CO-288: Referral absent

What causes it

• 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 to work it

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

How to stop it recurring

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.

Codes worked the same way

CO-288 is checked against the contract before any work is done. 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-45 — Charge exceeds the fee schedule
• CO-97 — Payment included in another service
• CO-18 — Exact duplicate claim or service
• PR-204 — Not covered by this plan
• OA-23 — Prior payer already adjudicated
• CO-286 — Appeal filed too late

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.

• Anesthesia
  Post-op pain blocks bundled into the anesthesia claim
• Ophthalmology
  Retinal imaging and fundus photography done at the same visit, with one line denied as bundled because the record never gives a separate reason for each test.
• Otolaryngology
  The operative note does not state which sinuses were entered on which side, so the sinus surgery lines are bundled together or only one side is allowed.
• Urgent Care
  A global urgent care case rate billed alongside a separate evaluation and management line where the contract pays one or the other, and the second line drops off
• Primary Care
  A preventive visit and a same-day problem visit written up in one undivided note, so the problem visit bundles into the wellness visit and is not paid separately.
• Oncology
  Payer required the drug through its contracted specialty pharmacy, the practice infused from its own stock, and the buy-and-bill claim was denied in full.

What leaving it costs

Working a denied claim costs $57.23 per denied claim in administrative time. Source. At 100 denials a month — an illustration, not a measurement of your practice — that is $5,723 a month, or $68,676 a year, in labour alone.

The figure that makes it worth spending: about 90% of initially denied claims are eventually paid. Source. The reason a denial sits is almost never that nobody knows how to work it — it is that nobody has the hours.

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.