CO-227: Patient failed to return requested info

The payer is telling you they asked the member for information and never got a response. Often this is about other insurance coverage, accident details, student status, coordination of benefits forms, or subscriber verification. On the payer side the edit fires when they have an open member information request tied to the date of service that is past due. They then reduce or deny payment using CO-227 and mark the amount as provider write off unless the information is later provided and the claim is reopened.

In behavioral health you see CO-227 a lot when a member has possible other coverage and the payer is waiting on the patient to confirm primary versus secondary insurance. Residential and PHP per diem bills can sit unpaid because the patient never returned a coordination of benefits form the health plan mailed or texted to them. You also see this when Medicaid or an MCO thinks a third party may be liable, such as an accident, workers comp, or EAP, and they send the member a questionnaire. If the member does not answer, your IOP or SUD residential claims get hit with CO-227 even though your documentation and coding are clean. Telehealth and MAT programs are not immune. For example, an OTP billing weekly methadone bundles or a tele-IOP using 95 modifiers can get CO-227 when a commercial plan flags possible student coverage or previous out-of-state Medicaid and waits on the patient to clear it up.

• Confirm in the payer portal or by phone that the denial is tied to a member information request and not a coding issue.
• Ask exactly what information the payer requested from the patient and how the patient can still submit it, such as COB form, accident details, or other insurance card.
• Contact the patient or guarantor, explain that their benefit is on hold due to missing information, and assist them in submitting what the plan needs.
• Once the payer confirms they received the member information, ask if the claim will auto-reprocess or if you must submit a corrected claim.
• If reprocessing is not automatic, resend the claim as a corrected claim with any updated insurance information or COB indicators.
• If the payer refuses to reopen despite the patient now responding, file an appeal with evidence of the member's submission and any access-to-care risk, especially for residential or SUD services.

• Verify insurance thoroughly at intake and ask targeted questions about other coverage, recent insurance changes, and accidents.
• Build a script for front desk and admissions to warn patients that ignoring payer questionnaires can delay or stop payment for their treatment.
• Have eligibility staff monitor payer portals for open member information requests and proactively reach out to patients before claims deny.
• For long-stay levels of care like residential and PHP, set a weekly task to review COB and TPL flags on active patients and resolve them early.