CO45 denial code description and corrective action

Charges exceed the fee schedule/ maximum allowable or contracted fee agreement.

This is basically an adjustment and occurs when the charge amount exceeds the maximum allowable limit or the contracted fee schedule.
A fee schedule refers to the predetermined list that defines how much a procedure should be allowed or reimbursed by the insurance.
For example, let us consider that the contracted amount for a procedure is $80. This means that if the claim is not denied, the allowed amount should be $80. If we bill that procedure with a charge amount of $150 without any error, the insurance will allow $80 and adjust the remaining $70 with this remark code.
For out-of-network (OON) providers, denial code 45 may also come with category PR. This does not mean the amount should be billed to the patient. In most cases, we adjust it, or if the client has specific SOPs related to this situation, we proceed accordingly.

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.
If the claim is processed and paid, or processed as copay, coinsurance, or deductible, then the amount associated with this code should be written off.
When there is no paid amount or patient responsibility, and another denial code appears along with this code, disregard this code and work on resolving the other denial mentioned.
If there is neither a paid amount nor patient responsibility and the total amount is adjusted with this code, then we must contact the insurance company to obtain the exact reason for the denial.
If the representative provides the exact reason, then proceed accordingly based on the information given.
If the representative also does not have any information about the exact denial reason, then ask them to send the claim back for reprocessing since no clear denial reason is available. Be sure to note the claim number, representative’s name, and call reference number, and then follow up on the claim after the provided TAT.