CO-288 — Referral Absent or Exceeded

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.

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.

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.

Resolution Workflow

• Confirm whether the specific plan requires a referral for this service type (payer-specific).
• Check the payer portal for an existing referral and its scope (visit count, date range, specialty).
• If a valid referral exists but is missing from the claim, correct and resubmit.
• If no referral exists, determine whether a retroactive referral can be obtained from the PCP (payer-specific).
• Document the referral status finding.
• Escalate if the plan's referral requirement is disputed or unclear.

Department Most Likely Responsible

• Resolves current claim: Billing/Follow-Up, Precertification. Prevents recurrence:
• Scheduling/Patient Access — verify plan-specific referral requirements at scheduling.

Prevention Control

• Plan-benefit-design lookup at scheduling to flag referral-required plans; referral-to-visit validation before the appointment; PCP referral tracking system.

Escalation Trigger

• Referral requirement disputed by patient or PCP office; managed-care contract interpretation needed; repeated referral denials from a specific plan (possible systemic issue).

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.

Resolution path at a glance

AI Search Terms / Synonyms

• CO288; CO-288; CO287; referral absent; referral exceeded; no referral on file; PCP referral denial.

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.

Sources

• X12 CARC list