Health insurance denial & claim adjustment codes

What health insurance denial code 167 means on your EOB

The plan excluded the condition itself. Often a coding problem rather than a real exclusion, because the diagnosis submitted may not be the one that best describes your care.

What usually causes it

• The submitted diagnosis does not match the plan's covered list.
• A more accurate diagnosis exists and was not used.
• The diagnosis was entered in error.

The documents that decide it

• The diagnosis codes as submitted.
• Your provider's chart notes.
• The plan's exclusion list.

What to do next

Ask your provider whether the submitted diagnosis is the most accurate one. A corrected code resolves more of these than an appeal does.

This page explains what a code means. It is information, not advice — it does not tell you whether your specific claim should have been paid, and it is not legal, medical, or insurance advice. Your plan documents and your denial notice govern your situation.