date is after coverage ended; verify the termination date is right — retroactive terminations and record errors can be disputed with the insurer or employer
• PR-31: insurer couldn't match the patient to a member on file; usually a typo in name/DOB/member ID — give the provider the correct card details to rebill
• CO-32: insurer's records say the patient isn't an eligible dependent on this plan; check enrollment records with the policyholder's employer/insurer and correct if wrong
• CO-33: the plan on file has no dependent coverage; confirm the right policy was billed and whether dependents were actually enrolled
• CO-34: plan on file shows no newborn coverage; newborns often must be added within a deadline — check enrollment status and state newborn-coverage rules
• CO-35: insurer says a lifetime benefit maximum was reached; note the ACA bans lifetime dollar limits on essential health benefits for most plans, so this is worth questioning
• CO-39: authorization was requested but denied at the time; the underlying authorization denial can itself be appealed with clinical support
• CO-40: insurer says the visit didn't qualify as emergent/urgent care; ER claims are commonly appealed under the prudent-layperson standard — describe the symptoms you had, not the final diagnosis
• PR-49: billed as a routine/preventive or screening service the plan doesn't cover; many preventive services are actually free under the ACA, and coding (preventive vs diagnostic) is often the real issue — worth checking
• CO-51: denied as a pre-existing condition; the ACA prohibits pre-existing-condition exclusions in most health plans, so this deserves scrutiny unless it's a non-ACA plan (short-term, some grandfathered)
• CO-54: insurer won't pay for multiple surgeons/assistants on this case; typically a provider-side billing dispute
• CO-60: outpatient charges close to an inpatient stay are folded into the inpatient payment; typically a provider/hospital billing matter, not patient debt
• CO-95: insurer says the plan's required steps (e.g. referrals, notification rules) weren't followed; find out from the insurer exactly which step was missed — it may be fixable retroactively
• CO-100: payment was sent to the patient/insured rather than the provider; not a denial — the provider may bill you for the amount you received
• CO-107: a related/qualifying claim or service wasn't identified on this claim; provider needs to link or rebill with the related claim info
• CO-108: equipment rent/purchase guidelines weren't met (common for DME); ask the supplier to verify the rental-vs-purchase billing against plan rules
• CO-110: the claim's billing date is before the service date; a data-entry error for the provider to correct and resubmit
• CO-111: not covered unless the provider accepts assignment (agrees to the plan's approved amount); ask the provider about their assignment status
• CO-114: product/procedure isn't FDA-approved in the insurer's view; like experimental denials, this can be appealed with evidence of approval status or medical literature
• CO-115: procedure was postponed, canceled, or delayed; billing needs to reflect what actually happened — a provider-side correction
• CO-116: the advance notice (e.g. an ABN in Medicare) you signed didn't meet requirements; if the notice was defective you generally can't be billed for the denied amount — that protects you
• CO-117: transportation is only covered to the nearest facility able to provide the needed care; appeals can argue the closer facility couldn't actually provide it
• CO-125: claim had submission/billing errors; the provider should correct and resubmit — no patient action beyond nudging the billing office
• CO-128: newborn's services are paid within the mother's claim allowance; an accounting arrangement, not a coverage denial
• CO-129: insurer believes earlier processing information was incorrect; ask which prior claim conflicts and have the provider reconcile
• CO-131: a claim-specific negotiated discount was applied; a pricing adjustment, not a denial — you shouldn't owe the discounted portion
• CO-133: this line is pending further review — not a final decision; follow up with the insurer for the outcome before paying anything
• CO-136: the primary insurer's coverage rules weren't followed before billing this (secondary) payer; usually resolved by fixing the claim path through the primary plan first
