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CO-242 Denial Code: Not Provided by Network Provider

CO-242 means the services were not provided by a network or primary care provider. The patient's plan requires care from in-network or designated providers, and the rendering provider was not one of them for this service.

Quick facts

Code
CO-242 (CARC 242)
Status
Active In use since June 3, 2012; last modified June 2, 2013.
Code set
Claim Adjustment Reason Codes (CARC)
Group codes
  • CO (Contractual Obligation): The provider is responsible, usually because a network contract or plan rule bars billing the patient for out-of-network care the plan did not approve.
  • PR (Patient Responsibility): The plan assigns the amount to the patient, for example when the member chose an out-of-network provider on a plan without out-of-network benefits. Balance-billing laws, including the federal No Surprises Act, may limit this.
Official description
Services not provided by network/primary care providers.
X12 Claim Adjustment Reason Codes, retrieved September 25, 2026
Last verified
against the official X12 list.

What CO-242 means

CARC 242 says the services were not provided by network/primary care providers. It applies to plans that limit coverage to a network, such as HMOs and EPOs, or that require care from an assigned primary care provider. When a claim comes from a provider outside that network, or from a provider other than the assigned PCP when the plan requires it, the payer denies it with CARC 242.

X12 created CARC 242 in 2012 by splitting deactivated code 38 into two ideas. 242 is about who provided the service. Its sibling, CO-243, is about who authorized it.

Not every CO-242 means you are truly out of network. Payers decide network status from their provider file, so a data mismatch can produce the same denial.

Common causes

  • Provider not contracted with the patient’s specific plan or product, even if contracted with other plans from the same payer.
  • Patient assigned to a different PCP, and the plan pays only the assigned PCP for primary care.
  • Rendering provider not yet credentialed or linked to the group’s contract.
  • Service location not on file with the payer as a network location.
  • Plan changed at the start of a year, moving the patient into a narrower network.
  • Wrong NPI or tax ID on the claim (box 24J, 25, or 33a) that does not match the contracted record.

How to fix it

  1. Verify network status for the rendering provider, billing entity, and location on the date of service, for the patient’s specific plan.
  2. If you were in network, correct the claim data (NPI, TIN, location) and send a corrected claim, or ask the payer to fix its provider file and reprocess.
  3. If the patient’s PCP assignment was wrong, ask the patient to update it with the plan, and ask whether the plan will apply the change retroactively.
  4. If you were truly out of network, check whether an exception applies: emergency care, network adequacy, continuity of care, or a single case agreement. Appeal with that basis if it applies.
  5. Before billing the patient, confirm the group code, your contract terms, and federal and state balance-billing rules.

For more on network and enrollment mismatches, see provider enrollment denials.

How to prevent it

  • Verify the patient’s specific plan and network, not just the payer, at scheduling.
  • Confirm the patient’s assigned PCP for HMO plans before primary care visits.
  • Keep your credentialing roster current and do not schedule new clinicians under a plan until they are active.
  • Set up single case agreements before treating out-of-network patients when possible.
  • Give out-of-network patients clear cost estimates and follow notice-and-consent rules where they apply.

Specialty notes

Behavioral health often relies on single case agreements because of limited network capacity. Arrange them in advance and track their approved dates and visit counts.

Remark codes that may appear with CO-242

  • N52 (Patient not enrolled in the billing provider's managed care plan on the date of service.): The patient is not enrolled in the billing provider's managed care plan on the date of service.
  • N130 (Consult plan benefit documents/guidelines for information about restrictions for this service.): Points to plan documents describing network requirements.
  • N492 (Alert: A network provider may bill the member for this service if the member requested the service and agreed in writing, prior to receiving the…): A network provider may bill the member if the member requested the service and agreed in writing.
  • CO-243 (Services not authorized by network/primary care providers.): The service was not authorized by the network or primary care provider, rather than not provided by one.
  • CO-38Deactivated (Services not provided or authorized by designated (network/primary care) providers.): Deactivated. It combined provided-by and authorized-by network problems; X12 replaced it with 242 and 243.
  • CO-B7 (This provider was not certified/eligible to be paid for this procedure/service on this date of service.): The provider was not certified or eligible for this service on this date.
  • CO-208 (National Provider Identifier - Not matched.): The NPI did not match payer records, which can make an in-network provider look out of network.

CO-242 FAQ

Can I bill the patient for CO-242?

Not under the CO group. If the payer uses PR-242, you may be able to bill the patient, but check your contracts, the plan's terms, and federal and state balance-billing protections first.

What if I am actually in network?

Check that the rendering and billing NPI, tax ID, and location on the claim match your payer enrollment. A mismatch can make the payer treat you as out of network. Fix the data and resubmit, or ask the payer to correct its provider file.

What is a single case agreement?

It is a one-time agreement where a payer agrees to cover an out-of-network provider for a specific patient, often when no suitable network provider is available. It usually must be arranged before care is given.

Does the No Surprises Act affect CO-242?

It can. For emergency services and certain non-emergency services at in-network facilities, federal rules limit patient cost sharing and balance billing. Check whether the service falls under those protections.