CO-242: Services not provided by network/primary care providers.
The rendering provider or facility is out of network, or is not the designated primary care provider required for this benefit, so the plan is denying or reducing payment based on network status.
What the group code means
- CO
- Contractual Obligation. The provider is responsible and the amount cannot be billed to the patient.
This CARC is reported under more than one group code depending on the payer and the circumstances: CO, PR.
Why it fires
- The provider is out of network for the patient's specific plan
- The plan requires services to be coordinated through a designated PCP and this provider is not that PCP
- The patient sought care outside their network's service area without an authorized exception
Corrective actions, ranked
- 1
Verify network status
Confirm whether the provider is actually in network for this specific plan or product, not just the payer generally.
- 2
Check for a network exception
Look for referrals, authorizations, or continuity-of-care exceptions that may allow in-network processing despite the flag.
- 3
Bill the patient per out-of-network terms
If truly out of network with no exception, handle billing per your out-of-network patient agreement.
Is it worth appealing
Appeal when the provider is verifiably in network, or when an emergency or no-network-availability exception applies that should trigger in-network benefits.
Retrieved 2026-07-18.
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DenialPath provides billing and administrative guidance based on published CMS and X12 sources. It is not medical advice, not a coverage determination, and not a guarantee of payment. NCCI and MUE edits are republished quarterly and payer policies vary by contract. Always confirm against the payer's own current policy before submitting or appealing.