CO288 denial code description and corrective action

• Referral is a recommendation to a patient from Primary Care Physician to receive medical services from another health care provider or medical specialist.

• In some plans, such as HMOs, a referral from the PCP is necessary to visit a specialist, and if it is not present, the insurance denies the claim with this denial code.

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 the patient’s plan type and whether a referral is required for the services. If a referral is not required and the claim was denied in error, 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.

• If a referral is required, check whether it was entered on the claim. If it was entered, ask the representative to verify whether the referral is present on their side. If it is present, request the representative to reprocess the claim. Be sure to note the claim number, representative’s name, and call reference number, and follow up on the claim after the provided TAT.

• If we submitted the referral but the insurance did not receive it, this would be a system glitch. In this case, we resubmit the claim and check again if the referral is updated on the new claim. If it is still not updated, we submit the claim through fax or mail.

• If a referral is required but not present, then we proceed according to the client’s instructions (write-off or appeal).

• For submitting an appeal/corrected 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/corrected claim even after the timely filing limit has passed, so we should proceed according to their instructions.

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