Category summary: This is often not a denial. First decide whether the line paid correctly under the contract, fee schedule, or BlueCard pricing rule.
Top codes in this category
OA-23Impact of prior payer adjudicationCO-45Charge exceeds fee schedule or contracted allowanceCO-66Blood deductible adjustmentCO-70Cost outlier adjustmentCO-256Service not payable per managed care contract
How to work these denials
- Separate true zero-pay denials from paid lines with contractual write-offs.
- Compare the allowed amount to the contract, product, network status, modifier, units, and place of service.
- Recalculate expected reimbursement at line level and show the exact variance.
- File a payment dispute when the plan used the wrong contract, fee schedule, provider status, or pricing rule.
- Post the adjustment when the allowance is correct and patient liability is not supported.
Evidence checklist
- ERA/EOB allowed amount
- Contract or fee schedule excerpt
- Expected payment calculation
- Network/product verification
- Modifier/unit documentation
- Prior payer EOB if secondary