Official X12 description
“Benefit maximum for this time period or occurrence has been reached.”
Source: X12 Claim Adjustment Reason Codes. The X12 External Code Lists are the single authoritative source for every CARC descriptor — always verify against the current release before building a claim-scrub rule.
What CARC 119 actually means
CARC 119 means the patient has hit a benefit limit — annual visit cap, lifetime maximum, procedure-specific frequency limit, or dollar maximum. Common examples include chiropractic visit caps, PT/OT visits per year, routine physicals once per 12 months, and mental-health session limits on older plans. The remedy is usually to bill the patient (if ABN/financial-responsibility was executed) or to verify whether a medical-necessity exception exists under the plan.
Common root causes
- Annual or lifetime benefit maximum reached for the specific service category.
- Frequency limit exceeded (e.g., routine physical more than once per plan year).
- Visit-count cap for a therapeutic service (PT/OT, chiropractic, acupuncture).
Prevention checklist
- Track benefit accumulators from 271 responses in the PM system — specifically deductible-met, out-of-pocket-met, and visit-limit-remaining where the payer publishes them.
- Before rendering additional visits in a limited category, confirm remaining benefits through the payer portal.
- Secure ABN or financial-responsibility signatures before delivering services that will exceed known caps.
Appeal strategy — step by step
Most CARC 119 denials clear faster with the right remediation than with a formal appeal. Work the steps in order and escalate only when a lower-effort path has been ruled out.
- 1If the plan has a medical-necessity exception for exceeding the cap (some commercial plans do for PT/OT), submit with the clinical justification.
- 2Verify the payer's accumulator is correct — sometimes cross-provider counts are mis-tallied.
- 3If the limit is correctly applied, transfer the balance to patient responsibility and collect per the financial-responsibility agreement.
Sample appeal-letter language for CARC 119
Edit the bracketed fields before sending. This template is a starting point; a payer-specific appeal form may still be required — check the provider portal first.
Payer-specific notes
Payer-specific behavior for CARC 119 publishes here as the QuickIntell anonymized denial ETL ingests sufficient volume. In the meantime, consult the payer directory for the relevant provider manual and appeal form.
How common is CARC 119?
Out of 306 seeded CARCs, ranked by combined US monthly search volume for "CARC 119", "CO-119 denial", and "denial code 119".
Platform frequency ranks publish once the anonymized denial-rate pipeline reaches the publication threshold (strategy §12 Phase 2).
How QuickRCM prevents CARC 119
QuickRCM catches the root causes above before the 837 leaves the clearinghouse:
- Claim-scrub rules fire on every root cause listed above — the scrub references the same X12 CAS segment logic that drives the denial, so what the payer checks, QuickRCM checks first.
- When a denial lands, QuickRCM routes it to the correct worker with the documentation bundle already attached (op note, LCD citation, modifier rationale, EOB, primary 835).
- Appeal templates tuned to each CARC (including this one) pull the supporting facts from the claim and fill the bracketed fields automatically.
CAQH CORE code combinations for CARC 119
Under the CAQH CORE Payment and Remittance Uniform Use rule, health plans may pair CARC 119 only with the remark codes and group codes below for the defined business scenario 3 (Billed service not covered by the health plan). A combination outside this list on an 835 is itself a payer compliance issue worth raising.
