Why Does a Commercial Payer Bundle Codes With CO-97 That Medicare Pays Separately?

How to Contest a Commercial CO-97 That the CMS Tables Say Is Clean

The goal is simple: every commercial bundling denial traced to the payer’s own policy, then contested or scrubbed against that policy instead of the national tables. Here is what does that, move by move.

1. Stop Scrubbing Only Against the CMS Tables

The first mistake is assuming the national correct-coding tables are the whole rulebook. They are not, for commercial claims. A commercial plan can bundle a pair the national edits leave separate, using its own proprietary logic, and no amount of checking the CMS tables will reveal it because the edit does not live there. When a pair Medicare pays denies CO-97 at a commercial plan, the answer is never in the federal table; it is in the payer’s own policy, and that is where the search has to start.

2. Build a Payer Bundling Policy Library for Your Top Pairs

You cannot contest an edit you cannot see, so the move is to make the payer’s rules visible. For the practice’s highest-volume code pairs, collect each major commercial payer’s published bundling and reimbursement policies into one reference. When a CO-97 hits, the coder checks that library first: does this plan actually publish this edit, or did it apply one it never disclosed? A payer bundling policy library turns an unexplainable denial into a specific policy you can either satisfy or challenge.

3. Scrub High-Volume Combinations Against Each Payer’s Own List

Prevention beats appeal here too, but it has to be payer-aware. Scrubbing your top code combinations against each commercial payer’s own edit list before submission catches the pairs a specific plan will bundle, so the claim goes out correct for that payer rather than correct only for Medicare. A pair that is clean nationally but bundled by one plan gets flagged for that plan alone, and the CO-97 that used to arrive after the fact is prevented at the front end.

4. Appeal by Citing the Payer’s Own Policy or Demanding the Source

When a payer-specific CO-97 lands, the appeal is not a clinical argument, it is a policy one. If the payer publishes the edit, you contest it on its own terms; if the pair is not on the payer’s own published edit list, that is the appeal: show the plan its policy does not support the bundling and demand the edit source in writing. A payer that cannot point to a published policy for the edit it applied is a payer that has to pay. Tracking which denials were contested on which policy is what keeps the payer honest across the whole book.

5. Hand Payer-Specific Bundling to a Dedicated Team

Practices that stop losing pairs to unexplainable commercial denials do it by handing payer-specific bundling to a dedicated team: remote specialists who keep the policy library, scrub per payer, and appeal on the plan’s own rules, live in 1 to 2 weeks. The coder goes back to the work only they can do, a trained backup covers every gap, and the commercial denials that used to look unexplainable stop being unexplainable. Below is what it sounds like when nobody owns it yet, in providers’ own words.

Why This Keeps Happening

If Medicare pays the pair, why does a commercial plan bundle it? Because commercial payers are not bound to the national correct-coding edits the way Medicare is. They run their own proprietary bundling logic, layered on top of or in place of the federal rules, and they can bundle a pair the national edits leave separate. The national tables are the floor for correct coding, not the ceiling, and a commercial plan is free to build a stricter book. So a pair that is genuinely, verifiably separate under Medicare can still trip a payer-specific edit that exists only inside that plan’s policy.

The reason it feels unexplainable is that most practices scrub only against what they can see, and what they can see is the national tables. A commercial edit that is not a national edit is invisible to that scrub, so the coder checks the pair, finds it clean, and has no idea where the denial came from. Making the payer’s own rules visible, collecting them into a reference the team can actually check, is the step that turns an unexplainable CO-97 into a specific policy, and it is exactly the kind of payer-aware work a dedicated revenue cycle management workflow is built around.

And the cost is that these denials get written off precisely because they look unbeatable. A CO-97 you cannot trace to a rule feels like a lost cause, so it goes to write-off without a fight, even when the pair is not on the payer’s own published edit list and the plan cannot actually cite a policy for it. HFMA and MGMA both flag payer-specific and proprietary-edit denials as a growing and recoverable category, because a meaningful share of them collapse the moment the practice demands the edit source in writing. The pair was payable. The rulebook was just hidden.

Most groups have already tried the obvious fixes before they talk to anyone. Each one fails the same way: the work lands back on the practice. The pattern, in one table:

The Solution

So what does “someone whose whole job it is” look like on a commercial CO-97? The specialist starts where the practice usually cannot: instead of scrubbing the pair against the national tables that call it clean, they check the payer’s own bundling policy for that pair. They keep a payer policy library for your top combinations, so when a denial lands they can see immediately whether the plan actually publishes this edit or applied one it never disclosed. Most commercial bundling loss is a payer-visibility problem, and that is exactly what dedicated denials and appeals management is built to solve before a payable pair gets written off as unexplainable.

Then the specialist moves the fight upstream and onto the payer’s own terms. High-volume combinations get scrubbed against each payer’s own edit list before submission, so a pair one plan bundles goes out correct for that plan. And when a payer-specific CO-97 does land, the appeal cites the plan’s published policy directly, or, when the pair is not on the payer’s own list, demands the edit source in writing. A payer that cannot point to a published policy for the edit it applied has to pay, and tracking which denials were contested on which policy keeps every plan honest across the book.

