CARC 242CO · Contractual Obligation
The service was performed by a provider outside the patient's plan network or outside their assigned primary care provider group.
- Common causes
- The patient sought care out-of-network, or an HMO plan requires primary care provider referral or coordination that wasn't followed.
- Suggested fix
- Confirm the plan's network requirements; if an emergency or referral exception applies, submit documentation on appeal.
Related Contractual Obligation codes
107This claim depends on another related claim or service being referenced, but that link wasn't provided.11The diagnosis code doesn't support medical necessity for the procedure billed, based on the payer's coverage edits.13The claim shows a date of service after the patient's recorded date of death.146The diagnosis code billed wasn't a valid, active code as of the date of service.150The documentation submitted doesn't justify the complexity or level of the service billed, commonly seen with evaluation and management visit levels.16The claim is missing required information or contains a billing error that prevented the payer from processing it.170This payer doesn't reimburse this specific provider type for this service.171This payer doesn't cover this service when it's billed by this provider type in this particular facility setting.
Frequently asked questions
What does CARC 242 mean?
The service was performed by a provider outside the patient's plan network or outside their assigned primary care provider group.
How do I resolve CARC 242?
Confirm the plan's network requirements; if an emergency or referral exception applies, submit documentation on appeal.
Why does CARC 242 happen?
The patient sought care out-of-network, or an HMO plan requires primary care provider referral or coordination that wasn't followed.
CARC codes maintained by X12 (x12.org). Descriptions on this site are original reference interpretations. Always verify codes with authoritative sources before making billing decisions.