835 Denial Combination

CO-16+N264

CO

Contractual Obligation · Claim-Level Adjustment

Missing Information

What This Combination Means

The claim was denied due to missing, incomplete, or invalid ordering provider name information. This is a contractual adjustment resulting from a billing error where the required ordering provider identification was not properly submitted or was incomplete. The payer cannot process the claim without valid ordering provider details as required by regulatory and contractual standards.

Financial Responsibility

provider writeoff

The provider must write off the denied amount per contractual obligation with the payer. The patient cannot be billed for this adjustment because it results from the provider's billing error.

N/A

Appeal Success

7-14 days (corrected claim reprocessing)

Avg. Resolution

Medium

Difficulty

No

Appealable

Step-by-Step Resolution

Steps tailored specifically to this CO-16+N264 combination — not generic advice.

Not Appealable:This is a billing error adjustment under contractual obligation; the appropriate remedy is correcting and resubmitting the claim, not appealing.
  1. 1

    Verify ordering provider NPI and name in practice management system

    Ensure ordering provider information matches NPPES registry exactly, including proper credentials and spelling

  2. 2

    Update claim with complete ordering provider information in Loop 2310A

    Include ordering provider NPI in REF segment and full name in NM1 segment per X12 837 requirements

  3. 3

    Submit corrected claim with Claim Frequency Code 7

    File as replacement claim to correct the ordering provider information and obtain proper adjudication

Specialty Context

How CO-16+N264 typically presents across different practice types.

Dental

Medical

Common for diagnostic imaging, laboratory services, durable medical equipment, and home health claims where an ordering provider separate from the rendering/billing provider is required by Medicare and commercial payers

Behavioral Health

May occur on outpatient therapy or psychiatric claims when services require a physician order but the ordering psychiatrist or physician NPI/name is missing or incomplete

Individual Code References

View the standalone definition for each code in this combination.

CARC 16RARC N264

Medicare Contractor Guidance for CARC 16

FCSO + Noridian + uhc + aetna + bcbs_az

This RUC is received when a claim is submitted with missing, incorrect, or invalid information. For details pertaining to your claim, please refer to the remittance advice remark codes (RARCs) on the remittance advice (RA).

How to Prevent CARC 16 Denials

  • ✓

    Review the RARC on the remittance advice to identify which specific field has the error.

  • ✓

    Per Medicare guidelines, claims must be filed no later than 12 months after the date of service. RUCs are not considered filed/submitted.

CMS guidelines for completion of form CMS-1500 in the Medicare Claims Processing Manual (100-04), Chapter 26SPOTFee Schedule Lookup ToolCMS laboratory demographics lookupModifier lookup toolNoridian Medicare PortalNMPIVRSame or SimilarPECOSPDAC

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Synthesized from official definitions — not from training data

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