• CO-140: patient's health-plan ID number and name don't match the insurer's records; give the provider your exact card details to correct and rebill
• CO-146: the diagnosis code wasn't valid on the service date (e.g. an outdated code); a coding correction for the provider
• CO-147: the provider's contracted rate was expired or not on file with the insurer; a provider-insurer contracting issue, not patient debt on in-network care
• CO-148: information needed from another provider (e.g. referring or prior doctor) was missing or incomplete; ask that provider's office to send the records
• CO-149: lifetime maximum reached for this specific service/benefit category; verify the insurer's count of prior services is accurate
• CO-150: insurer says the records don't justify this level (intensity) of service; can be appealed with clinical documentation showing why that level was needed
• CO-152: insurer says the records don't justify this length/duration of service; appealable with clinical documentation supporting the duration
• CO-153: insurer says the records don't support this drug dosage; appealable with prescriber documentation of why the dose is needed
• CO-160: injury/illness attributed to an activity the plan excludes (e.g. certain hazardous activities); check whether the exclusion actually applies to what happened
• CO-163: a document referenced on the claim never arrived at the insurer; have the provider (or you, if it's your document) resend it
• CO-164: a referenced document arrived too late; ask whether it can still be considered or whether the claim can be reopened
• CO-166: claim was submitted after this payer stopped being responsible for the plan's claims; the claim likely belongs with a successor payer/administrator
• CO-170: this provider type isn't paid for this service under the plan; largely a provider enrollment/billing matter
• CO-171: this provider type isn't paid for services in this facility type; a provider-side billing/enrollment matter
• CO-172: payment adjusted because of the billing provider's specialty; provider-side matter, usually not patient debt
• CO-173: service/equipment wasn't prescribed by a physician per the insurer's records; get the prescribing doctor's order submitted
• CO-176: the prescription on file isn't current; a renewed prescription from the doctor usually resolves it
• CO-177: insurer says the patient hasn't met the plan's eligibility requirements; ask which requirement specifically and verify against your enrollment records
• CO-178: patient hasn't met a required spend-down amount (common in Medicaid); check your spend-down status with the state agency
• CO-179: a required waiting period hasn't been satisfied; verify the plan's waiting-period terms and your enrollment date
• CO-181: the procedure code wasn't valid on the service date; a coding update for the provider to correct and resubmit
• CO-182: the procedure modifier wasn't valid on the service date; provider-side coding fix and resubmit
• CO-183: the referring provider isn't eligible to refer this service (e.g. not enrolled with the payer); the ordering doctor's enrollment usually needs fixing, then rebill
• CO-184: the prescribing/ordering provider isn't eligible to order this service; typically resolved by fixing provider enrollment or getting a new order
• CO-185: the provider who performed the service isn't eligible to perform it per the payer; a provider credentialing/enrollment matter — question any bill sent to you
• CO-189: a generic 'unlisted' code was billed when a specific procedure code exists; provider should rebill with the specific code
• CO-192: a non-standard adjustment code carried over from a paper remittance; ask the insurer what the actual reason is
• CO-199: hospital revenue code and procedure code don't match; a facility billing correction
• CO-200: expenses fall in a period when coverage had lapsed; verify the lapse dates — premium-payment and reinstatement records can contradict this
• CO-206: the provider's National Provider Identifier was missing from the claim; a simple provider-side resubmission fix
• CO-208: the provider's NPI on the claim didn't match payer records; provider-side data fix and resubmit
• CO-210: pre-certification/authorization wasn't obtained in time; retroactive authorization or an appeal citing why timely auth wasn't possible can succeed
