How do I resolve a CO-167 denial?

Verify the ICD-10 code is valid and fully specified (not truncated) Confirm the diagnosis code is covered for this payer and procedure See full resolution steps at tryarceum.com.

Can I appeal a CO-167 denial?

Yes. Most CO-167 denials can be appealed within 60-180 days depending on payer. This is appealable if documentation supports a different covered diagnosis or if the policy exclusion was applied incorrectly. Use our free tool to generate an appeal letter.

CARC Code

167

🔴 Hard Denial

Diagnosis Not Covered

The insurance plan does not cover services for the diagnosis code(s) submitted on the claim. The payer has determined that treatment for this specific condition is not a covered benefit under the patient's plan.

coding

Resolution: 75%Medium difficulty7-14 days avg

How to resolve this denial

Which payer denied this claim?

Verify diagnosis code accuracy and coverage; correct and resubmit

1
Verify the ICD-10 code is valid and fully specified (not truncated)
2
Confirm the diagnosis code is covered for this payer and procedure
3
Check if the diagnosis code has a coverage limitation (LCD/NCD for Medicare)
4
Correct the diagnosis code based on clinical documentation if coded incorrectly
5
Ensure the primary diagnosis supports medical necessity for the billed procedure
6
Resubmit with corrected diagnosis codes within timely filing window

Resolve this denial →

▶✓ Pre-action checklist — verify before contacting the payer

Review the full remittance advice (ERA/EOB) for additional RARC codes that explain the denial.
Verify the claim was submitted with correct patient eligibility and benefit information.
Check if this denial applies to a specific line item or the entire claim.

▶More about CO-167 — stats, related codes, appeal template

75%

Recovery Rate

7-14 days

Avg. Resolution

Medium

Difficulty

Common

Frequency

Payer-Specific Notes

How major payers handle CARC 167 by specialty.

Medicare

Check NCD/LCD covered ICD-10 list; unspecified codes often trigger CARC 167

UnitedHealthcare

Outdated fiscal year ICD-10 codes rejected; verify code validity for DOS

Common 835 Combinations

CARC 167 most often appears with these Group Code + RARC combinations on 835 remittances.

COCO-167+N362The payer has denied a portion of the claim because the submitted diagnosis

Look up any combination →

Appeal Letter Template

Generic appeal template for CARC 167 denials.

We are resubmitting claim [CLAIM_NUMBER] with a corrected ICD-10 diagnosis code. The original code [OLD_CODE] has been updated to [NEW_CODE] which accurately reflects the patient's condition documented by Dr. [PHYSICIAN] on [DOS]. The corrected code is covered for the billed procedure per plan benefits.

Generate a personalized appeal letter →

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