CO242 denial code description and corrective action

Services not provided by network/ primary care physician. (Services provided by OON provider).

This denial occurs when the provider is not contracted with the insurance.
The basis of this denial is that the provider is out-of-network (OON) while the patient’s plan does not cover OON benefits.
Plan types like HMO and EPO do not offer OON benefits, while PPO and POS plans do provide OON benefits.

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 the patient’s plan type and benefits. If the plan covers OON benefits and the provider is also OON, then ask the representative to reprocess the claim. Be sure to document the claim number, representative’s name, and call reference number, and follow up on the claim after the provided TAT.
Also check the provider’s status, and if the provider is found to be in-network (INN) on the date of service (DOS), then ask the representative to reprocess the claim. Be sure to document the important details and follow up after the provided TAT.
If the provider is OON and the patient has no OON benefits, then bill the claim to the secondary insurance, if available, after verifying eligibility.
If there is no other active insurance, then release the claim to the patient.