CO-272Contractual ObligationMedical Necessity
CO-272 Denial Code: Coverage/program guidelines not met
A general guidelines-not-met denial: the service didn't satisfy the plan's coverage criteria — the policy reference in the 835 says which.
Why CO-272 happens
- ●Clinical criteria (step therapy, conservative-care-first) unmet
- ●Program rules (frequency, setting, combination) violated
How to fix a CO-272 denial
- 1
Pull the cited policy; appeal with evidence the criteria were met, or cure the gap and rebill where possible
How to prevent it
Check coverage policies for criteria-heavy services before scheduling.
Drowning in CO-272 denials?
OakClaim works every denial within 48 hours and builds prevention rules so they stop recurring.