Immediate Solution: Track and Follow Up on Pending Payments
CO-143 denial means the insurance company is holding back a portion of your payment pending additional review, coordination with other payers, or receipt of missing information. This is not a true denial but a payment deferral requiring active tracking. To resolve immediately, contact the payer’s provider services to identify what specific information or process is causing the deferral, provide any missing documentation, and establish a follow-up timeline. Most CO-143 situations resolve within 30-60 days with proper follow-up.
Understanding CO-143: Root Causes and Triggers
The CO-143 adjustment reason code indicates that part of the claim payment is being held in suspense while the payer conducts additional review or awaits resolution of specific issues. Unlike standard denials, CO-143 represents a temporary hold rather than a permanent rejection, making it critical to understand the underlying cause and appropriate response strategy.
Primary Triggers for Payment Deferrals:
Coordination of Benefits (COB) Issues:
- Waiting for primary payer information or EOB
- Investigating potential third-party liability (auto accidents, workers’ comp)
- Resolving Medicare Secondary Payer (MSP) situations
- Coordinating with patient’s multiple insurance policies
Medical Review Requirements:
- Claims flagged for medical necessity review
- High-dollar claims requiring additional authorization
- Services requiring peer-to-peer physician consultation
- Experimental or investigational procedure reviews
Administrative Processing Delays:
- Missing or incomplete prior authorization documentation
- Pending provider credentialing or contract updates
- System processing delays for complex claims
- Multi-state coordination for out-of-network services
Claims Investigation Scenarios:
- Duplicate claim investigation (multiple submissions)
- Fraud and abuse screening reviews
- Unusual billing pattern analysis
- High-frequency service utilization reviews
Critical Information to Verify and Track
Essential Claim Details for CO-143 Follow-up
| Information Category | What to Document | Where to Find |
|---|---|---|
| Deferral Reason | Specific cause of payment hold | EOB remarks, payer correspondence |
| Deferred Amount | Exact dollar amount being held | EOB payment summary |
| Expected Resolution | Estimated timeframe for decision | Payer customer service |
| Required Actions | What provider must submit | EOB instructions, payer portal |
| Reference Numbers | Tracking numbers for deferred portion | EOB, claim confirmation |
CMS1500/UB04 Fields Frequently Involved in CO-143
| Form | Field | Common Deferral Issues |
|---|---|---|
| CMS1500 Box 11 | Other Insurance Info | Missing COB information |
| CMS1500 Box 23 | Prior Authorization | Pending auth verification |
| CMS1500 Box 24E | Diagnosis Pointers | Medical necessity review |
| UB04 FL 18-28 | Condition Codes | Liability investigation |
| UB04 FL 31-34 | Occurrence Codes | Accident-related deferrals |
| UB04 FL 50-55 | Payer Information | COB verification delays |
Documentation Requirements by Deferral Type
| Deferral Reason | Required Documentation | Submission Method | Timeline |
|---|---|---|---|
| COB Investigation | Primary payer EOB, insurance cards | Fax, portal upload | 30 days |
| Medical Review | Medical records, physician notes | Secure email, portal | 45 days |
| Prior Auth Pending | Authorization request, clinical notes | Electronic submission | 14 days |
| Liability Investigation | Accident reports, legal documentation | Certified mail | 60 days |
Prevention Strategies: Minimizing CO-143 Deferrals
Step 1: Comprehensive Pre-Service Verification
- Verify all insurance coverage including primary, secondary, and tertiary
- Check for third-party liability (auto, workers’ comp, general liability)
- Confirm prior authorization status for all services requiring approval
- Document coordination of benefits hierarchy and effective dates
Step 2: Complete Claim Submission Protocol
Front-End Verification Checklist:
- Primary insurance verification within 48 hours of service
- Secondary insurance coordination rules confirmed
- Prior authorization obtained and documented
- Third-party liability screening completed
- Medical necessity documentation prepared
- Provider credentialing status current
Claim Preparation Standards:
- All required fields completed accurately
- Supporting documentation attached proactively
- Coordination of benefits information included
- Prior authorization numbers referenced
- Medical necessity justification provided when applicable
Step 3: Proactive Communication Protocols
