Denial Code 27 and 26

Denial Code CO 27 also called as PR27 denial code – (Expenses-incurred-after-coverage-terminated).

Denial Code CO 26 also called as PR26 denial code – (Expenses-incurred-prior-to-coverage).

The above denials are coverage related denials. When insurance company come across coverage related issue of the patient policy, then they indicate the claim with denial code CO 27 / PR27 or CO 26 / PR26.

Denial Code CO 27 or PR27 denial code:

Insurance company will deny the claim, when policy of the patient is terminated at the time of service with the denial code CO 27 / PR27. It means doctor rendered the treatment to patient after the policy of the patient terminated.

For example:

Consider patient is having BCBS insurance and took the treatment from doctor on 10/21/2023. BCBS insurance eff from 01/01/2023 and termed on 10/01/2023. Provider billed the claim to BCBS insurance without checking eligibility.

In this case DOS is on 10/21/2023 but BCBS policy was termed on 10/01/2023, so insurance company will deny the claim with denial code CO 27 / PR27 denial code indicating expenses incurred after coverage terminated.

Denial Code CO 27 / PR27 denial code Solutions:

• First step is to verify the eligibility of the patient policy through that particular insurance website or reach out the insurance representative to check patient policy effective and termination date.
• After checking if you come to know the patient policy billed is active at the time the treatment rendered, then inform the same with representative and send the claim back for reprocessing.
• If in case the policy of the patient was terminated at the time service rendered, then check the software or contact patient to see any other active insurance available at the time service rendered.
• If you found an active health policy at the time service rendered, then update and file the claim/service.
• If patient doesn’t have any other active health policy, then go ahead and bill the patient.

Denial Code CO 26 / PR26 denial code:

Insurance company will deny the claim with denial code CO 26 / PR26, when policy of the patient is not effective at the time the service rendered. It means provider rendered the treatment prior patient coverage.

For example:

Consider patient is having Aetna insurance and took the treatment from doctor on 02/29/2023. Aetna insurance is effective from 03/01/2023 and termed on 12/31/2023. Provider billed the claim to Aetna insurance without checking eligibility.

In this case DOS is on 02/29/2023 but Aetna policy was effective from 03/01/2023, so insurance company will deny the claim with denial code CO 26 or PR26 denial code – indicating expenses incurred prior to coverage.

Denial Code CO 26 or PR26 denial code Solutions:

• Verify eligibility to find patient policy effective date.
• If the DOS is prior to effective date, then check application or contact patient to see any active health policy available at the time of service.
• If yes, then bill the claim to active payer.
• If not available then go ahead and bill the patient.

Medical Billing Denials and actions – Top Denial codes Solutions (medicalbillingcycle.com)