• CO-216: denial based on a review organization's (or the payer's own) findings; you're generally entitled to the review findings and can appeal them with clinical evidence
• CO-222: exceeds the provider's contracted maximum hours/days/units for the period; a provider-contract cap, usually not patient debt
• CO-226: information the insurer needs from the billing provider was missing or incomplete; the provider must supply it — follow up with their billing office
• CO-227: information requested from the patient/insured wasn't provided; check your mail/portal for an insurer questionnaire (accident details, other-coverage form) — answering it usually reprocesses the claim
• CO-231: two billed procedures are considered mutually exclusive on the same day/setting; a coding/bundling matter for the provider to correct or appeal
• CO-234: this procedure isn't paid separately (bundled into another payment); the provider generally can't bill you for it
• CO-236: this procedure/modifier combination conflicts with another billed procedure per coding rules; provider-side coding correction
• CO-242: services weren't provided by a network/primary-care provider; check the No Surprises Act (emergency and certain out-of-network facility care) and network-adequacy exceptions before accepting this
• CO-243: services weren't authorized by the network or primary-care provider; a retro-authorization or referral from the PCP may fix it
• CO-246: this code is for required reporting only and is never paid; informational — no patient balance should result
• CO-251: documentation received was incomplete or deficient; the provider needs to send complete records — ask them to resubmit
• CO-252: an attachment or documentation is required before the claim can be decided; not a final denial — the provider should send the requested records
• CO-253: a small reduction in federal (Medicare) payment under sequestration; automatic and not billable to the patient
• CO-254: claim went to the dental plan but benefits fall under the medical plan (or vice versa); resubmitting to the correct plan usually resolves it
• CO-256: service isn't payable under the provider's managed-care contract; a provider-insurer contract matter — question any balance bill
• PR-257: claim is on hold during a premium-payment grace period (ACA exchange plans); pay the overdue premium to have claims processed — not yet a final denial
• CO-261: procedure/service seems inconsistent with the patient's history per the insurer; clinical records explaining the history usually resolve or support an appeal
• PR-275: this payer doesn't cover the primary plan's deductible/coinsurance/copay amounts; a secondary-coverage gap, i.e. patient cost-sharing
• CO-276: services the primary payer denied aren't covered by this (secondary) payer either; the fight is with the primary plan's denial, appeal there first
• CO-279: services weren't from the plan's preferred network providers; check No Surprises Act protections and whether an in-network exception applies
• CO-282: revenue code doesn't match the type of bill (facility claims); a facility coding correction
• CO-284: the authorization number may be valid but doesn't cover the services actually billed; the provider should match services to the auth or request an updated one
• CO-285: the appeal wasn't filed per the plan's required procedures; get the plan's exact appeal instructions (in the denial letter) and refile correctly
• CO-286: the appeal was filed past the plan's deadline; some plans and states allow good-cause late appeals — ask, and consider an external-review request where eligible
• CO-287: the referral's approved visits/scope were used up; a new or extended referral from the PCP is the usual fix
• CO-288: no referral was on file for a plan that requires one; a retroactive referral from your PCP, or an appeal explaining the circumstances, often fixes this
• CO-A1: a generic 'claim denied' code used when no specific reason code fits; the real reason lives in the remark (RARC) codes — demand the specific reason in writing
• CO-B1: these visits aren't covered; ask the insurer which benefit rule excludes them and verify against your plan documents
• CO-B4: a penalty was applied for late claim filing; a provider-side timeliness issue — the penalty generally isn't the patient's to pay
• CO-B9: patient is enrolled in hospice, so services related to the terminal condition are paid through the hospice benefit; unrelated care can still be covered separately — check how the claim was routed