Pre-submission Communication:
- Contact payer for complex cases before submission
- Verify specific documentation requirements
- Confirm processing timelines for unusual services
- Establish direct contact for high-dollar claims
Post-submission Monitoring:
- Track claims through payer portals daily
- Follow up on pending claims within 14 days
- Document all communication with payers
- Escalate delays beyond normal processing times
Resolution Process: Converting Deferrals to Payments
Step 1: Immediate Assessment (Day 1-2)
- Review EOB thoroughly to identify specific deferral reason
- Check payer portal for additional information or requests
- Verify claim completeness against original submission
- Document deferral details in practice management system
Step 2: Information Gathering (Day 3-5)
- Contact payer customer service for specific requirements
- Gather requested documentation from appropriate sources
- Verify completeness of information package
- Prepare submission in payer’s preferred format
Step 3: Response Submission (Day 6-10)
For COB-Related Deferrals:
- Submit primary payer EOB or denial letter
- Include insurance verification documentation
- Provide coordination of benefits worksheet if available
- Submit via payer’s preferred method (portal, fax, mail)
For Medical Review Deferrals:
- Compile complete medical records for services
- Include physician’s notes supporting medical necessity
- Attach any relevant diagnostic test results
- Prepare peer-to-peer consultation if requested
For Administrative Deferrals:
- Submit missing prior authorization documentation
- Provide updated provider credentialing information
- Include any requested administrative forms
- Confirm receipt through payer confirmation system
Step 4: Follow-up and Tracking (Day 11-30)
- Confirm receipt of submitted documentation
- Establish follow-up timeline with payer representative
- Document all interactions in patient account
- Monitor payer portal for status updates
- Escalate to supervisor if delays exceed expected timeframes
Appeal Process: When Deferrals Become Denials
Understanding Deferral-to-Denial Conversion
Automatic Conversion Triggers:
- No response to information requests within specified timeframe
- Incomplete documentation submission
- Failure to provide requested clinical information
- Missing coordination of benefits information beyond deadline
Timeline Considerations:
- Most payers convert deferrals to denials after 30-90 days
- Medicare has specific timelines for medical review deferrals
- Commercial payers vary in deferral-to-denial conversion policies
- Workers’ compensation may extend deferral periods indefinitely
Deferral-Specific Appeal Strategy
Pre-Conversion Appeals:
- Submit appeal before automatic denial occurs
- Include all requested documentation with appeal
- Reference original deferral and CO-143 code
- Provide timeline of attempted resolutions
Post-Conversion Appeals:
- Follow standard appeal process for converted denial code
- Include documentation of original CO-143 deferral
- Demonstrate good faith effort to provide information
- Request reconsideration based on administrative delay
Appeal Documentation Package
Required Components:
- Original EOB showing CO-143 deferral
- All correspondence with payer regarding deferral
- Documentation submitted in response to deferral
- Timeline of provider actions and payer responses
- Appeal letter requesting payment of deferred amount
Tools & Software Recommendations
Deferral Tracking and Management Systems
| Software Platform | Key Features | Monthly Cost | Best Use Case |
|---|---|---|---|
| AdvancedMD Revenue Cycle | Automated deferral tracking | $299-$599 | Multi-provider practices |
| Practice Management Plus | CO-143 specific workflows | $199-$399 | Specialty practices |
| Kareo Billing | Integrated follow-up reminders | $80-$440 | Small to medium practices |
| Epic Revenue Guardian | Enterprise deferral management | Enterprise pricing | Hospital systems |
Communication and Documentation Tools
| Tool Type | Recommended Solution | Features | Cost Range |
|---|---|---|---|
| Payer Portal Aggregator | Availity Essentials | Multi-payer access | $89-$299/month |
| Document Management | Office 365 SharePoint | Secure file sharing | $5-$22/user/month |
| Communication Tracking | Salesforce Health Cloud | Interaction logging | $150-$300/user/month |
| Workflow Automation | Microsoft Power Automate | Automated follow-ups | $15-$40/user/month |
Reporting and Analytics Platforms
| Platform | Analytics Features | Integration Options | Pricing Model |
|---|---|---|---|
| Tableau Healthcare | Deferral trend analysis | API connections | $70-$175/user/month |
