CO-242Contractual ObligationEligibility
CO-242 Denial Code: Services not provided by network/primary care providers
Services were not provided by network or designated primary care providers.
Why CO-242 happens
- ●Out-of-network provider for an HMO/EPO member
- ●Member's PCP designation is a different provider
How to fix a CO-242 denial
- 1
Verify network status for the member's specific plan/network
- 2
Appeal with network-adequacy or continuity-of-care arguments where valid
- 3
Bill patient per plan OON rules if applicable
How to prevent it
Verify network participation per plan (not just per payer) at scheduling.
Drowning in CO-242 denials?
OakClaim works every denial within 48 hours and builds prevention rules so they stop recurring.