CO 90 denial code
Claim adjustment reason code 90. Often reported as CO 90.
Drug ingredient cost adjusted
Unofficial reference. This is our own plain-English explanation, not the official code text. Payer rules differ. Verify with the payer and the official X12 code list. AlphaPrefix is not affiliated with X12, CMS or any payer. Data last updated .
What 90 means
The payer changed the ingredient cost of a pharmacy claim to its own allowed price for the drug.
This code is used on pharmacy claims. The payer priced the drug product itself at an amount different from what was submitted, usually based on its reference pricing or contracted rate for that drug.
The dispensing fee is reported separately under its own code. A difference here normally reflects pricing terms rather than an error on the claim, unless the quantity or product identifier was wrong.
Group codes seen with 90
On a remittance, 90 comes after a group code. These are the ones it is most often reported with:
- CO 90 (Contractual Obligation): The provider's side of the ledger. The reduction comes from the payer contract or a rule the provider has to follow, and the patient normally cannot be billed for it.
The payer chooses the group code for each adjustment, so the same reason code can appear with another group code on your remittance. Read the two together. More about group codes.
Common causes
- The submitted ingredient cost was above the payer's maximum allowable cost or contracted price.
- The product identifier or package size submitted led to a different price.
- The quantity dispensed did not match the days' supply or package size the payer expected.
What to do next
- Compare the allowed ingredient cost with the pharmacy contract and the payer's price list for that product.
- Verify the product identifier, package size and quantity on the claim.
- Submit a pricing appeal with acquisition cost support if the payer's price is out of date.
Related codes
Source
Official wording: X12 Claim Adjustment Reason Codes list. The explanation on this page is our own plain-English wording, not the X12 text.
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