CO 16 Denial Code: Avoiding Denials

August 4, 2020Denial Management

Basics of CO 16

CO 16 Denial Code: Claim/service lacks information which is needed for adjudication. Insurance will deny the claim with denial reason code CO 16 accompanied with remarks code, whenever claims submitted with missing, invalid, or incorrect information.

The CO16 denial code alerts you that there is information that is missing in order to process the claim. Due to the CO (Contractual Obligation) Group Code, the omitted information is the responsibility of the provider and, therefore, the patient cannot be billed for these claims. Additional information regarding why the claim is denied may be supplied through remittance advice remarks codes. If the additional remark codes are not provided, suppliers must call and speak with a representative to get the information needed to resubmit the claim.

Major Reason Code

Patient demographics

Resoultion

Review and make a copy of the insurance card for your file, and verify eligibility.  Refer to Item 1a on the claim form. Enter the member ID as indicated on the insurance card.  Refer to Item 2 on the claim form. Enter the patient’s name (last name, first name, and middle initial if any) as indicated on the insurance card.

Billing entity/provider

Resoultion

Refer to Items 33 and 33a on the claim form. Enter the billing provider/supplier name, address, zip code and telephone number in Item 33, and the billing provider/group NPI in Item 33A. Do not enter anything in the Item 33b.

Charges on claim

Resoultion

Refer to Item 24F on the claim form. Enter a charge for each service listed on the claim.

Date range not valid with units submitted

Resloution

Refer to Item(s) 24A and/or 24G on the claim form. Ensure date(s) of service (DOS) correspond(s) to the number of units/days billed. If billing for more than one unit on a single day, services may need to be itemized, one per line.

Facility ZIP code

Resolution

Refer to Item 32 on the claim form. Service facility information is used to price claims. Enter the state code and ZIP code on the claim.

Facility/laboratory name and/or address

Resolution

Refer to Item 32 on the claim form. Service facility information is used to price claims. Enter the service location name and complete address on the claim. Enter the service location name, street address, city, state, and valid ZIP code in item 32. The location where the service was rendered is required for all place of service (POS) codes. If additional entries are needed, separate claim forms must be submitted. If required, enter the service facility NPI in item 32a.

Purchased service/primary provider identifier

Resolution

Enter the valid performing physician/supplier NPI in item 32a. Enter the performing physician/supplier name, address, and ZIP code in item 32.

ICD diagnosis codes

Resolution

Refer to Item 21 on the claim form. Enter up to 12 diagnosis codes in priority order. Indicator ‘0’ is used for ICD-10-CM diagnosis codes. The diagnosis codes must be coded to the highest level of specificity.

Incorrect claim form/format

Resolution

Refer to Items 11b, 12, 14, 16, 18, 19, 24A and 31 on the claim form. You have the option to enter either a 6-digit (MMDDYY) or 8-digit (MMDDCCYY) date. However, you must be consistent with the date format throughout the entire claim, including the provider portion.

Ordering or referring physician name, qualifier and/or NPI

Resolution

Refer to Items 17 and 17b on the claim form. Enter the name of the referring, ordering or supervising physician in Item 17. Enter the individual provider name – not the group name.

Physician/supplier signature

Resolution

Refer to Item 31 on the claim form. The physician/non-physician practitioner signature is required. The following formats are acceptable.

• Actual signature
• “Signature on file” notation (if applicable)
• Computer-generated signature

Primary or secondary payer information

Resolution

Refer to Item 11 on the claim form. This is a required field. By completing this item, the physician/supplier acknowledges that he/she made a good faith effort to determine whether Medicare is the primary or secondary payer.

• If Medicare is primary, enter the word “NONE.”
• If Medicare is secondary, enter the insured’s policy or group number, and continue to Items 11a -11c.

Procedure codes

Resolution

Refer to Item 24D on the claim form. Select a valid procedure code using the most current year’s Current Procedural Terminology (CPT®) and/or Healthcare Common Procedure Coding System (HCPCS) code(s) based on the date(s) of service on your claim.

Rendering physician NPI

Resoluton

Refer to Items 24J and 33 on the claim form. For services rendered by a provider in a group: Enter the individual provider NPI in Item 24J in the unshaded portion of this field. Do not report anything in the upper shaded portion. Do not enter the group NPI in this field. (Billing group NPI goes in Item 33a.). Rendering provider must be associated with group indicated in Item 33. For services rendered by a non-physician practitioner (e.g., laboratory technician, ultrasound technician, radiology technician), enter the supervising physician NPI. Enter the billing group name, address, zip code, and telephone number in Item 33.

End Note

When you receive a CO 16 denial code from a commercial payer, as stated above, the first place to look would be at any remark code present on the ERA, paper EOB, or even the payer’s website. If the reason for the denial is not detailed enough in a remark code, the next step would be to contact the payer to see what information is required. Once the required information is obtained, make sure you know the method to submit the corrected or missing information for each specific payer. Some payers will be as simple as a resubmission, while others will want a corrected claim or information faxed to them along with a form.

Researching and resubmitting claims with common denial code like co 16 denial code can lead to long, frustrating hours trying to figure out why the claim was denied in the first place. The good news is that on average, 63% of denied claims are recoverable and nearly 90% are preventable. E2E Medical Billing Services can assist you in addressing these denials and recover the insurance reimbursement. For more information, feel free to call us at 888-552-1290 or write to us at info@e2eMedicalBilling.com