CO-167Contractual ObligationMedical Necessity
CO-167 Denial Code: Diagnosis not covered
This diagnosis is not covered by the payer/plan.
Why CO-167 happens
- ●Diagnosis outside the plan's covered conditions for the service
- ●More specific covered diagnosis available but not coded
How to fix a CO-167 denial
- 1
Review documentation for a more specific/appropriate diagnosis
- 2
Correct coding if supported; otherwise appeal with policy citations
How to prevent it
Check coverage policies for diagnosis-driven services pre-claim.
Drowning in CO-167 denials?
OakClaim works every denial within 48 hours and builds prevention rules so they stop recurring.