Introduction
Insurance claim denials can be a major roadblock for pediatric practices, affecting not just revenue, but also the ability to deliver timely care. Pediatric billing brings its own set of complexities from age-specific screenings and immunizations to developmental assessments each with unique coding and documentation needs. These specialized requirements often result in higher denial rates if not handled precisely.
On average, denial rates in healthcare range from 5% to 10%, with even small pediatric practices losing substantial revenue every month due to errors that could often be avoided. Whether it’s a coding mismatch, missing documentation, or payer-specific policy issues, these denials can delay payments and increase administrative burdens. This article breaks down the top 10 denial codes most commonly affecting pediatric claims, helping you understand the root causes and giving you practical solutions to reduce their occurrence.
Common Pediatric Denial Codes
| Denial Code | Description |
|---|---|
CO-50 | Non-covered service |
CO-197 | Precertification/Authorization Not Obtained |
CO-16 | Missing or incomplete information |
CO-11 | Diagnosis inconsistent with procedure |
CO-29 | Timely filing |
CO-22 | Coordination of benefits (COB) issue |
CO-18 | Duplicate claim/service |
CO-97 | Service included in another billed procedure (bundled) |
CO-96 | Non-covered charges |
CO-109 | Claim not covered by this payer |
Detailed Analysis of Top 10 Denials
1. Denial Code: CO-50
Description: Non-covered Services – Medical Necessity
Medical necessity denials occur when insurance providers decide that a particular service, test, or treatment doesn’t meet their criteria for being medically essential. In pediatric care, these denials often involve services that go beyond standard protocols like extra developmental screenings, certain genetic testing, prolonged therapy sessions, or specialized interventions. This can be especially frustrating for pediatric clinicians who rely on their training and understanding of the child’s specific needs to guide care. Unfortunately, insurers often follow more rigid, one-size-fits-all guidelines that may not reflect the nuances of individual cases.
Prevention:
- Document detailed clinical rationales for all services that might be questioned
- Include specific developmental concerns, behavioral observations, or family history that justify additional screenings or testing
- Stay updated on payer-specific coverage policies for common pediatric screenings and tests
- Use evidence-based guidelines to support medical necessity documentation
- Implement standardized templates that prompts for medical necessity justification
2. Denial Code: CO-197
Description: Precertification/Authorization Not Obtained
Prior authorization denials happen when a healthcare service is performed before getting the required approval from the insurance company. In pediatric settings, this often applies to things like advanced imaging, specialty consultations, certain diagnostic procedures, durable medical equipment, and specific medications or therapies. Insurance providers use the authorization process to confirm that the service is covered and considered appropriate ahead of time. If this step is missed, even unintentionally, the claim is likely to be denied—leading to delays in payment or additional administrative work for the practice.
Prevention:
- Create a centralized authorization tracking system for all providers in the practice
- Develop a comprehensive list of services requiring authorization by payer
- Assign dedicated staff responsibility for managing the authorization process
- Build authorization checks into the scheduling workflow for all procedures
- Document authorization numbers in both the scheduling and billing systems
3. Denial Code: CO-16
Description: Claim Lacks Required Information
This denial occurs when claims are submitted with missing, incomplete, or incorrect information. In pediatric billing, common issues include missing immunization administration codes, absent birth weight for neonatal care, missing modifiers for preventive services, incomplete EPSDT information, or errors in guardian/guarantor information. These technical denials are typically preventable with proper attention to detail and understanding of pediatric-specific billing requirements.
Prevention:
- Implement claim scrubbing software with pediatric-specific edits
- Create pediatric-specific billing checklists for common services (well visits, immunizations, etc.)
- Provide regular training on unique pediatric coding requirements
- Develop a second-level review process for complex claims
- Establish a quality control system to catch common errors before submission
- Keep provider information current with all payers
4. Denial Code: CO-11
Description: Diagnosis Inconsistent with Procedure
Diagnosis-related denials occur when the diagnosis code on a claim doesn’t align with or support the procedure or service billed, based on the insurer’s clinical guidelines. In pediatric care, this often comes up with developmental assessments, behavioral health visits, or when preventive services are combined with problem-focused care in the same visit. Even if the service was medically appropriate, if the diagnosis and procedure codes don’t match the insurer’s expectations, the claim may be denied.
Prevention:
- Create procedure-specific diagnosis code mapping tools for common pediatric services
- Train providers on appropriate diagnostic coding for developmental screenings
- Document all presenting problems addressed during well visits
- Separate preventive and problem-focused services with appropriate modifiers
- Develop coding guidance specific to common pediatric scenarios (ADHD management, asthma care, etc.)
5. Denial Code: CO-29
Description: Time Limit for Filing Expired
Timely filing denials happen when a claim is submitted after the insurance company’s deadline has expired. These deadlines vary widely some payers require claims within 30 days, while others allow up to a year from the date of service. For pediatric practices, keeping up can be tough due to the high volume of preventive visits, immunizations, and detailed coding requirements. Unfortunately, if a deadline is missed, the claim is typically denied in full, and there are often few, if any, options to appeal.
