CO P25 denial code
Claim adjustment reason code P25. Often reported as CO P25.
Adjusted under a medical provider network
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 P25 means
On a property and casualty claim, the payment was adjusted under a medical provider network (MPN) agreement.
Property and casualty payers, including workers' compensation and auto carriers, are the only ones that use it. Medical provider networks are used mostly in workers' compensation, where the employer or carrier uses an approved network. P25 means the payer applied that network's rate.
It is only used with group code CO. The class of contract information on the remittance may identify the arrangement.
Group codes seen with P25
On a remittance, P25 comes after a group code. These are the ones it is most often reported with:
- CO P25 (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 provider is a member of the employer or carrier's medical provider network.
- The network contract rate is lower than the fee schedule or billed charge.
- The payer applied the network rate to a provider outside the network.
What to do next
- Confirm your participation in the network and the rate that applies.
- Compare the payment with the network contract.
- Dispute the reduction if you are not part of the network or the rate is wrong.
Related codes
- P24 (reason code) Adjusted under a PPO arrangement
- P26 (reason code) Adjusted under a voluntary network (VPN)
- P16 (reason code) Provider not authorized for workers' comp
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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