CO226 denial code description and corrective action

• This denial is related to medical records and supporting documentation for the claim.

• It mostly occurs when the requested medical records are not provided, or they are submitted after the allowed time.

• Sometimes this denial occurs when medical records are submitted but do not fully support the service, or when the records are incomplete.

• The absence of the provider’s signature from the records can also lead to this denial.

Actions

• First, we need to verify the status of the claim. This can be done by checking the status through the insurance web portal or by calling the payer.

• The most important step is to determine whether the claim denial is valid or if the insurance has denied the claim by mistake.

• Call the insurance company and confirm with the representative exactly what is required to process the claim, or if records were already submitted, confirm what specific information is missing. If it is found that all the required information has already been received, ask the representative to reprocess the claim. Be sure to document the claim number, representative’s name, and call reference number, and then follow up on the claim after the given TAT.

• If the representative confirms the exact document required, submit that document. If the document is not available in our system, ask the client to provide it so we can proceed further.

• Make sure the time limit for submitting records has not been exceeded. If it has, the claim needs to be written off. However, some providers still wants the documents to be sent even after the limit has passed, then we proceed accordingly.

• Sometimes, along with this denial code, there is a remark code that clearly indicates what the insurance requires, so proceed accordingly.

• Never forget to check the provider’s signature on the medical records.

• If all required records have already been submitted but the insurance still denies the claim and rep disagree to send back for reprocess, then we proceed with submitting an appeal along with the complete documents to support the service.

• For submitting an appeal claim, must calculate the timely filing limit starting from the processed date. If the limit has been exceeded, the claim will be denied again for exceeding the filing deadline. In such cases, we should consult with the provider. Some clients may still want us to submit the appeal claim even after the timely filing limit has passed, so we should proceed according to their instructions.

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