Every healthcare provider has dealt with claim denials. They’re cumbersome, time-consuming, and can significantly impact your revenue cycle. They become especially frustrating when caused by simple, avoidable mistakes. CO 226 denial code represents one such denial.
What makes this denial code particularly important is that it’s entirely preventable with the right processes in place. That’s why we have created this detailed guide to help you not only resolve but also prevent 226 denials. Let’s start.
CO 226 Denial Code – Description
CO 226 denial code is defined as:
“Information requested from the billing or rendering provider was either not provided at all, not submitted within the required timeframe, or was insufficient or incomplete for claim processing.”
The definition is self-explanatory, so let’s discuss other essential points that the definition does not cover.
According to the Claim Adjustment Reason Code (CARC) code list, when a CO 226 denial is issued, at least one Remark Code must accompany it. These remark codes can be NCPDP Reject Reason Codes or Remittance Advice Remark Codes. These remark codes simplify your work as a healthcare provider, as they tell you exactly what is missing from your claims. For example, you will frequently find the following remark codes appended to denial code CO 226:
- M127: Missing patient medical record for this service.
- N517: Resubmit a new claim with the requested information.
- N706: Missing documentation.
What’s important to note is that CO 226 is not a hard denial. It is just a temporary pause in the claim processing. When insurance payers reject a claim with 226, they are not necessarily saying that a service is not covered or medically unnecessary. They’re saying they can’t make that determination yet because something’s missing from the paperwork.
What Causes the CO 226 Denial Code?
Before we explain how to prevent or resolve the denial code CO 226, it’s important to first understand its root causes. Take a look at the most common factors that lead to 226 denials:
Incomplete Patient Information
As is evident from the definition. Incomplete patient information is the leading cause of denial code 226. When patient information at the point of intake is inaccurate or incomplete, it creates a domino effect throughout the billing process. Due to this, the final submitted claim has missing or incomplete information, which leads to 226 claim denials.
Insufficient Clinical Documentation
Your clinical notes need to paint a complete picture of why the service was necessary and what was done. If the documentation doesn’t clearly support the billed service, payers will issue a CO 226 denial code requesting additional records. This might involve missing operative reports, incomplete progress notes, absent lab results that justify the treatment, or inadequate explanation of medical decision-making.
Missing or Expired Authorization
Another less common cause can be a missing or expired pre-authorization. Some procedures need prior authorization from the insurance payer before you can perform them. If that authorization was not obtained or expired, you will likely see a CO 226 denial.
Delayed Response
Timing matters in claims processing. When payers request additional information, they typically set a deadline, often 30 to 45 days. If you don’t respond within that window, even if you eventually send the documentation, you will receive a CO 226 denial for untimely submission.
How to Prevent the CO 226 Denial Code?
Prevention is always better than correction. Here is what you can do to prevent the CO 226 denial code:
Strengthen Front-End Processes
- Train staff to collect complete, accurate patient information at every visit.
- Verify insurance eligibility before rendering services.
- Use automated systems to flag incomplete information before scheduling.
- Photocopy insurance cards and government IDs for all patient visits.
Implement Documentation Protocols
- Create clear documentation guidelines for each service type.
- Use EHR templates with mandatory fields that cannot be bypassed.
- Conduct regular documentation audits.
- Hold weekly billing/clinical team meetings to address documentation gaps.
Ensure Pre-Submission Claim Scrubbing
- Run all claims through quality checks before submission.
- Use claim scrubbing software to catch errors and missing information.
- Manually review high-dollar claims before submission.
- Develop service-specific checklists to ensure completeness.
Respond Promptly to Payer Requests
- Assign specific staff to monitor payer correspondence.
- Set internal deadlines earlier than payer deadlines.
- Use certified mail or electronic delivery confirmation.
- Maintain detailed logs of all payer communications.
How to Resolve Denial Code 226?
CO 226 is not a hard denial, meaning you can still get the reimbursement if you know how to act. Here’s what you can do if you are ever faced with a 226 denial:
- Examine the denial and remark codes to determine why the claim was rejected.
- Use this information to identify what documentation or details were missing.
- Gather all necessary patient information and supporting documents.
- Verify the patient’s current insurance plan and coverage details.
- Cross-check that your system has accurate, up-to-date information (patient name, insurance carrier, policy number).
- Ensure your records match the patient’s active coverage.
- Compile all required information for proper reimbursement.
- Resubmit the corrected claim.
- Update the claim with complete information.
- Follow payer-specific guidelines and requirements.
- Attach all necessary supporting documents.
- Fill every field on the claim form.
- Submit before the payer’s deadline.
- Track the resubmitted claim’s progress.
Final Word
Finally, we have reached the end of this guide. Let’s quickly recap the important points that we discussed in this blog, in case you missed anything.
CO 226 denial code is a temporary or soft denial. Payers reject a claim with 226 when you don’t provide the requested information, provide insufficient information, or fail to provide the requested details within the payer’s deadline. Luckily, you can prevent this from happening by following the guidelines that we provided in this blog.
However, even with all the precautions, denials can still occur. They are inevitable, especially for less experienced teams. That’s why it is better to get professional denial management services from reliable companies like NeuraBill.