Behind all of it, AI drafts the first pass and a credentialed human verifies. The workflow traces the denial to the payer’s policy, checks whether the pair is on the plan’s published edit list, and assembles the appeal; a person confirms the policy argument is right and owns the challenge to the payer. Every security control that protects the chart data moving through that process is documented and auditable, and the whole approach is described on our HIPAA and security page, because moving claim and clinical documentation through a payer-appeals workflow is only safe when the controls are real.

Who Actually Does This Work

Fair question: why would an outsourced team beat your commercial bundling denials better than your own coders? Because reading payer policy and tracking each plan’s edit book all day is their entire job, not the thing they squeeze between other work. The people working your denials are credentialed medical professionals: overseas-trained physicians, US-licensed nurses and pharmacists, and PharmDs, all trained in US coding, payer policy, and denial management workflows. They know that a national scrub is not enough for commercial claims, how to find a plan’s published bundling policy, and how to push a payer to cite the edit source when the pair is not on its own list. That is not a generalist task handed to whoever is free; it is a specialty.

We are not a call center. We are a clinical operations partner, a healthcare BPO built on dedicated virtual staff: 500+ credentialed professionals, 24/7 coverage, and the AI-first-pass plus human-verify workflow you just read about behind every one of them. A typical practice is live in 1 to 2 weeks, at up to 70% below the cost of hiring locally, and no one on our side goes out without a trained backup already inside your workflow, so a payable pair never gets surrendered because the one coder who knows the payer books is on vacation.

And the security piece your compliance officer will ask about: we are audited to SOC 2 Type II with zero exceptions and certified for ISO/IEC 27001:2022, HIPAA, and GDPR, with zero breaches in eight years. Every workstation runs inside a secure enclave on US-based servers, with screen captures and downloads blocked by policy, so PHI never sits on someone’s home laptop. Every client account carries a $5M E&O and cyber liability policy and a BAA signed before any work starts; the full detail lives in our HIPAA and security posture.

Put the routine and the people together, and a specific list of things simply stops happening.

How We Permanently Fix the Process

A person alone is not the fix, and neither is a bot alone. The fix is a documented payer-bundling workflow: a policy library of each major plan’s published edits for your top code pairs, a payer-aware scrub that checks combinations against the plan they are going to rather than only the national tables, and an appeal path that cites the payer’s own policy or demands the edit source, all written down and worked the same way every time. Before we take a single claim for a new practice, we chart your commercial CO-97 volume by payer and pair so we can see which plans are bundling what, and we build the workflow against that, not against a generic template.

From there the workflow becomes a living playbook rather than one coder’s scattered notes. It records which payers bundle which pairs, where each plan’s published policy lives, how to scrub for a specific payer, and the exact appeal language for an edit the plan cannot cite. It is written down, kept current as payers revise their books, and owned by the team. When your specialist is out, a trained backup works the same playbook the same way, so a payable pair never gets surrendered because one person was away.

That is the difference between writing off this month’s unexplainable denials and fixing the process for good, and it is what a dedicated revenue cycle management partner actually buys you. A coder leaving used to mean the team went back to scrubbing only the national tables and surrendering commercial denials. Under this model the workflow keeps running, the policy library stays current, the backup steps in, and a commercial CO-97 stops being the denial nobody can explain.

The Whole Thing in Four Sentences

A commercial payer bundles codes with CO-97 that Medicare pays separately because commercial plans run their own proprietary bundling logic, layered on top of or in place of the national correct-coding rules, so a pair that is clean on the CMS tables can still trip a payer-specific edit. That is why the denial looks unexplainable: your team scrubs the federal tables and finds nothing, because the edit lives in the payer’s policy, not the federal one. Scrubbing only against the CMS tables, writing off commercial denials as legitimate, or treating every plan like Medicare all fail the same way. The fix is to keep a payer bundling policy library, scrub per payer before submission, and appeal by citing the plan’s published policy or demanding the edit source in writing. An ophthalmology practice runs exactly this model with us today, names withheld, no patient data shown.

If you want to check us out before talking to anyone: our security posture is independently auditable, we are an MGMA 2026 Corporate Member, and 800+ providers run back office work with us.

Ready to contest the denials that look unexplainable? Try us risk free: two weeks, your real commercial denial queue, dedicated specialists tracing each one to the payer’s policy and appealing on the plan’s own rules, and if it does not earn the handoff, you walk away. From here down is the sales part, and it is short: here is exactly what it costs.

Written By

Dan Nandan

Founder and CEO, Staffingly, Inc. · Piscataway, NJ

Dan Nandan has spent 25+ years in IT consulting and healthcare BPO, was among the first in the US to build an RPO/BPO delivery network in India, and has been featured in Computerworld. He runs the operations and the dedicated virtual teams behind the workflows on this page; the team-voice answers above come from the remote specialists who work them every day.

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