CARC Code CO-45 & Silent PPO Repricing Recovery
Stop Writing Off Legitimate Revenue Under "Contractual Adjustment" — Reclaim Out-of-Network and Third-Party Repricer Haircuts.
CARC Code CO-45 ("Charge exceeds fee schedule/maximum allowable or contracted rate") is frequently treated by billing offices as an untouchable contractual write-off. However, third-party repricers (MultiPlan, Zelis, Viant, Data iSight) systematically apply unauthorized discount contracts to non-par claims through "silent PPOs." If your practice never signed a direct participation agreement with that specific network, applying a CO-45 write-off is illegal under federal law. Our audit team leverages ERISA Section 502(a) fiduciary disclosure requests to force full payment of billed charges.
Audit red flags
- Billing team automatically writing off secondary balances under CO-45 without confirming contract fee schedules.
- Remittance advice displaying "Repriced by MultiPlan" or "Zelis Network Discount" for out-of-network services.
- Virtual credit card payments deducting a mandatory 3% to 5% processing surcharge.
- Failure to send formal ERISA dispute letters within 180 days of unauthorized repricing.
Audit action plan
- 1. Repricing Entity Identification — Scan all 835 line items tagged with CO-45 to isolate third-party repricing codes (MultiPlan, Zelis, Data iSight) on non-par and commercial claims.
- 2. Contract Verification & Proof of Agreement Demand — Issue a formal legal Demand for Contractual Privity requesting the exact signed agreement binding your tax ID to that discounted fee schedule.
- 3. ERISA Section 502(a) Administrative Demand — File formal administrative appeals citing federal fiduciary violations and demanding immediate reimbursement of full billed charges.
Codes reviewed
- MultiPlan Discount — Third-party repricing haircut applied without provider participating contract
- Zelis Payment Network — Virtual credit card or automated fee discount applied on self-funded employer plans
- Silent PPO Affiliation — Payer leasing a network discount without provider knowledge or consent
- Usual, Customary & Reasonable (UCR) — Arbitrary payer definition of FAIR Health or median geographical rates
Frequently asked questions
Is it legal for our practice to challenge CO-45 write-offs?
Yes. If your practice does not hold an active, direct participating provider contract with the repricing entity, you have zero legal obligation to accept their discount. Accepting it is essentially giving away earned practice revenue.
How long does an ERISA silent PPO recovery take?
Under federal ERISA regulations (29 C.F.R. § 2560.503-1), plan administrators must respond to administrative appeals within 30 to 60 days.