CO-292: Medical Plan Claim Forwarded to Pharmacy Plan
CO-292 means the medical plan contractually denies the service and forwarded it to the pharmacy plan. Do not bill the patient until the pharmacy plan has made its determination.
What Does CO-292 Mean?
When CARC 292 appears with CO, the medical plan is contractually denying the claim while forwarding it to the pharmacy plan. The provider cannot bill the patient for the medical plan's denied amount while the pharmacy plan adjudicates the claim.
CARC 292 indicates the medical plan received the claim, determined the service falls under the pharmacy benefit rather than the medical benefit, and has forwarded the claim to the patient's pharmacy plan for processing. This is a routing code that signals the claim is being redirected, not permanently denied.
This code most commonly appears for injectable or infusible medications, specialty drugs, and certain pharmacy-related services that some plans manage through a pharmacy benefit manager (PBM) rather than through the medical benefit. The split between medical and pharmacy benefits varies significantly by payer and plan design. Some plans cover certain drugs under the medical benefit when administered in a provider's office, while others route all drug claims through the pharmacy benefit regardless of setting.
The distinction between CARC 292 and CARC 280 is important: CARC 292 confirms the claim was forwarded to the pharmacy plan, while CARC 280 indicates the medical plan denied the claim without forwarding it. Providers should track the forwarded claim with the pharmacy plan to ensure it does not fall through the cracks during the routing process.
Common Causes
| Cause | Frequency |
|---|---|
| Service classified under pharmacy benefit The medical plan determined the service or medication should be processed through the pharmacy plan rather than the medical plan | Most Common |
| Incorrect plan selection for submission Provider billed the medical plan for a drug or service that should have been submitted to the pharmacy benefit | Common |
| Coordination of benefits routing Multiple insurance plans involved and the medical plan is forwarding to the pharmacy plan per COB rules | Common |
| Plan limitations or exclusions Medical plan excludes certain drugs or infusion services that are covered under the pharmacy benefit design | Common |
| Missing pre-authorization Required approval was not obtained from the correct plan before service delivery | Occasional |
How to Resolve
Confirm the pharmacy plan received the forwarded claim and ensure it is processed correctly.
- Track pharmacy plan adjudication Wait for the pharmacy plan to process the forwarded claim. Do not write off the balance until the pharmacy plan has completed adjudication.
- Reconcile after determination Post the appropriate payment or adjustment based on the pharmacy plan's determination.
How to Prevent CO-292
- Identify the correct benefit plan (medical vs. pharmacy) for drugs and infusion services before billing
- Contact the PBM for benefit verification before administering high-cost specialty medications
General Prevention
- Verify whether services should be billed to the medical or pharmacy plan before initial submission
- Understand plan-specific benefit design separating medical and pharmacy benefits
- Coordinate benefits between medical and pharmacy plans proactively
- Stay updated on plan changes regarding medical vs. pharmacy benefit classifications
Also Filed As
The same CARC 292 may appear with different Group Codes:
Related Denial Codes
Sources
- https://www.mdclarity.com/denial-code/292
- https://x12.org/codes/claim-adjustment-reason-codes
- Codes maintained by X12. Visit x12.org for official definitions.