Denial codes · Denial code
CO-242 on a nutrition claim: the plan only pays its network providers
By Javier Alvarez · Updated · 4 min read
| Official description | Services not provided by network/primary care providers. |
|---|---|
| History | Replaced deactivated CARC 38 in 2012 |
| Group code | Usually CO; sometimes PR when the plan assigns it to the member |
| Typical plans | HMO and EPO products without out-of-network benefits |
| First check | Are you in network for this member's specific product, on this date? |
| Fix route | Reprocessing if you are in network; exception or agreement going forward if not |
CO-242 tells you the plan has a closed door and you were outside it. The patient has coverage, and the service may well be covered, but only when a provider in the plan's network (or the patient's primary care provider's network) delivers it. For dietitians, it usually shows up the first time you see a patient on a product you did not know you were not contracted for.
What CO-242 means (official X12 wording)
The X12 Claim Adjustment Reason Code list defines CARC 242 as:
"Services not provided by network/primary care providers."
X12 notes it replaced the deactivated code 38. Remark codes vary; N52 ("Patient not enrolled in the billing provider's managed care plan on the date of service.") and N130 ("Consult plan benefit documents/guidelines for information about restrictions for this service.") are two you may see alongside it.
Why network status is product by product
A common trap: "I'm in network with Carrier X." Carriers sell many products, and a provider contract usually lists which ones it covers. HealthCare.gov's plan types guide summarizes the main designs:
| Plan type | Out-of-network coverage | What it means for your claim |
|---|---|---|
| HMO | Generally none except emergencies; often requires a PCP and referrals | Out-of-network visits come back unpaid, often CO-242 |
| EPO | Generally none except emergencies | Same result, usually without the PCP requirement |
| PPO | Yes, at higher member cost | Out of network pays less but pays; CO-242 is unusual |
| POS | Yes, usually with a PCP referral | Depends on referral and network rules |
The HMO and EPO glossary entries describe the "network only" rule. Marketplace plans, narrow-network employer plans and Medicaid managed care products are often HMO or EPO designs.
The usual causes on nutrition claims
1. You are contracted for the PPO but the patient has the HMO or EPO
The card has the carrier's logo you know, so the visit got booked. The product on the card is one your contract excludes. This is the single most common cause.
2. A Marketplace or narrow-network product
Marketplace plans and some employer plans use smaller networks than the carrier's commercial PPO. Being in the big network does not put you in the small one.
3. A PCP-directed plan
Some HMOs and medical-group-based plans pay specialists and allied providers only within the PCP's contracted group or with the PCP's referral on file. A dietitian outside that group, or without the referral, gets CO-242.
4. Medicaid managed care
A patient can move between Medicaid managed care plans, and your contract with one does not carry over to another. Verify the plan assignment for the date of service.
5. The payer did not recognize your contract
The claim was billed under an NPI, tax ID or service location that does not match your contract record (for example, a new group NPI or a new office address not yet added). The payer processes you as out of network. This one is fixable on the claim.
A BlueCard note
With out-of-state Blue members, the claim goes to your local Blue plan, and your network status depends on the member's product and your local contract. Read BlueCard for out-of-state Blue members before assuming.
How to fix a CO-242
- Check your participation for this exact plan and date. Call provider services or check the payer's provider directory and portal. Ask: "Am I participating for the [product name] product on [date]?"
- If you are in network, and the payer made an error, ask for reprocessing with a call reference; if refused, file a reconsideration or appeal with your contract or participation letter.
- If your provider data was wrong (NPI, tax ID, location), fix it with the payer and send a corrected claim (frequency code 7 with the original claim number).
- If the plan needed a PCP referral and the patient has one, submit it as the plan requires and ask for reprocessing; referral rules differ by plan.
- If you are truly out of network, the claim will not be paid as billed. For ongoing care, ask the plan about a network gap exception or a single-case agreement before the next visit. Some plans offer them when no in-network dietitian can reasonably provide the service; none are guaranteed.
- Patient balance: follow your contracts, state rules and the patient's signed financial policy. If you told the patient you were in network, fix that expectation directly before any statement goes out.
How to prevent CO-242
- Keep a list of the products each contract covers, not just the carriers. Get it in writing when you credential.
- Verify the plan type at booking. The product name, plan type (HMO, EPO, PPO) and group number are on the card and in the eligibility response. Our insurance verification call script includes "Is this provider in network for this member's plan?"
- Ask about PCP and referral rules for every HMO member.
- Offer a clear self-pay path for out-of-network patients, agreed before the visit. See cash pay vs insurance for how practices structure it.
- Update the payer when you move or change NPI/tax ID, before you bill from the new setup.
If the payer says you, specifically, were not yet credentialed on that date, the code is usually CO-B7 instead. For every other code, see the denial code lookup.