• CO-B10: payment was reduced because a component of this procedure/test was already paid; a bundling adjustment, not new patient debt
• CO-B11: the claim was forwarded to the correct payer/processor; informational — watch for the other payer's decision
• CO-B12: services weren't documented in the medical record per the payer; the provider must produce documentation — this is their burden, not yours
• CO-B13: insurer believes this was already paid on an earlier claim; if you're billed anyway, ask the provider to reconcile against the earlier payment
• CO-B14: only one visit/consultation per physician per day is covered; a frequency rule — provider may appeal with documentation of a distinct, separate service
• CO-B16: the 'new patient' billing criteria weren't met (patient was seen recently by the practice); usually a downcoding correction by the provider
• CO-B20: the service was partly or fully performed by a different provider than billed; the providers need to sort out who bills — question duplicate bills
• CO-B22: payment was adjusted based on the diagnosis; ask what diagnosis rule drove the change and whether the coded diagnosis is accurate
• CO-B23: the lab test isn't authorized under the provider's CLIA lab certification; a lab credentialing matter — not proper patient debt

ER cost-sharing by metro

• N/R
• Dallas-Fort Worth-Arlington, TX
• Houston-The Woodlands-Sugar Land, TX
• Austin-Round Rock-Georgetown, TX
• San Antonio-New Braunfels, TX
• Phoenix-Mesa-Chandler, AZ
• Atlanta-Sandy Springs-Alpharetta, GA
• Longview, TX
• Corpus Christi, TX
• Tyler, TX
• Richmond, VA
• Oklahoma City, OK
• Memphis, TN-MS-AR
• Indianapolis-Carmel-Anderson, IN
• Beaumont-Port Arthur, TX
• Miami-Fort Lauderdale-Pompano Beach, FL
• Nashville-Davidson--Murfreesboro--Franklin, TN
• Los Angeles-Long Beach-Anaheim, CA
• New Orleans-Metairie, LA
• Texarkana, TX-AR
• Las Vegas-Henderson-Paradise, NV
• Albuquerque, NM
• Odessa, TX
• Alexandria, LA
• New York-Newark-Jersey City, NY-NJ-PA
• Sacramento-Roseville-Folsom, CA
• Chicago-Naperville-Elgin, IL-IN-WI
• College Station-Bryan, TX
• Little Rock-North Little Rock-Conway, AR
• Tucson, AZ
• El Paso, TX
• Carson City, NV
• Tulsa, OK
• Tampa-St. Petersburg-Clearwater, FL
• St. Louis, MO-IL
• Laredo, TX
• Fort Smith, AR-OK
• Birmingham-Hoover, AL
• Victoria, TX
• Charlotte-Concord-Gastonia, NC-SC
• Amarillo, TX
• Modesto, CA
• Kansas City, MO-KS
• Las Cruces, NM
• Midland, TX
• Virginia Beach-Norfolk-Newport News, VA-NC
• Coeur d'Alene, ID
• Orlando-Kissimmee-Sanford, FL
• Columbus, OH
• Jackson, MS
• Seattle-Tacoma-Bellevue, WA
• Washington-Arlington-Alexandria, DC-VA-MD-WV
• McAllen-Edinburg-Mission, TX
• Detroit-Warren-Dearborn, MI
• Baton Rouge, LA
• Asheville, NC
• Shreveport-Bossier City, LA
• Cincinnati, OH-KY-IN
• Yuma, AZ
• Louisville/Jefferson County, KY-IN
• Charleston-North Charleston, SC
• Jacksonville, FL
• Dayton-Kettering, OH
• Abilene, TX
• Sherman-Denison, TX
• Riverside-San Bernardino-Ontario, CA
• Johnson City, TN
• Fayetteville-Springdale-Rogers, AR
• Chattanooga, TN-GA
• Brownsville-Harlingen, TX
• Roanoke, VA
• Lafayette, LA
• Raleigh-Cary, NC
• Topeka, KS
• Jefferson City, MO
• Augusta-Richmond County, GA-SC
• Wichita Falls, TX
• Killeen-Temple, TX
• San Angelo, TX
• Denver-Aurora-Lakewood, CO
• Greenville-Anderson, SC
• Fort Wayne, IN
• Prescott Valley-Prescott, AZ
• Savannah, GA
• Florence-Muscle Shoals, AL
• Kennewick-Richland, WA
• San Francisco-Oakland-Berkeley, CA
• Lubbock, TX
• Cape Coral-Fort Myers, FL
• Poughkeepsie-Newburgh-Middletown, NY
• Toledo, OH
• San Diego-Chula Vista-Carlsbad, CA
• Nacogdoches, TX
• Philadelphia-Camden-Wilmington, PA-NJ-DE-MD
• Gulfport-Biloxi, MS
• Kingsport-Bristol, TN-VA
• Montgomery, AL
• Deltona-Daytona Beach-Ormond Beach, FL
• Knoxville, TN
• Palm Bay-Melbourne-Titusville, FL
• Myrtle Beach-Conway-North Myrtle Beach, SC-NC
• Morristown, TN
• Wichita, KS
• Wilmington, NC
• Clarksville, TN-KY
• Pensacola-Ferry Pass-Brent, FL
• Gadsden, AL
• Lawton, OK
• Frankfort, KY
• Columbia, MO
• Cleveland-Elyria, OH
• Lake Charles, LA
• Oxnard-Thousand Oaks-Ventura, CA
• Columbus, MS
• Bellefontaine, OH
• Boston-Cambridge-Newton, MA-NH
• Milwaukee-Waukesha, WI
• Hartford-East Hartford-Middletown, CT
• Michigan City-La Porte, IN
• Athens-Clarke County, GA