172Denial Code (CARC)Active
CO 172 Denial Code - Resolve Provider Specialty Issues
Code 172 indicates that the payment has been adjusted because the service was performed or billed by a provider of a specialty that is not authorized for this payment. The 835 remittance may include a Healthcare Policy Identification Segment in loop 2110, which provides more details if present.
Who Pays: Group Code Liability
For code 172, the group code is typically CO, meaning this is a contractual adjustment and the provider must write off the amount. The patient should not be billed for this adjustment.
Why Claims Get Code 172
- The provider's specialty does not align with the payer's reimbursement policy for the billed service.
- The claim was submitted under a provider specialty not covered for the specific service by the contract.
- The payer's system incorrectly identified the provider's specialty.
- The provider's specialty information is outdated or incorrectly recorded in the payer's system.
How to Fix & Resubmit
- Review the 835 remittance advice for the Healthcare Policy Identification Segment in loop 2110 for additional details.
- Verify the provider's specialty information in both your billing system and the payer's records.
- Check the payer's policy or contract to confirm whether the service is covered under the provider's specialty.
- If the provider's specialty is correct and aligns with the policy, contact the payer to address any discrepancies.
- If necessary, update the provider's specialty information with the payer and resubmit the claim if allowed.
Corrected Claim or Appeal?
For code 172, if the denial is due to incorrect specialty information, correct the provider's details and resubmit the claim. An appeal may be warranted if the provider's specialty should be covered by the policy but was denied incorrectly.
Preventing Future 172 Denials
- Ensure provider specialty information is up-to-date and accurately reflected in both internal records and with payers.
- Review payer contracts and policies regularly to confirm which specialties are covered for specific services.
- Verify the provider's specialty before submitting claims to avoid misalignment with payer policies.
- Implement a system to regularly audit claims for specialty-related denials.