This (these) diagnosis(es) is (are) not covered. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
Group code
CO, PI or PR
Category
Non-Covered Service
Risk level
Medium
Appealable
Review Required
Common RARC pairings
RARCs (Remittance Advice Remark Codes) provide the specific reason detail alongside CARC 167 on the 835 electronic remittance. These are the RARCs seen most often with this CARC.
| RARC | Meaning |
|---|---|
| MA63 | Missing/incomplete/invalid principal diagnosis. |
| N30 | Patient ineligible for this service. |
| 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. |
| 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. Visit CMS.gov and search for Medicare Coverage Database to find a copy of the policy. |
| N428 | Not covered when performed in this place of service. |
| N607 | Service provided for non-compensable condition(s). |
| N647 | Adjusted based on diagnosis-related group (DRG). |
See the full resolution workflow for CARC 167
Members of the EDI-Code Intelligence Lab get the step-by-step rework path, appeal language, root-cause drivers, and prevention checklist for every CARC and RARC pairing, plus payer-specific quirks.
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