Appealing a Blue Cross Blue Shield (generic) CO-97 Denial
A Blue Cross Blue Shield (generic) CO-97 denial (bundled / already adjudicated) is one of the most common claim rejections behavioral health therapists face. This guide explains exactly what caused the denial and the most effective appeal strategy for behavioral health practices.
What this denial means
The payer says this service is included in another service that's already been billed and paid. In behavioral health, this most commonly happens when an E/M visit (99213/99214) and psychotherapy (90834/90837) are billed on the same day without the -25 modifier on the E/M code to establish that it is a separately identifiable service.
Your appeal strategy
Cite documentation establishing the services as separately identifiable — distinct CPT codes, a separate clinical purpose for each, and (when applicable) the -25 modifier on the E/M code. Reference CMS NCCI Edit Policy Chapter 11, which explicitly permits same-day E/M + psychotherapy when -25 is applied. If the modifier was present and the denial is still issued, request the specific NCCI edit being invoked.
What Blue Cross Blue Shield (generic) requires
30 calendar days (Level-1 appeal)
60 days from Level-1 denial
BCBS affiliates are independent licensees — appeal addresses, portals, and state parity rules vary by state plan. Look up the specific affiliate (e.g. BCBS of Illinois, BCBS of Michigan) for accurate address. The BCBS Federal Employee Program (FEP) has a separate appeals process.
Generate your Blue Cross Blue Shield (generic) CO-97 appeal letter
First 5 letters free. No credit card. Editable draft in about 60 seconds.
Generate my appeal letter →Frequently asked questions
How long does Blue Cross Blue Shield (generic) have to respond to a CO-97 appeal?
Under federal regulations and most state prompt-payment laws, Blue Cross Blue Shield (generic) must respond to a Level-1 internal appeal within 30 calendar days. If you receive an adverse determination, you typically have 60 calendar days from the date of the Level-1 denial to request external review. Send the appeal via certified mail or through the payer's portal and keep documentation of the submission date. Note: these timelines are best-effort estimates — verify current deadlines directly with the payer.
Does MHPAEA apply to CO-97 denials?
CO-97 denials are not directly tied to mental health parity protections in most cases — this code is a general adjudication rule that applies equally to all claim types. MHPAEA may still be relevant if the underlying reason for the denial differs for mental health vs. medical/surgical services. When in doubt, include a parity argument in your appeal.
Can I appeal a CO-97 denial more than once?
Yes. Most payers, including Blue Cross Blue Shield (generic), allow at least two levels of internal appeal (Level-1 and Level-2 or "expedited" review). After exhausting internal appeals, you have the right to request an Independent Medical Review (IMR) or external review through your state insurance commissioner. Keep copies of every appeal, submission confirmation, and payer response.
What documentation do I need to appeal a CO-97 denial from Blue Cross Blue Shield (generic)?
At minimum: the original Explanation of Benefits (EOB) or Remittance Advice (RA) showing the CO-97 denial, the original claim details (CPT code, date of service, NPI, charge amount), and any clinical documentation supporting medical necessity. Submit everything in one packet with a cover letter citing the specific denial code, the date of service, and the claim number.