CO-204 (Service Not Covered)
Contractual Obligation 204 — this service/equipment/drug is not covered under the patient's current benefit plan.
1 min read · Last reviewed May 23, 2026
At a glance
- Category
- Denials & Appeals
- Primary sources
- 1
- Workspace handoff
- denial workbench →
Where this comes up
This is denial-workbench territory. A remit posts with a CARC/RARC, the biller decides whether to rebill, appeal, or write off, and the appeal packet has to cite the chart, the order, and the payer's own policy language. Recurring patterns trace back to an upstream workflow gap.
Full definition
What it is in practice
CO-204 is a plan-design denial. It is different from medical-necessity (CO-50) — the service is simply not in the benefit.
How it shows up in your practice
If patient agreed to pay (with ABN or self-pay agreement), shift to patient billing. Otherwise, write off or appeal as appropriate.
Sources
- CMS — CARChttps://x12.org/codes/claim-adjustment-reason-codes
Resolve CO-204 denials in the Denial Workbench
Open denial workbench →Related terms
- Denials & AppealsCARC (Claim Adjustment Reason Code)X12-maintained codes communicating why a claim or service line was paid differently than billed.
- Denials & AppealsABN (Advance Beneficiary Notice of Non-coverage)A standardized notice (CMS-R-131) given to Medicare fee-for-service beneficiaries before furnishing a service Medicare may not cover.
- PayerFormularyA health plan's list of covered drugs, typically organized by tier with associated cost-sharing.
D3rx is a healthcare-billing and compliance research aid maintained by D3rx Inc. Articles are drafted by an LLM (Anthropic Claude) against primary HHS, OCR, CMS, eCFR, NIST, and state-regulator publications, and reviewed for restraint and source fidelity by the D3rx team.
Reviewer status: a named credentialed reviewer (CHC, CHPC, or healthcare attorney) is being engaged. Until that engagement is finalized, this page does not claim credentialed review.
Related across the archive
- GlossaryCARC (Claim Adjustment Reason Code)X12-maintained codes communicating why a claim or service line was paid differently than billed.
- GlossaryABN (Advance Beneficiary Notice of Non-coverage)A standardized notice (CMS-R-131) given to Medicare fee-for-service beneficiaries before furnishing a service Medicare may not cover.
- GlossaryFormularyA health plan's list of covered drugs, typically organized by tier with associated cost-sharing.
- GlossaryAppeal LetterThe written request to a payer to reconsider a denied or partially-paid claim.
- GlossaryCO-109 (Claim Not Covered by Payer)Contractual Obligation 109 — the claim is not covered by this payer/contractor.
- GlossaryCO-16 (Claim Lacks Information)Contractual Obligation 16 — the claim or service line lacks information or has submission/billing errors.
- GlossaryCO-18 (Duplicate Claim)Contractual Obligation 18 — exact duplicate of another claim.
- BillingHow to Appeal an Insurance Denial: Step-by-Step GuideClaim denied? Step-by-step appeal process with payer deadlines, denial code fixes, appeal letter template, and escalation options.
This glossary entry is a research aid for billing and compliance staff. It does not provide legal, medical, or financial advice and does not replace counsel. References cited link to primary sources at HHS, OCR, CMS, eCFR, NIST, and the relevant payer or industry body.