How do I resolve a CO-196+N115 denial?

Access the referenced LCD at www.cms.gov/mcd or request it from the contractor: The LCD will explain the specific coverage criteria that were not met according to the prior payer's determination Verify coordination of benefits and confirm prior payer's coverage determination was processed correctly: Ensure the prior payer EOB shows the coverage determination that led to this denial Post the contractual adjustment as a write-off in the billing system: Code this as a CO adjustment related to prior payer LCD non-coverage; patient cannot be billed

835 Denial Combination

CO-196+N115

Contractual Obligation · Service-Line Level Adjustment

Contractual Obligation

What This Combination Means

The prior payer (typically primary insurance or Medicare) made a coverage determination that this service is not covered according to a Local Coverage Determination policy. The current payer is denying based on that prior coverage decision and directing the provider to the specific LCD that governs this service. The provider must write off the amount per contractual obligation.

Financial Responsibility

provider writeoff

The provider must write off this amount as a contractual adjustment and cannot bill the patient. The denial is based on the prior payer's LCD coverage rules.

N/A

Appeal Success

Immediate (write-off)

Avg. Resolution

Easy

Difficulty

Appealable

Step-by-Step Resolution

Steps tailored specifically to this CO-196+N115 combination — not generic advice.

Not Appealable:This is a contractual obligation based on the prior payer's LCD coverage determination, which the current payer is contractually bound to follow.

1
Access the referenced LCD at www.cms.gov/mcd or request it from the contractor
The LCD will explain the specific coverage criteria that were not met according to the prior payer's determination
2
Verify coordination of benefits and confirm prior payer's coverage determination was processed correctly
Ensure the prior payer EOB shows the coverage determination that led to this denial
3
Post the contractual adjustment as a write-off in the billing system
Code this as a CO adjustment related to prior payer LCD non-coverage; patient cannot be billed

Specialty Context

How CO-196+N115 typically presents across different practice types.

Dental

Medical

Common for durable medical equipment, lab tests, or procedures where Medicare LCDs define specific coverage criteria that primary payers follow; secondary payers defer to primary payer LCD determinations

Behavioral Health

May occur when primary payer has LCD restrictions on frequency, medical necessity criteria, or service types for mental health or substance abuse services that secondary payer honors

Individual Code References

View the standalone definition for each code in this combination.

CARC 196 RARC N115

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Synthesized from official definitions — not from training data

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