Denied as out of network
The plan says the provider wasn't in your network. You may still be protected: emergency care and many out-of-network clinicians at in-network hospitals fall under the No Surprises Act.
Official meaning (X12 code 242): Services not provided by network/primary care providers.
Who pays
CO-242. Contractual obligation: the provider's contract with your plan makes this the provider's write-off. An in-network provider generally can't bill you for a CO amount.
PR-242. Patient responsibility: the plan says this part is yours to pay (deductible, copay, coinsurance, or a non-covered service).
What to do
- Was it an emergency, or an out-of-network doctor at an in-network hospital? If so, cite the No Surprises Act.
- If no in-network provider could treat you in a reasonable time or distance, ask for a network-adequacy exception.
- Check whether the provider's network status was listed wrong in the plan's directory; plans must honor directory errors.
- Appeal before the deadline.
If you appeal
Ask for in-network coverage if no in-network provider could give this care in a reasonable time or distance (a network-adequacy exception). Emergency care, and care from out-of-network clinicians at in-network hospitals, is protected by the No Surprises Act.
Deadlines for the first appeal
- employer plan
- 180 days from the notice
- ACA Marketplace plan
- 180 days from the notice
- Medicare Advantage plan
- 65 days from the notice
- Original Medicare
- 120 days from the notice
- Medicaid
- 60 days from the notice
The date printed on your notice controls. Urgent care can be appealed on an expedited (72-hour) basis.
What the data show
Averages across all denials; not a prediction for yours.
Appeal this denial
Upload your denial. We draft the appeal around this code, you approve it, and we fax it to your plan and mail a certified copy. Free check first, then $59.
General information, not legal or medical advice. Owed is a document-preparation and sending service, not a law firm.