Denial code CO-167: Diagnosis not covered
The plan excludes the diagnosis submitted, so no service billed against it will be covered.
This (these) diagnosis(es) is (are) not covered.
What CO-167 actually means
Unlike CO-11, which is a mismatch between diagnosis and procedure, CO-167 says the diagnosis itself sits outside the plan’s covered benefits. Excluded diagnosis categories vary by plan and often involve conditions covered under a separate benefit or a different carrier entirely. Confirm the coded diagnosis reflects the documentation before treating this as a final exclusion — an unspecified or secondary diagnosis in the primary position produces this denial on an otherwise covered encounter.
Why this denial happens
- The plan excludes the diagnosis category from coverage.
- The primary diagnosis position holds a code that does not reflect the reason for the encounter.
- The condition is covered under a different benefit or a different carrier.
- The diagnosis is coded to an unspecified level the policy does not accept.
How to resolve a CO-167 denial
- Verify the coded diagnoses against the documentation and the correct sequencing.
- Correct and resubmit if the wrong diagnosis was sequenced first.
- Appeal with clinical documentation where the diagnosis is accurate and coverage should apply.
- Route to the correct carrier where the condition belongs to another benefit.
How to prevent it
- Sequence the diagnosis that establishes medical necessity in the primary position.
- Check plan exclusions for the conditions you treat most.
Frequently asked
What does denial code CO-167 mean?
The plan excludes the diagnosis submitted, so no service billed against it will be covered. The X12 description reads: "This (these) diagnosis(es) is (are) not covered."
How do I fix a CO-167 denial?
Verify the coded diagnoses against the documentation and the correct sequencing. Correct and resubmit if the wrong diagnosis was sequenced first. Appeal with clinical documentation where the diagnosis is accurate and coverage should apply. Route to the correct carrier where the condition belongs to another benefit.
Can CO-167 be billed to the patient?
Generally no. The recommended path for this code is "appeal or correct and resubmit" — check your payer agreement before transferring any balance to the patient.
Related denial codes
See how much CO-167 is costing you
Upload your 835 remittance files and PayerVista groups every denial by reason code, payer, and dollar impact — so this code stops being a claim you happened to notice and becomes a number you can work.
General revenue-cycle guidance, not legal, coding, or payer-specific advice. Claim adjustment reason codes are maintained by X12 and are revised periodically; payer policy and your provider agreement govern in any specific case. Always read the remark codes transmitted with the denial — they frequently carry the detail this code does not.