Charge Exceeds Fee Schedule

Charge exceeds fee schedule or maximum allowable amount. The payer reduces payment to the contracted or statutory allowed amount; this is often a contractual write-off, not a recoverable denial.

What This Means in Behavioral Health

CO-45 appears on every BH claim where billed charges exceed the payer's allowed per diem or fee schedule. High charge master amounts on residential per diem do not increase payment—understanding allowed vs billed prevents false A/R inflation. Cipher uses CO-45 patterns to identify underpaid contracts and negotiation opportunities.

Root Causes

• Billed amount higher than contracted fee schedule (expected contractual adjustment)
• Wrong fee schedule applied for provider type or program HCPCS
• Out-of-network allowed amount lower than in-network expectation
• Multiple units billed when payer allows one program per diem per day
• Medicare or Medicaid rate applied when commercial contract expected

Prevention Tips

• Reconcile allowed amounts to active contracts during onboarding
• Model cash flow on allowed amounts, not charge master totals
• Flag payers with declining allowed rates in denial trend reporting
• Pair CO-45 review with contract negotiation support for BH program rates