CO-97 | Benefit not covered
This code indicates that the service is not included as a covered benefit under the patient’s insurance policy.
What This Code Means
CO-97 is applied when an insurer determines that a billed service is not a covered benefit according to the plan’s benefit structure. This decision is based on plan design rather than claim submission accuracy. The code signals that payment is not allowed for this service under the current policy. It does not suggest that documentation was missing or that the claim failed technical validation. The service itself may be covered under other plans or policies but not under the one applied to the claim.
Where Users Usually See This Code
- Patient Explanation of Benefits (EOB)
- Provider remittance advice
- Online claim detail summaries
Why This Code Appears
- The plan excludes the specific service category
- The service is covered only under certain plan tiers
- The benefit applies only after specific conditions are met
What Typically Happens Next
- The insurer denies payment for the service
- The balance may transfer to patient responsibility
- The claim is finalized without further processing
What This Code Is Not
- It is not a documentation or coding error
- It is not related to authorization timing
- It is not an audit or investigation flag
Troubleshooting Checklist
- □ Verify coverage details in the plan document
- □ Check for alternate coverage pathways
- □ Request clarification from the payer
Notes And Edge Cases
Some plans cover services only when delivered in specific settings or for certain diagnoses. Employer plan changes mid-year may also cause unexpected non-coverage. Secondary insurance may affect final liability.