CARC 204
Not in the patient's benefit plan
The service, drug or equipment is not part of what this patient's plan covers.
Why you actually get this
- A genuine plan exclusion.
- A formulary or equipment list that does not include the item.
- The patient was enrolled in a different plan than the one verified.
How to check whether it’s correct
- 01Confirm which plan the patient held on the date of service.
- 02Check whether an alternative covered item exists.
- 03Establish whether the patient was told in advance.
Rarely worth appealing
A plan exclusion is not usually appealable. Where an exception process exists — a formulary exception, for instance — that is a different route and worth asking about. Otherwise this becomes a patient conversation, which goes much better before the service than after it.
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.