CARC 167
Diagnosis is not covered
The payer does not cover services for the diagnosis reported.
Why you actually get this
- The diagnosis falls outside the payer's covered conditions for this service.
- A more specific or additional diagnosis that would support coverage was omitted.
How to check whether it’s correct
- 01Check the payer's policy for which diagnoses support this service.
- 02Re-read the chart for a supporting diagnosis that was not coded.
Usually worth appealing
Frequently recoverable, because the supporting diagnosis is often present in the record and simply was not submitted. Worth working before older denials.
Often arrives with
Seeing a lot of these?
A single denial is a claim to work. A pattern of the same denial is a process to fix, and the two need completely different responses. A free panel reads ninety days of your claims data and shows which codes actually recur for you.
Claim Adjustment Reason Codes are maintained by X12 as External Code List 139. The official description of this code is theirs and is not reproduced here. Check the authoritative list for current wording and status.