Can I appeal a CO-226 or PR-226 denial?

Yes. Appealing is free and it is your legal right. For this code the odds are high: Purely administrative — records win it. Fewer than 1 in 100 denials are ever appealed — insurers count on silence.

Who has to pay after a code 226 denial?

Usually the provider's problem — not yours. The letters in front of the number matter: CO (contractual obligation) usually means an in-network provider must absorb it, while PR (patient responsibility) means the plan says you owe it.

How long do I have to appeal?

It depends on your coverage: 180 days for most employer and marketplace plans, 120 days for Original Medicare, about 90 days for Medicaid (varies by state), and only 65 days for Medicare Advantage. Set your deadline clock before you do anything else.

Denial code 226 · CO-226 / PR-226 · translated

Denial code 226: what it means — and how to fight it

Denial code 226 (shown on your EOB as CO-226 or PR-226) means: “Information requested from the Billing/Rendering Provider was not provided or was insufficient.” In plain English: The insurer asked your provider for records and didn't get them. The claim is stuck, not judged.

high appealability Usually the provider's problem — not yours

What they're really saying

“Information requested from the Billing/Rendering Provider was not provided or was insufficient.”

The insurer asked your provider for records and didn't get them. The claim is stuck, not judged.

Your odds

Strong — this type of denial has real weaknesses.

Purely administrative — records win it.

Fewer than 1 in 100 denied claims are ever appealed. When people do appeal, roughly 4 in 10 win the first round — and independent external review overturns 40–50% of what reaches it.

How to appeal a code 226 denial

Decode. You just did — this page is step one.
Set your clock. 180 days for most employer and marketplace plans, 120 for Original Medicare, ~90 for Medicaid, only 65 for Medicare Advantage.
Urgent? If this is care you still need, call and request an expedited appeal — they must decide within 72 hours.
Call the provider: "the insurer says you haven't sent the records — please send them this week." Push the provider's office to send the requested records, then confirm the insurer reprocesses.
Send it certified. Letter plus evidence, keep copies of everything.
Escalate. Denied again? Independent external review — a doctor who doesn't work for your insurer decides.

Do it in minutes, free

The AppealClock tool translates your denial, drafts your appeal letter, computes your exact deadline — and watches the clock so you don't have to. No account. Your medical details never leave your device.

Start your appeal & set your clock →

Common questions

What does denial code 226 mean?: The insurer asked your provider for records and didn't get them. The claim is stuck, not judged.
Can I appeal a CO-226 or PR-226 denial?: Yes. Appealing is free and it is your legal right. For this code the odds are high: Purely administrative — records win it. Fewer than 1 in 100 denials are ever appealed — insurers count on silence.
Who has to pay after a code 226 denial?: Usually the provider's problem — not yours. The letters in front of the number matter: CO (contractual obligation) usually means an in-network provider must absorb it, while PR (patient responsibility) means the plan says you owe it.
How long do I have to appeal?: It depends on your coverage: 180 days for most employer and marketplace plans, 120 days for Original Medicare, about 90 days for Medicaid (varies by state), and only 65 days for Medicare Advantage. Set your deadline clock before you do anything else.