Denial Code CO-111

Patient statement template

Use this statement to bill the patient for the adjusted amount. Before sending, verify the patient owes the balance per their plan (and for Medicare, that a valid ABN was signed when required).

[Your Practice Letterhead]
[Date]

[Patient Name]
[Patient Address]

Re: Account Balance, Date of Service [DOS]
Claim Number: [Claim Number]

Dear [Patient Name]:

Your insurance claim for the service provided on [DOS] has been processed by [Payer Name]. The insurer has determined that the following amount is your responsibility under your plan benefit design:

Adjustment code: CO-111
Description: Not covered unless the provider accepts assignment
Amount due: $[Amount]

This amount represents your [deductible / copay / coinsurance / non-covered portion] per your plan terms. Please remit payment by [Due Date] or contact our billing office at [Phone] to arrange a payment plan.

If you believe this amount is incorrect, please contact [Payer Name] member services using the number on the back of your insurance card to verify your benefit details.

Sincerely,
[Practice Name] Billing Department
[Phone] · [Email]

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Before sending: if this is a Medicare claim and a valid Advance Beneficiary Notice (ABN) was not signed before the service, consult Medicare guidelines. Certain non-covered services cannot be billed to the patient without proper advance notice. Practices should maintain ABN records and verify signature status before generating patient statements for PR-denied Medicare claims.

CO-111 FAQ