CO · Contractual ObligationCARC 272

Denial Code CO-272

Q: What does CO-272 mean?

CO-272 is a Contractual Obligation (CO) denial: "Coverage/program guidelines were not met." The service didn't meet the payer's specific coverage or program guidelines — a policy-based denial where a required condition, criterion, or program rule wasn't satisfied as billed.

Q: Is CO-272 the patient's responsibility or a provider write-off?

CO-272 carries the CO group code (Contractual Obligation): Provider/contractual responsibility — not billable to the patient while denied. A CO adjustment is the provider's responsibility, not the patient's: balance-billing the patient for a CO amount is a contract (and often compliance) violation. But CO does not automatically mean “write it off.” When the cause is fixable — missing information (CO-16), a modifier problem (CO-4), or NCCI bundling (CO-97) — you correct and resubmit, or appeal with documentation. You only truly write the amount off when it is a final contractual adjustment, such as the fee-schedule difference on CO-45.

Coverage/program guidelines were not met.

Source: X12 Claim Adjustment Reason Codes (CARC) & Group Codes. Maintained by the D3rx Clinical Billing Team.

What CO-272 means

The service didn't meet the payer's specific coverage or program guidelines — a policy-based denial where a required condition, criterion, or program rule wasn't satisfied as billed.

Why CO-272 happens

A preventive or screening service billed outside its covered frequency or age window
Medical-policy criteria for the service (indication, prior step) not met or not documented
A program-specific requirement (e.g., a covered-condition list) not satisfied
Documentation that doesn't establish the guideline was met

What to do when you get CO-272

1Read the paired remark and pull the payer's coverage policy/program guideline for the service
2Identify exactly which guideline element wasn't met
3If your documentation meets it, appeal with the records mapped to the guideline
4If a covered alternative or corrected coding applies, submit a corrected claim instead

Got this denial right now?

Generate a CO-272 appeal letter in 60 seconds — free

Generate CO-272 appeal Ask D3 about CO-272

Free e-sign appeal generator. No signup needed to start — you can review and edit before sending.

CO group code: who absorbs the charge

Contractual Obligation — Provider/contractual responsibility — not billable to the patient while denied.

A CO adjustment is the provider's responsibility, not the patient's: balance-billing the patient for a CO amount is a contract (and often compliance) violation. But CO does not automatically mean “write it off.” When the cause is fixable — missing information (CO-16), a modifier problem (CO-4), or NCCI bundling (CO-97) — you correct and resubmit, or appeal with documentation. You only truly write the amount off when it is a final contractual adjustment, such as the fee-schedule difference on CO-45.

Appeal, correct, or write off CO-272?

CO-272 is decided by the cited coverage guideline, so read it and respond to its specific elements. If the documentation shows each criterion was met, appeal with the record mapped to the policy. If the guideline genuinely wasn't met (e.g., a frequency or step-therapy rule), an appeal won't help — pursue a covered alternative or accept the determination. Under CO you can't bill the patient without advance notice.

Timing & deadlines

Appeal within the payer's window (Medicare redetermination 120 days from the remittance; commercial ~180 days). Corrected claims follow timely-filing limits (Medicare 12 months from date of service; commercial ~90-180 days).

Example

A screening service is billed and returns CO-272 because the payer's guideline requires a specific risk factor that wasn't coded. If the patient has the qualifying risk documented, a corrected claim with that diagnosis — or an appeal with the note — supports payment.

Prevent CO-272 going forward

Check the coverage policy/program guideline before delivering policy-gated services
Map each guideline's criteria to the documentation and coding you submit
Verify frequency and age windows for preventive/screening services
Maintain a crosswalk of services to their guideline requirements

Code families most affected

Preventive and screening services with coverage rules
Policy-gated diagnostics and procedures
Program-specific covered services

Related codes

Denial codes you'll often see alongside CO-272

CO-273 CO-50 PR-272

Payer notes

CO-272 (guidelines NOT met) is the mirror of CO-273 (guidelines EXCEEDED). The same CARC appears as PR-272 when the plan shifts the balance to the patient — the group code decides liability.

Turn this CO-272 denial into a sent appeal

D3rx drafts a ready-to-send, e-signable appeal letter for CO-272 from your claim details — free, backed by CMS, Medicare, and major-payer data.

Generate CO-272 appeal Ask D3 about CO-272 All denial codes

Medical billing disclaimer

CARC/RARC definitions are the standardized X12 set; group-code semantics follow the X12 Claim Adjustment Group Code standard. Filing and appeal windows vary by payer — the standard anchors shown (Medicare redetermination 120 days from the remittance; Medicare timely filing 12 months from date of service; most commercial payers ~90-180 days) are general references, not a guarantee for any specific plan. Always confirm the rule in the payer's provider manual before acting. D3rx is not responsible for claim outcomes.