What is CO 16 Mean?
The CO 16 denial stands for “Claim/service lacks information needed for adjudication or has inconsistent information.”
Simply put, this denial occurs when the insurance payer cannot process a claim because of some missing details or includes conflicting data — such as patient demographics, diagnosis codes, provider identifiers, or required documentation.
This is an administrative denial, not related to medical necessity or eligibility. The payer simply needs accurate, complete information to proceed with adjudication.
Common Reasons for CO 16 Denial
1. Incomplete or Missing Information
Claims may be denied if key details—such as patient name, date of birth, insurance ID, or provider NPI—are missing or incomplete. Even a small omission can cause the payer’s system to reject the claim.
2. Data Entry or Submission Errors
Simple typing mistakes, incorrect CPT or diagnosis codes, and mismatched patient or provider details can all lead to this denial. These errors often happen during manual entry or claim uploads.
3. Missing Remark or Reference Codes
When required remark codes (like NCPDP Reject Reason Codes or Remittance Advice Remark Codes) are not included, the payer cannot determine the reason or context for the claim—resulting in a CO 16 denial.
4. Incorrect Claim Attachments or Documentation
If supporting documents such as operative notes, prior authorization, or medical reports are missing or attached incorrectly, the claim will be considered incomplete and returned unpaid.
5. Outdated or Inconsistent Information
Using old patient details, expired insurance data, or mismatched information between the claim and medical record can make the claim inconsistent with payer records, causing it to be denied under CO 16.
On-Call Scenario: CO 16 – Claim/service lacks information needed for adjudication, or has inconsistent information.
Claim Denied as Additional Information Requested from Provider
“Hello, I’m calling regarding a denied claim. Could you please confirm the denial date for this claim?”
“What kind of documents have you requested from the provider?”
“Can you please provide the Fax number or Mailing address to send the documents?”
“What is the time limit to send the required documents?”
“May I have the claim number and call reference number, please?”
Important Notes & Actions
When a claim is denied due to missing or additional information requested, follow these steps to ensure proper handling:
Check for Required Documents
If the requested documents are available, submit them directly to the insurance company.
If documents are not available, contact the client to obtain them.
Calculate the Time Limit
Determine the time limit from the denial date.
If the time limit has not expired, send the required documents.
If the time limit has passed, write off the claim unless the client specifically instructs to submit it anyway.
Follow Client Instructions
In some cases, the client may request submission even after the deadline.
Always adhere to the client’s specific guidelines for handling such claims.
Check the Remark Code
Remark codes often provide precise reasons for the denial, which may differ from the general denial description.
Use the AR scenario tool to follow the correct workflow for the specific denial.
Pro Tip: Keeping documentation organized and verifying deadlines ensures timely resubmission and reduces the risk of lost revenue.
Click here for more AR Scenarios and Denials.
so much great info on here, : D.
Thankyou