| Power BI Premium | Custom deferral dashboards | Microsoft ecosystem | $20/user/month |
| QlikSense | Real-time deferral monitoring | Multiple data sources | $30-$60/user/month |
| Custom SQL Reports | Practice-specific metrics | Direct database access | Development costs |
Staff Training Implementation
Training Module 1: CO-143 Identification and Triage (Week1)
- Objective: Recognize CO-143 deferrals and categorize by type
- Activities: EOB analysis exercises, deferral reason classification
- Assessment: 95% accuracy in deferral type identification
- Duration: 4 hours initial training, 1 hour monthly review
Core Competencies Developed:
- Differentiate CO-143 from true denials
- Identify common deferral triggers
- Categorize deferrals by resolution pathway
- Prioritize deferrals by financial impact
Training Module 2: Information Gathering and Documentation (Week 2)
- Objective: Efficiently obtain and organize required documentation
- Activities: Mock information requests, documentation checklists
- Assessment: Complete documentation package assembly test
- Duration: 3 hours initial training, quarterly updates
Skills Development Focus:
- Payer-specific information requirements
- Documentation quality standards
- Submission method preferences by payer
- Follow-up communication protocols
Training Module 3: Payer Communication and Follow-up (Week 3)
- Objective: Effective communication with payer representatives
- Activities: Role-play scenarios, call tracking practice
- Assessment: Successful resolution of practice deferrals
- Duration: 5 hours initial training, bi-annual refresher
Communication Skills Training:
- Professional phone etiquette with payer representatives
- Effective email communication for complex issues
- Escalation procedures for unresponsive payers
- Documentation of all payer interactions
Training Module 4: Technology and Workflow Optimization (Week 4)
- Objective: Maximize efficiency using available tools
- Activities: Software training, workflow development
- Assessment: Demonstrate proficiency in tracking systems
- Duration: 3 hours initial training, technology updates as needed
Financial Impact & Key Performance Indicators
Revenue Impact Analysis
Average CO-143 Deferral Financial Impact:
- Typical Deferral Amount: $250-$1,800 per occurrence
- Resolution Timeline: 30-90 days average
- Conversion to Payment Rate: 78% with active follow-up
- Staff Time Investment: 2.5 hours per deferral resolution
- Administrative Costs: $85-$150 per deferral (staff time + materials)
CO-143 Specific KPI Dashboard
| Metric | Industry Target | Current Average | High-Performing Practices | Monitoring Frequency |
|---|---|---|---|---|
| Deferral Resolution Rate | >85% | 67.3% | 91.2% | Weekly |
| Average Resolution Time | <45 days | 68.7 days | 32.4 days | Daily tracking |
| Deferral-to-Denial Conversion | <15% | 28.9% | 8.7% | Monthly |
| Follow-up Response Rate | >95% | 73.2% | 98.1% | Daily |
| Documentation Completeness | >98% | 81.4% | 99.3% | Per submission |
Cost-Benefit Analysis: Deferral Management Investment
Investment Components:
- Specialized staff training: $1,800 per FTE
- Deferral tracking software: $200-$600 monthly
- Enhanced documentation systems: $2,500-$5,000 setup
- Process improvement consulting: $3,000-$8,000
Financial Returns (Annual):
- Recovered deferred payments: $35,000-$85,000
- Reduced conversion to denials: $18,000-$45,000
- Improved cash flow timing: $22,000-$40,000
- Reduced staff overtime: $12,000-$20,000
ROI Calculation:
- Initial investment: $8,000-$20,000
- Annual returns: $87,000-$190,000
- Net ROI: 435-950% within first year
Cash Flow Impact Modeling
Before Optimization:
- Average deferral resolution: 68.7 days
- Conversion to payment: 67.3%
- Average monthly deferrals: $25,000
- Cash flow delay cost: $2,100 monthly
After Optimization:
- Average deferral resolution: 32.4 days
- Conversion to payment: 91.2%
- Improved cash flow timing: $18,500 monthly acceleration
- Net monthly improvement: $16,400
Real-World Case Study: Multi-Payer Coordination Deferral
Patient: Maria Santos, Age 45
Primary Insurance: Aetna PPO
Secondary Insurance: Medicare Part B (ESRD)
Tertiary Coverage: State Medicaid
Deferred Amount: $4,127.85
Services: Dialysis treatments, physician visits, laboratory tests
Initial Scenario: Ms. Santos has End-Stage Renal Disease (ESRD) creating complex coordination between Aetna (group health), Medicare (ESRD coverage), and Medicaid (state assistance). Claims for three months of dialysis services were submitted to Aetna as primary payer, resulting in CO-143 deferrals totaling $4,127.85 while investigating Medicare coordination requirements.
