CO-62 denial code
Payment denied or reduced for absence of, or exceeded, pre-certification
How to fix it
Establish whether authorisation existed and what it covered. Where the service exceeded the approved scope, request retroactive extension.
How to prevent it
Track approved units and date ranges, not just authorisation numbers. Exceeding scope denies as surely as having none.
In practice
An inpatient admission is pre-certified for three days. The patient's recovery is slower than expected and the stay runs to six. The claim returns CO-62 against the additional days.
Pre-certification approved a length of stay, not an admission. Days four through six were delivered outside the approved scope, and the payer's position is that continued stay review should have happened while the patient was still admitted.
The appeal has to show the clinical justification for each additional day, drawn from the daily progress notes. A general assertion that the patient was not ready for discharge does not carry it; day-by-day documentation of why discharge criteria were unmet does.
What sits behind it
The consistent misunderstanding about pre-certification is that it is a yes-or-no decision. It is not. It approves a defined scope — a number of days, a set of procedures, a date range — and delivering outside that scope denies as completely as never having sought approval.
Concurrent review exists precisely for this. Where a stay is running longer than approved, the extension is requested while the patient is still admitted and the clinical picture is current. A retrospective request weeks later asks a reviewer to accept a case they cannot verify, and they generally do not.
Storing an authorisation number without its parameters is the operational root of most CO-62. The number proves something was approved; the approved units, dates and procedure codes are what determine whether the claim falls inside it. A billing system that captures only the number cannot tell you when you have gone past it.
Related codes
Terms used here — Prior Authorization · Medical Necessity · Appeal
How we handle it — Prior Authorization · Denial Management · Claims Management
Primary sources
The rules behind CO-62, at the bodies that publish them.
- CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F) (opens in a new tab)
Centers for Medicare & Medicaid Services — The rule imposing prior authorization decision timelines and API requirements on impacted payers. It is the single largest scheduled change to authorization workflow this decade.
- Medicare claims appeals process (opens in a new tab)
Centers for Medicare & Medicaid Services — The five levels of appeal, what each requires and the deadline for each. Missing a level's deadline ends the appeal regardless of the claim's merits.
- Medicare Claims Processing Manual (opens in a new tab)
Centers for Medicare & Medicaid Services — The operative manual for how Medicare claims must be coded, submitted, adjusted and appealed. When a payer policy and a vendor's advice disagree, this settles it.
Every denial code with a guide
Authorization
Bundling
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Coverage
Data quality
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Patient responsibility
Provider eligibility
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Looking for a different code? Search all 190 CARC and RARC codes
Questions about CO-62
CO-197 means no pre-certification was obtained at all. CO-62 covers both absence and exceeding — most commonly the latter, where approval existed but the services delivered went beyond the approved days, units or procedures.
With day-by-day clinical documentation showing why discharge criteria were unmet on each additional day. Progress notes carry this; a summary assertion that the patient was not ready does not, because it gives the reviewer nothing to evaluate.
Requesting continued authorisation while the patient is still receiving care, rather than after discharge. It is the intended mechanism for extending an approved stay and has a materially higher success rate than a retrospective request.
Store the authorisation's parameters, not just its number — approved units, date range and procedure codes — and alert when a case approaches its limit. An authorisation number alone cannot tell you when the claim has moved outside what was approved.
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