CO-190 Denials Explained: How to Identify, Appeal, and Prevent Them

Navigating the complexities of medical billing can be challenging, especially when faced with denial codes like CO-190. For healthcare revenue cycle management (RCM) teams, this denial not only disrupts workflows but also impacts financial performance. Understanding CO-190 denials is critical for resolving them effectively and preventing future occurrences.

In this post, we’ll break down what CO-190 means, how it compares to similar denial codes, common causes, and how RCM teams can mitigate its impact. You’ll also learn actionable steps to appeal CO-190 denials and strategies to prevent them altogether.

What Is a CO-190 Denial?

CO-190 is a contractual obligation denial code indicating that payment for the claim is bundled into the per diem rate for a Skilled Nursing Facility (SNF) qualified stay. The prefix “CO” (Contractual Obligation) means the payer does not expect the patient to bear financial responsibility. Instead, the provider must adjust the claim as no separate payment is allowed for the service in question.

In essence, the payer includes the denied service as part of the pre-negotiated SNF package rate, leaving the provider unable to bill for it separately.

Comparison: CO-190 vs Similar Denial Codes

Denial Code	Prefix Meaning	Reason/Description	Who's Financially Responsible
CO-190	Contractual Obligation	Payment is included in the allowance for an SNF stay.	Provider
CO-97	Contractual Obligation	Service is included in another billed procedure.	Provider
PR-49	Patient Responsibility	Routine services are non-covered by the patient's plan.	Patient

The key difference between CO-190 and other codes like CO-97 lies in the bundling rationale. CO-190 applies to SNF-specific bundled services, while CO-97 pertains to general procedure bundling. Additionally, PR-49 shifts financial responsibility to the patient for non-covered services, unlike CO-190.

Common Causes of CO-190 Denials

1. Improper Claim Submission: Submitting claims for services that are already included in the SNF per diem rate.
2. Lack of Eligibility Verification: Failing to confirm the patient’s SNF coverage details or bundled services.
3. Insufficient Documentation: Missing or incomplete documentation to justify separate reimbursement.
4. Coding Errors: Using incorrect codes that flag services as separately billable instead of bundled.
5. Payer Policy Changes: Unawareness of updates to payer-specific SNF bundling guidelines.

Impact on Revenue Cycle Teams

CO-190 denials pose both financial and operational challenges for healthcare organizations:

Financial Impact:
- Revenue losses due to denied claims requiring rework.
- Increased accounts receivable (AR) days, which strain cash flow.
- Potential write-offs if appeals fail or deadlines are missed.
- Higher operational costs for managing denials and re-submissions.

Operational Impact:
- Time-intensive denial management processes divert staff from other priorities.
- Need for deep understanding of SNF bundling policies and payer requirements.
- Greater demand for collaboration between billing, coding, and clinical teams.
- Burden of tracking denial trends and appeal outcomes to identify root causes.

To address these challenges, CombineHealth.ai offers innovative solutions like Adam (AI Denial Manager), which helps RCM teams identify, analyze, and resolve CO-190 denials efficiently. With Adam, organizations can reduce revenue leakage and improve cash flow.

Steps To Appeal a CO-190 Denial

Follow these steps to successfully appeal a CO-190 denial:

Step 1: Review the Denial Notice
Examine the Explanation of Benefits (EOB) or Electronic Remittance Advice (ERA) to confirm the denial details and rationale.

Step 2: Gather Documentation
Collect all supporting documents, including the patient’s medical records, SNF eligibility details, and prior authorization (if applicable).

Step 3: Verify Eligibility
Confirm that the denied service was not part of the SNF per diem rate and was separately billable under the payer’s policy.

Step 4: Prepare Appeal Letter
Draft a comprehensive appeal letter outlining the denial issue, supporting evidence, and justification for separate payment.

Step 5: Submit Within Deadline
Ensure the appeal is submitted within the payer’s specified timeframe to avoid automatic rejection.

Step 6: Track and Follow Up
Monitor the appeal status regularly and follow up with the payer to expedite resolution.

How To Prevent CO-190 Denials

Proactive measures can help healthcare organizations significantly reduce the incidence of CO-190 denials. Here’s how:

Front-End Prevention

• Implement robust eligibility verification processes to confirm SNF coverage and bundled services before claim submission.
• Train staff on payer-specific SNF bundling policies to ensure accurate claims submission.

Billing Best Practices

• Use accurate and up-to-date codes reflecting payer requirements for SNF stays.
• Conduct pre-bill audits to identify and correct errors before submission.

Technology Solutions

• Leverage claim scrubbing technology to flag potential bundling issues in real-time.
• Utilize AI tools like Adam (AI Denial Manager) and Rachel (AI Appeals Manager) from CombineHealth.ai to automate denial prevention and appeals, improving compliance and turnaround times.

FAQs

Q1: What does CO-190 mean in medical billing?
CO-190 indicates that payment for a claim is bundled within the Skilled Nursing Facility (SNF) per diem rate and cannot be billed separately.

Q2: Can CO-190 denials be appealed?
Yes, appeals can be submitted if there is evidence that the service was incorrectly bundled or should have been billed separately.

Q3: How long do I have to appeal?
Appeal deadlines vary by payer but are typically between 30-90 days from the denial date. Check the payer’s guidelines for specifics.

Q4: How can I prevent these denials?
Proactive eligibility verification, accurate coding, and leveraging smart technology solutions like CombineHealth.ai’s platform can help prevent CO-190 denials. See our complete guide on denial prevention

By understanding the nuances of CO-190 denials and implementing the strategies outlined above, RCM teams can minimize disruptions, reduce revenue leakage, and streamline operations effectively.