CO-288: Referral absent

What causes CO-288?

• The patient is on an HMO or point-of-service plan that requires a PCP referral and nobody checked
• A referral existed but expired, or covered a different number of visits
• The referral names a different specialist or a different practice than the one that billed
• The referral was obtained after the date of service and the plan does not accept it retroactively

How do you fix a CO-288 denial?

1. Check eligibility again and confirm whether the plan is referral-required — the answer differs by product line within the same payer
2. If a valid referral exists, get the referral number onto the claim and resubmit rather than appealing
3. If none exists, contact the PCP office; some will issue one covering the date of service, many will not
4. Where the patient self-referred, the balance may be theirs, but check the plan documents before transferring it

Can CO-288 be prevented?

Referral status is an eligibility question and belongs in the same check as coverage and benefits, before the visit. Found afterwards it is often unrecoverable.

A denial like this one is the recurring cost that medical billing outsourcing is built to take off your desk — a dedicated seat working the queue instead of it waiting for whoever has a free hour.

Codes worked the same way

CO-288 is taken back to the authorization. So are these, which is why a queue sorted by recovery route moves faster than one sorted by code number — the same person, in the same system, with the same evidence to hand, clears all of them in one pass.

• CO-197 — Prior authorization absent
• CO-198 — Authorization limit exceeded
• CO-15 — Authorization number missing
• CO-39 — Authorization already refused
• CO-272 — Coverage guidelines not met
• N54 — Claim does not match the authorization

Specialties that name this among their costliest

These are specialties whose own worst denials include one of this kind. The line under each is the denial they name, quoted from their page so you can see what the link is based on.

• Ambulatory Surgery Centers
  Prior authorization obtained for the surgeon but not the facility
• Behavioral Health
  Authorization units exhausted mid-course without renewal
• Urology
  Prior authorization missing for advanced imaging
• Radiology
  Advanced imaging denied for missing prior authorization
• Ophthalmology
  An injection given after the drug authorization lapsed, or under an authorization written for a different agent than the one actually drawn up that day.
• Neurology
  Long-term video EEG authorized as an ambulatory home recording but performed as an admission to the epilepsy monitoring unit, so the facility days sit outside the authorization

What leaving it costs

Working a denied claim costs $57.23 per denied claim in administrative time (source) — before any of it is recovered, and whether or not it ever is.

Payers ultimately pay roughly 90% of claims even while using an initial denial to slow payment (source), so the reason one sits is rarely that nobody knows how to work it. Put your own denial count in.

Questions

Code descriptions are the standard X12 claim adjustment reason and remittance advice remark code text. Payer policies differ, and the payer’s own coverage policy governs any individual claim. This page is working guidance, not legal or clinical advice.