CO-226: Payer missing information from provider

The payer is saying they asked your organization for specific claim information or documentation and never received what they needed to process payment. They are treating the unpaid amount as a contractual adjustment because, under the contract, you must supply that information in order to be paid. Mechanically, the payer system attaches CO-226 after a request for information goes unanswered by the billing provider within a set timeframe. The claim line or entire claim is reduced to zero or partially paid, and the CO group means the remaining balance must be written off unless you overturn the decision with a corrected claim or appeal.

Behavioral health gets hit with CO-226 when payers ask for treatment records, program details, or authorization proof and the billing office does not respond or responds late. Common triggers are requests for PHP or IOP daily progress notes, group therapy sign in sheets, or residential treatment plans that never reach the payer's review team. For SUD programs, payers often request documentation for higher cost days, like the first week of residential or inpatient detox, or for unusual billing such as long telehealth sessions with modifiers 95 or 93. If the UR or clinical team does not send records, or the billing office sends them to the wrong fax or portal, the payer closes the request and posts CO-226 on all affected per diem lines. Carve out behavioral health plans do this a lot around concurrent review. For example, a Medicaid MCO's behavioral vendor may ask for updated ASAM assessments and notes to extend residential or OTP services. If no packet arrives, they apply CO-226 to days after the last approved date, wiping out revenue for those dates and leaving you with a contractual write off unless you successfully reopen the case.

• Confirm there was a payer request for information by checking payer portals, faxes, and mail logs for the claim dates.
• Identify exactly what was requested, such as specific dates of notes, treatment plans, authorization letters, or level of care details.
• Verify whether the documentation was actually sent, and if so, gather proof like fax confirmations or portal upload receipts.
• If it was never sent or was incomplete, compile the full required clinical and administrative documentation, including auth numbers and level of care details, and submit as a corrected claim or per payer instruction.
• If it was sent on time, file an appeal with the documentation packet and proof of timely submission, referencing the original information request and denial codes.
• Track the reconsideration or appeal to resolution, and adjust off only if the payer upholds CO-226 and no further appeal is possible.

• Set up a daily work queue for payer record requests from portals, faxes, and mail, with clear owners and due dates.
• Create a standard packet for each level of care (IOP, PHP, residential, detox, telehealth) so requested documents can be pulled and sent quickly.
• Use your billing or EHR system to flag claims with open documentation requests and hold them from write off until a response and outcome are logged.
• Review payer contracts and policies so UR, clinical, and billing teams know what documentation each payer expects by level of care and code family.