Complexity Factors:
- Medicare becomes primary for ESRD after 30-month coordination period
- Aetna investigating whether 30-month period had elapsed
- State Medicaid coordination rules for ESRD patients
- Multiple service dates spanning coordination period transition
- Different Medicare coverage rules for dialysis vs. physician services
Resolution Timeline and Actions:
Days 1-3: Initial Assessment
- Reviewed EOB showing CO-143 deferrals for dialysis services
- Identified Medicare Secondary Payer (MSP) investigation as cause
- Contacted Aetna provider services for specific information requirements
- Documented patient’s ESRD diagnosis date and Medicare eligibility
Days 4-8: Information Gathering
- Obtained Medicare enrollment documentation showing 30-month coordination period
- Calculated exact transition date from Aetna primary to Medicare primary
- Gathered complete dialysis treatment records for affected period
- Verified Medicaid coverage and coordination rules for ESRD
Days 9-12: Documentation Submission
- Submitted Medicare enrollment documentation to Aetna
- Provided detailed timeline of ESRD diagnosis and treatment initiation
- Included physician documentation of medical necessity
- Submitted coordination of benefits worksheet for three-payer scenario
Days 13-25: Payer Investigation Period
- Aetna conducted internal review of Medicare coordination requirements
- Medicare confirmed primary payer status for services after 30-month period
- Medicaid verified tertiary payer responsibilities
- Patient advocacy required for expedited processing
Days 26-35: Partial Resolution
- Aetna paid $2,890.50 for services during their primary responsibility period
- Transferred $1,237.35 to Medicare as primary for post-30-month services
- Remaining balance of $0 identified as patient responsibility
Days 36-42: Final Coordination
- Medicare processed transferred claims and paid $1,089.22
- Medicaid paid remaining $148.13 as tertiary payer
- Patient responsibility finalized at $0 due to Medicaid coverage
Final Outcome:
- Total Resolution Time: 42 days
- Amount Recovered: $4,127.85 (100% success rate)
- Multiple Payer Coordination: Successfully navigated three-payer system
- Process Improvements: Developed ESRD-specific coordination protocols
Key Learnings:
- ESRD cases require specialized coordination knowledge due to Medicare’s unique 30-month rule
- Multi-payer deferrals need systematic tracking of each payer’s responsibilities
- Patient advocacy accelerates resolution for complex coordination scenarios
- Documentation requirements vary significantly between payers in coordination situations
Process Improvements Implemented:
- ESRD patient identification system for proactive coordination planning
- Automated Medicare 30-month period calculation tools
- Staff training on complex MSP coordination scenarios
- Patient communication protocols for extended resolution timeframes
Replication Strategy: This case demonstrates the importance of understanding payer-specific coordination rules and maintaining detailed documentation throughout the deferral resolution process. The systematic approach can be applied to other complex coordination scenarios involving multiple payers.
Summary and Next Steps
Immediate Action Items for CO-143 Management:
- Implement systematic deferral tracking using practice management system or dedicated software
- Establish standard follow-up timelines based on deferral type and payer
- Create documentation checklists for common deferral scenarios
- Train staff on payer-specific information requirements and submission methods
30-Day Implementation Roadmap:
- Week 1: Audit current deferrals and categorize by type and age
- Week 2: Implement tracking system and establish follow-up protocols
- Week 3: Train staff on deferral identification and resolution processes
- Week 4: Launch KPI monitoring and quality assurance measures
Long-term Strategic Goals (90 Days):
- Achieve 85%+ deferral resolution rate through systematic follow-up
- Reduce average resolution time to under 45 days
- Minimize deferral-to-denial conversion to below 15%
- Improve cash flow through faster deferral resolution
Success Factors for CO-143 Management:
- Proactive information gathering and submission
- Consistent follow-up communication with payers
- Complete documentation for all deferral responses
- Staff training on coordination of benefits and payer-specific requirements
- Technology utilization for tracking and workflow management
Financial Performance Targets:
- Increase deferral resolution rate from 67% to 90%
- Reduce average resolution time from 69 days to 35 days
- Achieve 95%+ documentation completeness rate
- Generate 400%+ ROI on deferral management investments
Quality Assurance Measures:
- Monthly deferral aging reports and trend analysis
- Quarterly staff performance reviews on deferral resolution
- Annual payer relationship assessment and improvement planning
- Continuous process improvement based on resolution outcomes
By implementing these comprehensive deferral management procedures, practices typically convert 85-95% of CO-143 deferrals to payments while significantly improving cash flow timing and reducing administrative burden on revenue cycle staff.
Frequently Asked Questions
Q: How long can a payer defer payment with CO-143? A: Timeframes vary by payer and reason. Most commercial payers resolve within 30-60 days, Medicare within 45-90 days. After set periods, deferrals typically convert to denials if unresolved.
Q: Should I submit additional documentation immediately for CO-143? A: Contact the payer first to understand specific requirements. Submitting incorrect or unnecessary documentation can delay resolution further.
Q: Can I appeal a CO-143 deferral? A: CO-143 is not technically a denial, so standard appeals don’t apply. However, you can request expedited processing if the deferral exceeds normal timeframes.
Q: What’s the difference between CO-143 and claim pending status? A: CO-143 indicates a specific portion is deferred pending additional information. Regular pending status means the entire claim is in normal processing queue.
Q: How do I prevent CO-143 deferrals? A: Complete pre-service verification, submit comprehensive documentation initially, verify coordination of benefits, and maintain current provider credentialing status.
