CARC 242: Services not provided by network/primary care providers
The service was delivered by a provider outside your plan's network when an in-network provider was required.
What this means for your claim
Many plans only cover care from network providers (or require a primary care provider to deliver or coordinate it). Out-of-network services can be denied or paid at a much lower rate.
What to do next
- 1
Verify the provider's network status as of your date of service with your insurer.
- 2
If you were referred to this provider by an in-network doctor or facility, you may qualify for in-network processing — file an appeal citing the referral.
- 3
If no in-network provider was reasonably available, request a network gap exception (single case agreement).
Have more codes on your EOB?
Upload your full Explanation of Benefits and our analyzer will identify every adjustment code, explain each one in plain English, and flag anything worth disputing.
Analyze My EOB Free →