Reference
Denial codes, and what to do about them.
Every guide restates the official wording. This one explains why you actually receive each code, how to tell whether it was applied correctly, and whether appealing is worth the time.
59 codes. Type to filter, or browse by category below.
Eligibility and coverage order
- CARC 22Another payer may be primaryThe payer believes someone else should pay first, and is waiting for coordination of benefits to be resolved.
- CARC 23Adjusted for what a prior payer already didNot a denial. The secondary payer is accounting for what the primary already paid or adjusted.
- CARC 24Covered under a capitation or managed care arrangementThe payer considers this service already paid for under a capitation agreement or managed care plan.
- CARC 26Service predates the patient's coverageThe date of service falls before the patient's coverage began with this payer.
- CARC 27Coverage had already endedThe patient's coverage with this payer terminated before the date of service.
- CARC 31Patient not found as a memberThe payer cannot match the patient to anyone on its records — often a data problem rather than a coverage problem.
- CARC 32Not an eligible dependantThe payer does not recognise the patient as a dependant eligible under the subscriber's plan.
- CARC 33Plan has no dependant coverageThe subscriber's plan covers the subscriber only, so no dependant claim can pay against it.
- CARC 34No newborn coverage under this planThe plan does not extend to newborns, so claims for the infant cannot pay against the parent's coverage.
- CARC 109Wrong payer entirelyThis payer is not responsible for the claim — it belongs somewhere else.
- MA04Primary payer information missingA secondary claim arrived without the primary payer's identity or payment details, so it cannot be considered.
Coding and claim data
- CARC 4Modifier conflicts with the procedureThe modifier attached does not fit the procedure code, or a required modifier is missing.
- CARC 5Procedure conflicts with the place of serviceThe payer does not accept this procedure as performed in the setting reported.
- CARC 6Procedure conflicts with the patient's ageThe payer's edits say this procedure is not expected for a patient of this age.
- CARC 7Procedure conflicts with the patient's genderThe payer's edits say this procedure is not expected for the gender on record.
- CARC 8Procedure conflicts with provider specialtyThe payer does not expect a provider with this taxonomy to perform this procedure.
- CARC 9Diagnosis conflicts with the patient's ageThe diagnosis reported is not one the payer expects for a patient of this age.
- CARC 10Diagnosis conflicts with the patient's genderThe diagnosis reported is not one the payer expects for the gender on record.
- CARC 11Diagnosis does not support the procedureThe payer does not accept the diagnosis reported as justifying the procedure billed.
- CARC 12Diagnosis conflicts with the provider typeThe payer does not expect a provider of this type to report this diagnosis.
- CARC 13Date of death precedes the serviceThe payer holds a date of death earlier than the date of service.
- CARC 14Date of birth follows the serviceThe date of birth on file is later than the date of service, which cannot be right.
- CARC 18Exact duplicateThe payer has already received an identical claim and will not pay it twice.
- CARC 181Code was not valid on that dateThe procedure code did not exist, or had been retired, on the date the service was performed.
- CARC 151Too many services for the payer's likingThe payer considers the frequency or quantity billed unsupported by what was submitted.
Authorisation
- CARC 39Authorisation was requested and refusedThe payer declined authorisation at the time it was asked for, and the service went ahead anyway.
- CARC 40Not urgent enough to bypass authorisationThe service was billed as emergent or urgent and the payer does not accept that characterisation.
- CARC 197No authorisation on fileThe service required prior authorisation and the payer has none recorded.
- CARC 198Authorisation limit exceededAn authorisation existed but the service went beyond the visits, units or window it covered.
Bundling and global periods
- CARC 97Bundled into another serviceThe payer considers this service part of something else it has already paid for.
- CARC B15A prerequisite service is missingThe payer requires another, qualifying service to have been performed and covered before this one can pay.
- M15Separately billed services were bundledServices billed separately were treated as components of the same procedure.
- M80Not covered on the same date as another serviceThe service is not payable when performed on the same day or session as something already processed.
Timely filing
Documentation
- CARC 16Something is missing or wrong on the claimThe most common and least specific denial there is. The payer needs more before it can adjudicate.
- CARC 252Documentation required before it can be adjudicatedThe payer is asking for records before it will make a decision. Not yet a refusal.
- MA130Unprocessable — incomplete or invalid informationThe claim could not be processed at all, so it carries no appeal rights. It must be corrected and resubmitted.
- M51Procedure code missing or invalidThe procedure code on the claim is absent, incomplete or not valid as submitted.
- M76Diagnosis missing or invalidThe diagnosis or condition on the claim is absent, incomplete or not valid as submitted.
- M127Medical record missingThe payer wants the patient's record for this service before it will decide.
Patient responsibility
- CARC 1Applied to the deductibleNot a denial. The payer has allowed the charge and applied it to the patient's deductible.
- CARC 2Applied to coinsuranceNot a denial. The patient's share of the allowed amount under their plan's coinsurance.
- CARC 3Applied to the co-paymentNot a denial. A fixed patient charge for the visit type under their plan.
- CARC 35Lifetime maximum reachedThe patient has exhausted a lifetime benefit limit under this plan.
- CARC 119Benefit maximum for the period reachedThe patient has used up a benefit limit for this period or occurrence.
- MA13Alert about billing the patientA warning that penalties may apply if the patient is billed for amounts not reported as their responsibility.
Coverage and benefit limits
- CARC 45Above the contracted rateNot a denial. The billed charge exceeded the fee schedule, and the difference is a contractual adjustment.
- CARC 44Prompt-pay discountNot a denial. A reduction applied under a prompt-payment arrangement.
- CARC 49Routine or preventive, and not covered as billedThe payer treats this as a routine or screening service outside the covered benefit.
- CARC 50Not medically necessary, per the payerThe payer's policy does not accept the service as necessary for the diagnosis reported.
- CARC 96Non-covered chargeThe payer does not cover this service — broad, and usually needing a remark code to interpret.
- CARC 167Diagnosis is not coveredThe payer does not cover services for the diagnosis reported.
- CARC 204Not in the patient's benefit planThe service, drug or equipment is not part of what this patient's plan covers.
- CARC 19Belongs to workers' compensationThe payer treats this as a work-related injury and the liability of the workers' compensation carrier.
- CARC 20Belongs to a liability carrierThe payer considers another party's liability insurer responsible for this injury.
- CARC 21Belongs to a no-fault carrierThe payer treats the injury as the responsibility of a no-fault auto insurer.
- CARC B7Provider not eligible for this service on that dateThe provider was not certified, enrolled or eligible to be paid for this service on the date it was delivered.
- N115Decision based on a Local Coverage DeterminationThe payer applied a Local Coverage Determination — a regional policy setting out when a service is covered.
- N130Check the plan documents for restrictionsThe payer is pointing at plan-specific restrictions rather than giving a reason of its own.
Claim Adjustment Reason Codes are maintained by X12 as External Code List 139. Remittance Advice Remark Codes are External Code List 411, maintained by CMS. The official code descriptions are theirs and are not reproduced here — everything on these pages is our own explanation of cause, verification and appeal. Always check the authoritative list for current wording and status; codes are revised several times a year.