CO-288 — Referral Absent or Exceeded
The plan (commonly an HMO/managed-care or Medicaid MCO plan requiring PCP referrals) either has no referral on file for this service or the service exceeds what the referral authorized.
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In plain language
The plan (commonly an HMO/managed-care or Medicaid MCO plan requiring PCP referrals) either has no referral on file for this service or the service exceeds what the referral authorized.
Start here
Confirm whether the specific plan requires a referral for this service type (payer-specific).
Who resolves it
Billing/Follow-Up, Precertification
Who prevents it
Scheduling/Patient Access — verify plan-specific referral requirements at scheduling.
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
Confirm whether the specific plan requires a referral for this service type (payer-specific).
- 2
Check the payer portal for an existing referral and its scope (visit count, date range, specialty).
- 3
If a valid referral exists but is missing from the claim, correct and resubmit.
- 4
If no referral exists, determine whether a retroactive referral can be obtained from the PCP (payer-specific).
- 5
Document the referral status finding.
- 6
Escalate if the plan's referral requirement is disputed or unclear.
Then choose the correct disposition
Corrected claim
when a valid referral exists but was omitted from the claim.
Reconsideration
when a retroactive referral is obtained after the fact (payer-specific whether accepted).
Write-off/patient responsibility
governed by plan and, for Medicaid MCOs, state contract terms; confirm before billing the patient.
Stop and escalate when
- Referral requirement disputed by patient or PCP office; managed-care contract interpretation needed; repeated referral denials from a specific plan (possible systemic issue).
What Needs to Be Corrected
- Claim correction: Add the referring provider/referral number if one exists and was omitted.
- Upstream correction: If no referral was obtained, the scheduling/registration workflow must confirm plan-specific referral requirements before the visit occurs.
Do Not Do This
- Do not create a referral record after the fact without the referring provider's actual authorization.
- Do not assume referral rules are identical across all plans from the same payer.
Plain-Language Meaning
- The plan (commonly an HMO/managed-care or Medicaid MCO plan requiring PCP referrals) either has no referral on file for this service or the service exceeds what the referral authorized.
Why the Claim Was Denied
- Referral requirements: this is a payer/plan-design-specific requirement — not all plans require referrals; verify the specific plan's benefit design before treating this as a universal rule.
- Registration/Scheduling: referral not obtained or not linked to the visit before scheduling.
- Claim construction: valid referral exists but referring-provider information was omitted from the claim.
Information the Biller Must Review
- Referral number/authorization, referring provider NPI and name, referral effective dates and visit-count limits, plan type (HMO/MCO vs PPO — referral rules differ), payer portal referral status.
Sample Scenario
- Scenario: Specialist claim denied CO-288.
- Finding: PCP referral exists in the payer portal but the referring provider NPI was left blank on the claim.
- Action: Corrected claim submitted with referring provider NPI populated.
Denial Identifier
- Primary CARC: CO-288 — "Referral absent." CO-287 — "Referral exceeded." (Both replace the deactivated code 165, "Referral absent or exceeded.") (X12)
- Related CARCs: 242 (services not provided by network/primary care providers), 243 (services not authorized by network/primary care providers) — both replace deactivated code 38
- Common RARC: N517 (resubmit a new claim with the requested information); combinations vary by payer.
Prevention Control
- Plan-benefit-design lookup at scheduling to flag referral-required plans; referral-to-visit validation before the appointment; PCP referral tracking system.
Department Most Likely Responsible
- Resolves current claim: Billing/Follow-Up, Precertification. Prevents recurrence:
- Scheduling/Patient Access — verify plan-specific referral requirements at scheduling.
AI Answer Guardrail
- Confirm whether the specific plan actually requires a referral (this is payer/plan-specific, not universal) before recommending any correction or appeal path.
AI Search Terms / Synonyms
- CO288; CO-288; CO287; referral absent; referral exceeded; no referral on file; PCP referral denial.
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