CO-288 denial code

Code 288 is short and so is the problem. The plan required a referral before this care and does not have one.

The code list's own wording: Referral absent

What it means: The plan requires a referral, normally from a primary care provider, before it pays a specialist or a particular service. There is none on file for this care.
Who owes the money: Read the letters CO makes it your write-off, on the basis that checking for a referral was your step. PR appears where the plan holds the member responsible for following their own plan's rules. Contract language decides which you can act on.
Is appealing worth it: Often successful when a referral exists and simply was not on file. Payers accept retroactive referrals more readily than retroactive authorisations, because the referring provider can confirm it after the fact.

Do not confuse this with CO-197. An authorisation comes from the payer and requires the payer's agreement. A referral comes from another provider and only requires that provider to confirm it. That makes a missing referral considerably easier to fix, because the person who can solve it is a colleague rather than a review department.

Why the payer sent it

No referral was ever obtained.
A referral exists at the referring office and was never sent to the plan.
The referral expired before the visit.
The referral covered a different number of visits or a different service.
The referral named a different provider in your practice.
The plan changed its referral rules and nobody was told.

Remark codes you will see with it

Remark code	What it adds
N130	Read the plan document for the referral requirements. Its own page.
N54	The claim information is inconsistent with the pre-certified or authorised services.

Remark code

What it adds

N130

Read the plan document for the referral requirements. Its own page.

N54

The claim information is inconsistent with the pre-certified or authorised services.

Read the letters in front of the 288

CO-288: Contractual obligation. Your write-off.
PR-288: Patient responsibility. Seen where the plan holds the member responsible for following the referral rules.
PI-288: Payer initiated. The patient owes nothing.

What to do next

Call the referring office first, not the payer

They are the ones who can produce or confirm the referral, and they can usually do it the same day.
If a referral exists: get it filed with the plan and resubmit. This resolves most of these.
Check the referral details against the claim

Provider named, service covered, visit count, date range. A referral that exists but does not match produces the same denial.
Ask whether the plan accepts a retroactive referral

Many do, and the answer is often more generous than for authorisation, because the clinical decision was made by a provider rather than by the plan.
Check for referrals at booking

The prevention is a question at the point the appointment is made, on the plans that require it. That list is short and stable, so it is worth writing down once.

Codes that get mixed up with 288

Code	How it differs from 288
197	Authorisation absent. From the payer rather than a provider, and harder to obtain late. See CO-197.
242	Services not provided by network providers. Network status rather than a missing step. See CO-242.
243	Services not authorised by network providers.
24	Covered under a capitation agreement, where referrals are usually part of the arrangement. See CO-24.

Code 288 in dental

Referral rules apply mostly on managed care dental plans, where a general dentist has to refer before a specialist is covered. On those plans the referral is the gate for endodontic, periodontal, oral surgery and orthodontic care.

Specialists inherit somebody else's paperwork

A specialist practice depends on the general dentist having done the referral properly, and finds out at the remittance if they did not. Confirming the referral is on file with the plan before the appointment, rather than trusting that it was sent, is the only reliable protection.

Questions people ask about CO-288

What is the difference between a referral and an authorisation?

A referral comes from another provider, usually the patient's primary care provider or general dentist, saying the patient should be seen. An authorisation comes from the payer, agreeing to cover a specific service. A missing referral is usually easier to fix, because the person who can produce it is a colleague rather than a review department.

Can a referral be backdated?

Payers accept retroactive referrals more often than retroactive authorisations, because the clinical decision was made by a provider at the time. Call the referring office first, since they can normally confirm or produce it the same day.

Related codes

Back to all denial codes

RemitBench reads dental EOB PDFs and turns them into posting-ready lines, in your browser, with no upload. It does not read medical remittances today.

Open the app

Opens your mail app with the message written. Nothing is sent from this page.