CO-242 — Out-of-network provider
Claim-adjustment reason code 242 · typically reported as CO-242 or PR-242
What it means
Services weren’t provided by a network provider, so the plan denied or reduced payment.
Why DME claims hit it
- MA/commercial members served by a supplier outside the plan’s DME network
- Plan networks changing at year-start while rentals continue
How to fix it
- Verify network participation per-plan at intake and at every January transition; obtain out-of-network authorization/gap exceptions when the network lacks a supplier
Appeal posture
Gap-exception appeals can work when no in-network supplier could serve the patient.
Related denial codes
CO-204 — Not covered under the patient’s current benefit planCO-27 — Expenses incurred after coverage endedCO-197 — Prior authorization absent
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