CARC 7
Procedure conflicts with the patient's gender
The payer's edits say this procedure is not expected for the gender on record.
Why you actually get this
- Gender recorded incorrectly at registration.
- The payer's record and the practice's record disagree.
- A gender-specific edit applied to a patient for whom it is clinically inappropriate.
How to check whether it’s correct
- 01Compare the gender on the claim against both your record and the payer's.
- 02Where the service was clinically correct, establish what documentation the payer needs.
Usually worth appealing
Often a data correction. Where the edit is clinically inappropriate for the patient, payers generally have a documented route to override it — ask rather than write off.
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.