What does CARC 119 mean?

CARC 119 means 'Benefit maximum for this time period or occurrence has been reached.' The patient has used all the benefits their plan allows for this service.

Can CARC 119 be appealed?

Sometimes. If the patient's plan has a medical necessity exception and you can document the need, an appeal may succeed. Otherwise, the service is the patient's responsibility.

How can I prevent CARC 119 denials?

Verify benefits and remaining visits before every appointment in specialties with visit limits. Have the patient sign an ABN when approaching the limit so you can bill them if needed.

Denial Brief

CARC 119: Benefit Maximum Reached. What it means, and how to appeal it.

Last updated: August 2026

CARC 119 means the patient's plan-defined visit, service, or dollar limit for this benefit has been reached. It is one of the most common denials in physical therapy, chiropractic, behavioral health, home health, and durable medical equipment billing, and it is one of the easiest to write off in error when the payer's count is wrong or the group code has not been verified. Reading the code correctly is how you decide between a corrected claim, a secondary submission, a patient statement, or a contractual adjustment.

By Mindy Corbett, CSPO, CPC, CPB, CPPM · 4 min read

Benefit maximum for this time period or occurrence has been reached.

Group code CO, PI or PR

Category Benefit Maximum/Limitation

Risk level High

Appealable Rarely

Common RARC pairings

RARCs (Remittance Advice Remark Codes) provide the specific reason detail alongside CARC 119 on the 835 electronic remittance. These are the RARCs seen most often with this CARC.

RARC	Meaning
M7	No rental payments after the item is purchased, returned or after the total of issued rental payments equals the purchase price.
M80	Not covered when performed during the same session/date as a previously processed service for the patient.
M83	Service is not covered unless the patient is classified as at high risk.
M86	Service denied because payment already made for same/similar procedure within set time frame.
M89	Not covered more than once under age 40.
M90	Not covered more than once in a 12 month period.
M139	Denied services exceed the coverage limit for the demonstration.
N45	Payment based on authorized amount.

Rendered live from the EDI Code Intelligence Lab data set

CARC 119

CLAIM ADJUSTMENT REASON CODE

Benefit maximum for this time period or occurrence has been reached.

High Risk

What This Means

The patient has reached the plan's visit, occurrence, or dollar benefit maximum for this service in the applicable benefit period; additional units are not payable.

Common drivers: Benefit accumulator not queried before service; accumulator includes incorrectly attributed visits (denied claims counted as used, or another provider's visits misapplied); or a denied claim from a prior period was counted toward the current-period limit.

Root Causes

Benefit accumulator not queried before service; accumulator includes incorrectly attributed visits (denied claims counted as used, or another provider's visits misapplied); or a denied claim from a prior period was counted toward the current-period limit.

Action Plan

Determine the specific limit exhausted: visit count, dollar maximum, or occurrence limit.
Pull the patient's current accumulator data from the payer portal and reconcile against your claims history for the benefit period.
If the payer's count includes denied visits or misattributed claims, document the discrepancy and submit a correction request.
Post the adjustment; if a patient balance remains above the limit, issue a patient statement.

Appeal Tips

If the accumulator is wrong (denied visits counted, another provider's visits misattributed, or prior-year visits carried forward), compile a reconciliation and appeal.
For mental health or substance use limits, check whether MHPAEA (Mental Health Parity and Addiction Equity Act) applies; payers may not impose tighter limits on behavioral health than medical/surgical benefits.
If the accumulator carried over at mid-year enrollment, provide enrollment documentation and request recalculation.

Prevention Strategy

Query payer benefit accumulators before high-frequency services (therapy, behavioral health, DME) to confirm remaining benefit availability.
Counsel patients approaching a benefit limit so they understand potential out-of-pocket exposure.
When CARC 119 is received, check whether any visits counted toward the limit were denied; if so, challenge the accumulator before writing off the balance.

✅ Verified 2026-06-16 · Source: ASC X12 · Rendered live from the EDI Code Intelligence Lab data set.

🔗 Complete the Story, Find Your RARC Paired Code

CARC 119 is only half the answer. The RARC (Remittance Advice Remark Code) on your remittance tells you exactly what to fix.

Common RARCs that appear with CARC 119:

M7 No rental payments after the item is purchased, returned or after the total of issued rental payments equals the purchase price. M80 Not covered when performed during the same session/date as a previously processed service for the patient. M83 Service is not covered unless the patient is classified as at high risk. M86 Service denied because payment already made for same/similar procedure within set time frame. M89 Not covered more than once under age 40. M90 Not covered more than once in a 12 month period. M139 Denied services exceed the coverage limit for the demonstration. N45 Payment based on authorized amount.

These pairings come from the most frequently occurring CARC/RARC combinations in production remittance data. Click any code to open it in the EDI Code Intelligence Lab.

What CARC 119 Actually Means

Claim Adjustment Reason Code (CARC) 119 is a benefit limit denial. The patient's insurance plan allows a specific number of visits, services, or dollar amount for a particular type of care within a defined time period, and that limit has been exhausted. The payer is not questioning whether the service was medically necessary. They're telling you the plan simply won't pay for any more of that service this year.

Common services that trigger a CARC 119 denial: physical therapy visits, chiropractic adjustments, behavioral health sessions, home health visits, and durable medical equipment.

Medicare Specific Note: Medicare's hard therapy caps were repealed in 2018. Medicare now pays for therapy without a visit or dollar cap, but once a patient's yearly therapy costs pass $2,480 (the 2026 threshold), every claim must include the KX modifier to attest medical necessity. A Medicare therapy denial at the threshold usually means a missing KX modifier, not an exhausted benefit, and the fix is a corrected claim rather than a patient bill.

What the full brief covers

Signed-in members see the full brief. Here is what it contains.

What to Do Immediately
When Medical Necessity Exception Applies
Mental Health and Substance Use Parity Check
How to Prevent CARC 119 Denials

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See the full resolution workflow for CARC 119

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