Prevention:
- Create a filing deadline calendar organized by payer
- Establish a standard claim submission schedule (daily or weekly)
- Implement electronic claims submission for faster processing
- Develop a tracking system for claims approaching filing deadlines
- Prioritize high-risk claims (out-of-network, high-dollar services)
- Train staff on varied timely filing requirements by payer type
6. Denial Code: CO-22
Description: Coordination of Benefits Issues
Coordination of Benefits (COB) denials happen when there’s uncertainty or incorrect information about which insurance plan should pay first. This is a common issue in pediatrics, where a child might be covered under both parents’ plans, have Medicaid as a secondary payer, or be enrolled in a children’s health program. When COB details aren’t clear or up to date, claims can get stuck between insurers, delaying reimbursement and adding extra administrative work for the practice.
Prevention:
- Implement a thorough insurance verification process that identifies all potential coverage
- Document birth dates of both parents to determine primary coverage under the “birthday rule”
- Verify primary vs. secondary insurance status at every visit
- Capture images of all insurance cards (front and back)
- Ask specific questions about other potential coverage (Medicaid, CHIP, etc.)
- Create a dedicated process for handling patients with dual coverage
7. Denial Code: CO-18
Description: Duplicate Claim/Service
Duplicate claim denials arise when a payer believes the same service has been billed more than once. In pediatric practices, this often happens with vaccine administration, where multiple vaccines given during the same visit may be mistakenly identified as duplicates. These denials can also occur when a claim is resubmitted for non-payment without first verifying whether the original claim is still being processed or already paid, leading to unnecessary confusion and delays.
Prevention:
- Implement a claim tracking system to monitor submission status
- Verify claim status before resubmitting
- Create clear protocols for when to correct claims versus submitting new ones
- Use appropriate vaccine administration codes with distinct vaccine products
- Train billing staff on proper claim follow-up procedures
- Review all “duplicate” denials to understand root causes
8. Denial Code: CO-97
Description: Bundled Services
Bundling denials happen when an insurance payer determines that a service is part of another billed procedure and shouldn’t be charged separately. In pediatric care, this often applies to components of preventive visits, lab panels, vaccine administration, or routine vision and hearing screenings. Knowing which services are bundled and which can be billed on their own is key to avoiding denials and ensuring accurate reimbursement.
Prevention:
- Stay current on CPT coding guidelines for pediatric services
- Understand the components included in preventive medicine CPT codes
- Use appropriate modifiers (25, 59) to indicate separately identifiable services
- Train providers on documentation requirements to support separate services
- Create reference guides for common bundling scenarios in pediatrics
- Review Correct Coding Initiative (CCI) edits regularly
9. Denial Code: CO-96
Description: Non-covered Services – Benefits Limitation
Non-covered service denials occur when a procedure or treatment isn’t included in the patient’s insurance benefits. Unlike medical necessity denials, these services are excluded outright regardless of whether they’re clinically appropriate. In pediatrics, this can include specific vision or hearing services, developmental therapies beyond the plan’s visit limit, select vaccines, or specialized treatments. These denials can be especially difficult, as they typically leave families responsible for the full cost of care.
Prevention:
- Verify specific benefits before providing services
- Create a payer-specific reference guide detailing covered services and limitations
- Provide patients with advance beneficiary notices (ABNs) when coverage is questionable
- Train front desk staff to verify coverage for specific services beyond general eligibility
- Stay informed about payer policy updates regarding pediatric service coverage
10. Denial Code: CO-109
Description: Non-Participating Provider
This denials happen when care is provided by a physician or practice that isn’t contracted with the patient’s insurance plan. In pediatrics, being in-network is especially important, since many families are limited in their provider choices due to narrow networks or managed care rules. When services are rendered out-of-network, insurers may pay less or nothing at all leaving families with unexpected bills and practices facing both revenue loss and potential dissatisfaction from patients.
Prevention:
- Verify provider network status during scheduling and registration
- Maintain updated contracts with major payers in your region
- Create clear financial policies for out-of-network patients
- Train scheduling staff on insurance network verification
- Consider strategic contracting with dominant payers in your area
Conclusion
For pediatric practices, addressing the most common claim denials takes a practical approach that includes accurate documentation, efficient workflows, regular staff training, and using technology wisely. By creating prevention plans that focus on each type of denial, practices can improve their clean claim rates, reduce the time and cost of appeals, and get paid faster for the care they provide.
A good first step is to run a denial trend analysis based on your own data. Knowing which types of denials are affecting your revenue the most helps you target your efforts where they’ll have the biggest impact. When denial management is part of your larger business strategy, your team can spend less time fixing billing issues. Reducing denials not only supports your financial health, it also helps your practice grow, invest in better tools, and offer a better experience for patients and families.