How do I resolve a CO-38 denial?

Confirm the rendering provider's in-network status with this patient's specific plan — network status can vary by plan even within the same insurer family. If the provider is in-network but denied as OON, submit the provider's current contract addendum and request reconsideration. If genuinely OON, verify whether the patient has OON benefits under their plan. For emergency services, apply No Surprises Act protections — balance billing is prohibited for emergency OON services. Inform the patient of their OON financial responsibility and discuss payment options.

Can I appeal a CO-38 denial?

Yes. CO-38 denials are typically appealable with a 35% success rate. Resolution difficulty is Hard and typically takes 21-45 days.

835 Denial Combination

CO-38

Contractual Obligation · Claim-Level Adjustment

What This Combination Means

The services were not provided by a participating (in-network) provider. The rendering provider is not contracted with this patient's plan. The patient may have out-of-network benefits, but the amount paid (if any) reflects out-of-network reimbursement levels.

35%

Appeal Success

21-45 days

Avg. Resolution

Hard

Difficulty

Yes

Appealable

Step-by-Step Resolution

Steps tailored specifically to this CO-38 combination — not generic advice.

1
Confirm the rendering provider's in-network status with this patient's specific plan — network status can vary by plan even within the same insurer family.
2
If the provider is in-network but denied as OON, submit the provider's current contract addendum and request reconsideration.
3
If genuinely OON, verify whether the patient has OON benefits under their plan.
4
For emergency services, apply No Surprises Act protections — balance billing is prohibited for emergency OON services.
5
Inform the patient of their OON financial responsibility and discuss payment options.

Specialty Context

How CO-38 typically presents across different practice types.

Dental

Patients may not realize their dentist is out-of-network until they see the EOB. Proactively verify provider network status at patient check-in.

Medical

Out-of-network denials can result in balance billing up to the billed charges, depending on state law and plan type (HMO/PPO/EPO). No Surprises Act (2022) restricts surprise billing in certain contexts.

Behavioral Health

Mental health provider shortages mean many patients see out-of-network therapists. Under MHPAEA, payers cannot apply stricter OON cost-sharing to BH than to medical services.

Individual Code References

View the standalone definition for each code in this combination.

CARC 38

Decode every 835 combination automatically

Arceum Pro reads your ERA files and surfaces the combined interpretation + recovery steps for every denial — no manual lookups.

Join the Waitlist →

← Back to Combo Lookup Browse All Codes →