CO-26 — Coverage Not in Effect on Date of Service (Termination)
The payer's records show the patient's coverage ended before (CO-27) or had not started as of (CO-26) the date of service billed.
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In plain language
The payer's records show the patient's coverage ended before (CO-27) or had not started as of (CO-26) the date of service billed.
Start here
Verify coverage dates via real-time eligibility and payer portal for the specific date of service.
Who resolves it
Registration/Patient Access, Billing
Who prevents it
Registration/Patient Access — eligibility verification timed close to the date of service, including for recurring/scheduled series of visits.
Sources
- X12 CARC list
Validated ClaimetryX Source — Denial Management Knowledge Base, 2026 Research Edition
Research date August 18, 2026. CARC/RARC combinations and payer processes vary. Always check the specific remittance advice and the payer's current requirements before acting on any denial.
Published by ClaimetryX. Sources identify the code standards, agency guidance, and payer policies supporting this reference. How we use sources
How to resolve this denial, step by step
- 1
Verify coverage dates via real-time eligibility and payer portal for the specific date of service.
- 2
Compare to claim submission.
- 3
If payer data conflicts with proof of active coverage, contact payer with documentation (enrollment confirmation, COBRA election, retro-eligibility letter).
- 4
If coverage genuinely lapsed, identify the correct payer (new plan, Medicaid retro- eligibility, self-pay) and rebill accordingly.
- 5
Document the eligibility timeline.
- 6
Escalate if a Medicaid or Medicare Advantage retroactive disenrollment/enrollment issue is involved.
Then choose the correct disposition
Eligibility correction
most common resolution.
Reconsideration/appeal
appropriate only if the provider has documentation proving the payer's termination date is factually incorrect.
Patient responsibility
only after confirming no other payer is responsible and regulatory/contractual rules permit billing the patient.
Stop and escalate when
- Conflicting coverage-date information between payer systems; suspected retroactive Medicaid/MA disenrollment (see CMS timely filing exception categories, cross-reference D11); patient disputes termination.
What Needs to Be Corrected
- Claim correction: If the plan was actually active and the payer's termination date is wrong, request payer correction/reprocessing with proof of active coverage (e.g., enrollment letter).
- Upstream correction: If coverage truly ended before the date of service, the account moves to secondary payer billing, self-pay, or the retro-eligibility/COBRA process — not a claim data fix.
Do Not Do This
- Do not bill the patient automatically without confirming no secondary coverage or retroactive eligibility applies.
- Do not change the date of service to fall inside a coverage window.
Plain-Language Meaning
- The payer's records show the patient's coverage ended before (CO-27) or had not started as of (CO-26) the date of service billed.
Why the Claim Was Denied
- Registration/Eligibility: coverage verification not performed close enough to the date of service; plan termination not caught before the visit
- Payer processing: retroactive termination or retroactive enrollment not yet reflected in the payer's real-time system at the time of the original eligibility check
- COB: patient moved to a new plan and the old plan was billed by mistake
Information the Biller Must Review
- Coverage effective and termination dates, date of service, real-time eligibility response, payer portal history, COB/other-payer information, patient's current insurance card.
Sample Scenario
- Scenario: Claim denied CO-27 for a visit two weeks after a plan's stated termination date.
- Finding: Patient enrolled in a new employer plan effective the same date; old plan correctly terminated coverage.
- Action: Claim rebilled to the new payer identified through updated registration/COB data.
Denial Identifier
- Primary CARC: CO-27 — "Expenses incurred after coverage terminated." Related: CO-26 — "Expenses incurred prior to coverage." (X12)
- Common RARCs: N30 (patient ineligible for this service), MA27, N130 (consult plan benefit documents/guidelines)
- Group code is typically CO but payer-dependent.
Prevention Control
- Real-time eligibility verification on the date of service (not only at initial scheduling); automated alerts for high-risk coverage-gap populations (Medicaid, Marketplace); COB data refresh at each visit.
Department Most Likely Responsible
- Resolves current claim: Registration/Patient Access, Billing. Prevents recurrence:
- Registration/Patient Access — eligibility verification timed close to the date of service, including for recurring/scheduled series of visits.
AI Answer Guardrail
- Verify the exact coverage effective/termination dates against the date of service using a real- time eligibility source before recommending patient billing or rebilling to another payer.
AI Search Terms / Synonyms
- CO27; CO-27; CO26; coverage terminated; expenses incurred after coverage terminated; policy termination denial.
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