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CO-272 Denial Code: Coverage or Program Guidelines Not Met

CO-272 means the service didn't meet the payer's coverage or program guidelines, such as documentation, prerequisite, or program participation requirements. It's a broad code, so the remark codes and any policy reference on the ERA tell you which requirement was missed.

Quick facts

Code
CO-272 (CARC 272)
Status
Active In use since November 1, 2015.
Code set
Claim Adjustment Reason Codes (CARC)
Group codes
  • CO (Contractual Obligation): The usual group. The provider absorbs the amount unless the claim is corrected or the denial overturned.
  • PR (Patient Responsibility): Used when the patient is responsible, for example when they didn't meet a program requirement that was theirs to satisfy, or accepted liability in advance.
Official description
Coverage/program guidelines were not met.
X12 Claim Adjustment Reason Codes, retrieved September 25, 2026
Last verified
against the official X12 list.

What CO-272 means

CARC 272 says coverage or program guidelines were not met. It’s a broad denial: the payer has a set of conditions a service must satisfy to be covered, and this claim fell short of at least one of them. Guidelines can be clinical (criteria in a coverage policy), administrative (documentation, forms, or enrollment in a program), or program-specific (rules of a Medicaid waiver, demonstration project, or specialty program).

X12 created CARC 272 and 273 to replace a deactivated code, B5, that combined “not met” and “exceeded” in one. So CO-272 is specifically about a missing requirement, while CO-273 is about going past a limit.

Because it’s general, the remark codes and any policy reference in the 835 are critical. Without them, call the payer and ask which guideline was not met.

Common causes

  • Prerequisites not documented, such as required prior treatment, testing, or evaluations.
  • Program enrollment or eligibility not established, for example a patient not enrolled in a specific program the service requires.
  • Required forms missing, such as certifications, plans of care, or physician orders.
  • Competitive bidding or demonstration rules not followed for DME or other program services.
  • Early intervention or waiver program requirements not satisfied.
  • Provider not qualified under the program’s rules.

How to fix it

  1. Read the remark codes and look up any policy ID in the 835 REF segment.
  2. Get the guideline and list each requirement.
  3. Compare your documentation and claim to each requirement.
  4. If information was missing from the claim, add it and send a corrected claim with resubmission code 7 in box 22.
  5. If the requirement was met but not shown, appeal or request reconsideration with the supporting documentation.
  6. If it truly wasn’t met, write off under CO, or bill the patient only when PR applies.

How to prevent it

  • Keep program requirements on file for each payer program you participate in.
  • Build checklists for services with prerequisites or required forms.
  • Verify program enrollment for patients before providing program-specific services.
  • Validate claims against payer rules. A Claims Validator can check for required elements before submission.

Specialty notes

DME suppliers, early intervention providers, home and community-based services programs, and behavioral health programs with Medicaid-specific rules see CO-272 most, because their services depend on program criteria beyond basic medical necessity.

Remark codes that may appear with CO-272

  • N130 (Consult plan benefit documents/guidelines for information about restrictions for this service.): Points to plan documents describing the guideline that applies.
  • N825 (Early intervention guidelines were not met.): Early intervention guidelines weren't met, one specific program example.
  • M114 (This service was processed in accordance with rules and guidelines under the DMEPOS Competitive Bidding Program or a Demonstration Project.): Processed under DMEPOS Competitive Bidding or a demonstration project's rules.
  • CO-273 (Coverage/program guidelines were exceeded.): Guidelines were exceeded rather than not met, such as going past a program limit.
  • CO-50 (These are non-covered services because this is not deemed a 'medical necessity' by the payer.): Not medically necessary, a more specific clinical denial.
  • CO-95 (Plan procedures not followed.): Plan procedures not followed.
  • CO-B5Deactivated (Coverage/program guidelines were not met or were exceeded.): Deactivated code that combined 'not met or exceeded'; CARC 272 and 273 replaced it.

CO-272 FAQ

Why is CO-272 so vague?

It's a general code for any coverage or program guideline the claim didn't satisfy. Payers are expected to use remark codes or a policy reference to say which guideline, so start there.

What's the difference between CO-272 and CO-273?

CO-272 means a requirement wasn't met, such as a missing prerequisite or documentation element. CO-273 means a limit was exceeded, such as more services than the program allows.

How do I fix CO-272?

Identify the guideline, compare it with your documentation and claim, and either send a corrected claim if information was missing or wrong, or appeal with documentation showing the guideline was met.

Can I bill the patient?

Only when the payer reports PR or the patient agreed in advance, as the payer's rules allow.