CO 170 Denial Code: Provider Type Mismatch Fixes
CARC 170 indicates that payment is denied because the procedure or service was performed or billed by a provider type not approved for it. The payer's policy, which might be detailed in the 835 Healthcare Policy Identification Segment, determines the specific provider restrictions.
Who Pays: Group Code Liability
For CARC 170, the group code is typically CO, meaning the provider must write off the amount, and the patient cannot be billed for it. However, if the provider believes the denial was incorrect, they should verify with the payer's policy.
Why Claims Get Code 170
- The provider's specialty or credentials do not align with payer requirements for the billed service.
- The billing provider was not authorized to perform the procedure under the payer's policy.
- A clerical error was made, such as selecting the wrong provider type or specialty during claim submission.
- The provider's contract with the payer does not cover the specific service or procedure.
- The payer's system has outdated or incorrect provider information.
How to Fix & Resubmit
- Verify the provider's credentials and specialty align with the service requirements per the payer's policy.
- Check the payer's policy referenced in the 835 Healthcare Policy Identification Segment for specific provider restrictions.
- If a clerical error occurred, correct the provider type or specialty and resubmit the claim.
- Contact the payer to update any outdated provider information in their system.
- If the denial seems incorrect, gather supporting documentation and request a reconsideration or appeal.
Corrected Claim or Appeal?
Submit a corrected claim if the denial was due to a clerical error or incorrect provider information. If the payer's policy seems misapplied, an appeal with supporting documentation is warranted. If the denial is legitimate per contract, accept the adjustment.
Preventing Future 170 Denials
- Ensure provider credentials and specialties are up-to-date and align with payer requirements before claim submission.
- Regularly review payer contracts and policies for changes affecting provider eligibility.
- Implement a verification step to confirm provider type matches service requirements during claim preparation.
- Maintain open communication with payers to promptly update any changes in provider information.