835 Denial Combination
CO-31
Contractual Obligation · Claim-Level Adjustment
What This Combination Means
The patient is not identified as an insured member under this policy. The patient's name, date of birth, or member ID does not match an active subscriber or dependent in the payer's enrollment system. This requires verifying the patient's actual insurance information.
N/A
Appeal Success
5-14 days
Avg. Resolution
Medium
Difficulty
No
Appealable
Step-by-Step Resolution
Steps tailored specifically to this CO-31 combination — not generic advice.
- 1
Ask the patient for their insurance card and verify the member ID, name, and date of birth match exactly.
- 2
Run eligibility verification to confirm the patient is an active member under the submitted policy.
- 3
If the patient's information doesn't match: determine if the correct plan was submitted or if there is a demographic issue to correct.
- 4
If the patient has been dropped from the policy (e.g., dependent age limit): help the patient identify their current insurance coverage.
- 5
Resubmit with corrected patient/subscriber information if a data entry error is found.
Specialty Context
How CO-31 typically presents across different practice types.
Dental
Common when a dependent child ages out of coverage (typically 26 for ACA plans) or when a name change (marriage/divorce) has not been updated with the insurer.
Medical
Verify the patient's relationship to the subscriber (self/spouse/dependent) and confirm the dependent is listed on the policy.
Behavioral Health
Minor patients must be enrolled as dependents. Adult children off the subscriber's plan must have their own policy.
Individual Code References
View the standalone definition for each code in this combination.
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