| RARC | Remark description | Group code | Scenario |
|---|---|---|---|
| (no RARC) | CARC used without a remark code | CO, PI or PR | 3 |
| M7 | No rental payments after the item is purchased, returned or after the total of issued rental payments equals the purchase price. | CO, PI or PR | 3 |
| M80 | Not covered when performed during the same session/date as a previously processed service for the patient. | CO, PI or PR | 3 |
| M83 | Service is not covered unless the patient is classified as at high risk. | CO, PI or PR | 3 |
| M86 | Service denied because payment already made for same/similar procedure within set time frame. | CO, PI or PR | 3 |
| M89 | Not covered more than once under age 40. | CO, PI or PR | 3 |
| M90 | Not covered more than once in a 12 month period. | CO, PI or PR | 3 |
| M139 | Denied services exceed the coverage limit for the demonstration. | CO, PI or PR | 3 |
| N45 | Payment based on authorized amount. | CO, PI or PR | 3 |
| N111 | No appeal right except duplicate claim/service issue. This service was included in a claim that has been previously billed and adjudicated. | CO, PI or PR | 3 |
| N115 | This decision was based on a Local Coverage Determination (LCD). An LCD provides a guide to assist in determining whether a particular item or service is covered. A copy of this policy is available at www.cms.gov/mcd, or if you do not have web access, you may contact the contractor to request a copy of the LCD. | CO, PI or PR | 3 |
| N117 | This service is paid only once in a patient’s lifetime. | CO, PI or PR | 3 |
| N130 | Consult plan benefit documents/guidelines for information about restrictions for this service. | CO, PI or PR | 3 |
| N357 | Time frame requirements between this service/procedure/supply and a related service/procedure/supply have not been met. | CO, PI or PR | 3 |
| N362 | The number of Days or Units of Service exceeds our acceptable maximum. | CO, PI or PR | 3 |
| N386 | This decision was based on a National Coverage Determination (NCD). An NCD provides a coverage determination as to whether a particular item or service is covered. A copy of this policy is available at www.cms.gov/mcd/search.asp. If you do not have web access, you may contact the contractor to request a copy of the NCD. | CO, PI or PR | 3 |
| N411 | This service is allowed one time in a 6-month period. | CO, PI or PR | 3 |
| N412 | This service is allowed 2 times in a 12-month period. | CO, PI or PR | 3 |
| N413 | This service is allowed 2 times in a benefit year. | CO, PI or PR | 3 |
| N414 | This service is allowed 4 times in a 12-month period. | CO, PI or PR | 3 |
| N415 | This service is allowed 1 time in an 18-month period. | CO, PI or PR | 3 |
| N416 | This service is allowed 1 time in a 3-year period. | CO, PI or PR | 3 |
| N417 | This service is allowed 1 time in a 5-year period. | CO, PI or PR | 3 |
| N435 | Exceeds number/frequency approved /allowed within time period without support documentation. | CO, PI or PR | 3 |
| N587 | Policy benefits have been exhausted. | CO, PI or PR | 3 |
| N636 | Adjusted because this is reimbursable only once per injury. | CO, PI or PR | 3 |
| N640 | Exceeds number/frequency approved/allowed within time period. | CO, PI or PR | 3 |
| N786 | Benefit limitation for the orthodontic active and/or retention phase of treatment. | CO, PI or PR | 3 |
| N853 | The number of modalities performed per session exceeds our acceptable maximum. | CO, PI or PR | 3 |
Frequently asked questions — CARC 119
What does CARC 119 mean?
CARC 119 is an X12 Claim Adjustment Reason Code. The official definition is: "Benefit maximum for this time period or occurrence has been reached." In plain English, the payer is telling you cARC 119 means the patient has hit a benefit limit — annual visit cap, lifetime maximum, procedure-specific frequency limit, or dollar maximum. Common examples include chiropractic visit caps, PT/OT visits per year, routine physicals once per 12 months, and mental-health session limits on older plans. The remedy is usually to bill the patient (if ABN/financial-responsibility was executed) or to verify whether a medical-necessity exception exists under the plan.
How do I resolve a CARC 119 (CO-119) denial?
Start with the most common root cause: Annual or lifetime benefit maximum reached for the specific service category. First step: If the plan has a medical-necessity exception for exceeding the cap (some commercial plans do for PT/OT), submit with the clinical justification. See the full remediation and appeal checklist on this page before filing a formal appeal.
Is CARC 119 patient responsibility?
No — CARC 119 is typically carried under CO (Contractual Obligation) or OA (Other Adjustment), which means it is the provider's responsibility, not the patient's. Do not bill the patient unless the 835 CAS group code is PR.
What does CARC 119 look like on an EOB or 835 remittance?
On the 835 ERA, CARC 119 appears in Loop 2110 CAS segment as "CAS*CO*119*{amount}". On a paper EOB the same code prints in the Adjustment/Denial Reason column with the X12 description: "Benefit maximum for this time period or occurrence has been reached." — usually paired with one or more RARC remark codes in the same remittance line for additional context.
Which RARC is paired with CARC 119?
CARC 119 is commonly observed with RARC N362. The RARC narrows the reason — for example, pointing at a missing modifier, an LCD citation, or a specific policy. Fix the underlying CARC first; the RARC usually clears with the corrected claim.
Disclaimer
This page is operational reference for medical-billing professionals. It is not legal, clinical, or contractual advice. X12 code descriptors are maintained by the X12 External Code Lists; always verify against the current X12 release and the payer's own published policy before submitting or appealing a claim.