DENIAL CODE · CO-B16

CO-B16: New Patient Qualifications Not Met

CARC B16 means the payer denied a new-patient E/M because its records show the patient was seen by your group within the prior three years, so it expects an established-patient code.

Official (X12/WPC): "'New Patient' qualifications were not met."

Why payers issue CO-B16

The patient was seen by the same specialty/group in the last 3 years
A different provider in the group saw the patient (same-group rule)
The payer's history is wrong or matched the wrong patient
A new-patient code was billed when established applied

Is it recoverable? Recoverable when the new-patient rule genuinely applies (no face-to-face in 3 years, or a different specialty) — otherwise recode to the established-patient level, which still pays.

Common questions

What does CO-B16 mean?

CARC B16 means the payer denied a new-patient E/M because its records show the patient was seen by your group within the prior three years, so it expects an established-patient code. 'New Patient' qualifications were not met.

How do I appeal or fix a CO-B16 denial?

Recoverable when the new-patient rule genuinely applies (no face-to-face in 3 years, or a different specialty) — otherwise recode to the established-patient level, which still pays. Common causes: the patient was seen by the same specialty/group in the last 3 years; a different provider in the group saw the patient (same-group rule); the payer's history is wrong or matched the wrong patient; a new-patient code was billed when established applied.

Is a CO-B16 denial worth appealing?

Other denial codes

CO-197 · Precertification / Authorization Absent →CO-50 · Not Medically Necessary →CO-16 · Missing or Invalid Information →CO-45 · Charge Exceeds Fee Schedule →CO-97 · Bundled into Another Service →CO-29 · Timely Filing Expired →CO-96 · Non-Covered Charge →OA-18 · Duplicate Claim →OA-22 · Coordination of Benefits →CO-11 · Diagnosis Inconsistent with Procedure →CO-151 · Too Many Services (Frequency/MUE) →CO-B7 · Provider Not Eligible →CO-27 · Coverage Terminated →CO-204 · Not Covered Under Current Plan →CO-109 · Not Covered by This Payer →CO-119 · Benefit Maximum Reached →CO-4 · Modifier Inconsistent or Missing →CO-15 · Authorization Number Missing or Invalid →OA-23 · Prior Payer Adjudication Impact →CO-24 · Charges Covered Under Capitation →CO-26 · Expenses Incurred Prior to Coverage →CO-54 · Assistant Surgeon Not Covered →CO-55 · Experimental / Investigational →CO-58 · Inappropriate Place of Service →CO-59 · Multiple/Concurrent Procedure Reduction →CO-107 · Related/Qualifying Claim Not Identified →CO-167 · Diagnosis Not Covered →CO-170 · Denied for This Provider Type →CO-181 · Procedure Code Invalid on Date of Service →CO-182 · Procedure Modifier Invalid on Date of Service →CO-183 · Referring Provider Not Eligible to Refer →CO-185 · Rendering Provider Not Eligible →CO-198 · Precertification / Authorization Exceeded →CO-226 · Requested Provider Information Not Provided →CO-231 · Mutually Exclusive Procedures →CO-234 · Procedure Not Paid Separately →CO-236 · Procedure/Modifier Combination Not Compatible →CO-242 · Out-of-Network / Non-Network Provider →CO-252 · Documentation Required to Adjudicate →CO-253 · Sequestration Reduction →CO-256 · Not Payable Per Managed-Care Contract →CO-288 · Referral Absent →CO-B15 · Qualifying Service Not Received →CO-A1 · Claim/Service Denied (Remark Required) →

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