Denial code reference
All CARC (Claim Adjustment Reason) codes
The complete X12-published list of Claim Adjustment Reason Codes that appear on insurance EOBs and 835 ERAs. 119 of the 194 indexed here are codes that DenialHelp recognises as typically appealable.
Total codes indexed
194
Typically appealable
119
Source
X12 (Washington Publishing Company)
Refresh cadence
Quarterly + monthly audit
Use the table below to find a specific code. Click any code to see the plain-language meaning, the group code it appears under (CO, PR, OA, PI), the common scenarios where it appears, and what to do — including whether DenialHelp can draft an appeal letter for you.
| Code | Description | Group(s) | Appealable |
|---|---|---|---|
| CARC 1 | Deductible Amount | PR | No |
| CARC 2 | Coinsurance Amount | PR | No |
| CARC 3 | Co-payment Amount | PR | No |
| CARC 4 | The procedure code is inconsistent with the modifier used. | CO | Yes |
| CARC 5 | The procedure code/type of bill is inconsistent with the place of service. | CO | Yes |
| CARC 6 | The procedure/revenue code is inconsistent with the patient's age. | CO | Yes |
| CARC 7 | The procedure/revenue code is inconsistent with the patient's gender. | CO | Yes |
| CARC 8 | The procedure code is inconsistent with the provider type/specialty. | CO | Yes |
| CARC 9 | The diagnosis is inconsistent with the patient's age. | CO | Yes |
| CARC 10 | The diagnosis is inconsistent with the patient's gender. | CO | Yes |
| CARC 11 | The diagnosis is inconsistent with the procedure. | CO | Yes |
| CARC 12 | The diagnosis is inconsistent with the provider type. | CO | Yes |
| CARC 13 | The date of death precedes the date of service. | CO | No |
| CARC 14 | The date of birth follows the date of service. | CO | No |
| CARC 15 | The authorization number is missing, invalid, or does not apply to the billed services or provider. | CO | Yes |
| CARC 16 | Claim/service lacks information or has submission/billing error(s). | CO | Yes |
| CARC 18 | Exact duplicate claim/service. | CO | No |
| CARC 19 | This is a work-related injury/illness and thus the liability of the Worker's Compensation Carrier. | CO | Yes |
| CARC 20 | This injury/illness is covered by the liability carrier. | CO | Yes |
| CARC 21 | This injury/illness is the liability of the no-fault carrier. | CO | Yes |
| CARC 22 | This care may be covered by another payer per coordination of benefits. | CO | Yes |
| CARC 23 | The impact of prior payer(s) adjudication including payments and/or adjustments. | OA | No |
| CARC 24 | Charges are covered under a capitation agreement/managed care plan. | CO | No |
| CARC 26 | Expenses incurred prior to coverage. | CO | Yes |
| CARC 27 | Expenses incurred after coverage terminated. | CO | No |
| CARC 29 | The time limit for filing has expired. | CO | Yes |
| CARC 31 | Patient cannot be identified as our insured. | CO | No |
| CARC 32 | Our records indicate the patient is not an eligible dependent. | CO | Yes |
| CARC 33 | Insured has no dependent coverage. | CO | No |
| CARC 34 | Insured has no coverage for newborns. | CO | Yes |
| CARC 35 | Lifetime benefit maximum has been reached. | CO | Yes |
| CARC 39 | Services denied at the time authorization/pre-certification was requested. | CO | Yes |
| CARC 40 | Charges do not meet qualifications for emergent/urgent care. | CO | Yes |
| CARC 44 | Prompt-pay discount. | OA | No |
| CARC 45 | Charge exceeds fee schedule/maximum allowable or contracted/legislated fee arrangement. | CO | No |
| CARC 49 | These are non-covered services because this is a routine/preventive exam or a diagnostic/screening procedure done in conjunction with a routine/preventive exam. | CO | Yes |
| CARC 50 | These are non-covered services because this is not deemed a 'medical necessity' by the payer. | CO | Yes |
| CARC 51 | These are non-covered services because this is a pre-existing condition. | CO | Yes |
| CARC 53 | Services by an immediate relative or a member of the same household are not covered. | CO | No |
| CARC 54 | Multiple physicians/assistants are not covered in this case. | CO | Yes |
| CARC 55 | Procedure/treatment/drug is deemed experimental/investigational by the payer. | CO | Yes |
| CARC 58 | Treatment was deemed by the payer to have been rendered in an inappropriate or invalid place of service. | CO | Yes |
| CARC 59 | Processed based on multiple or concurrent procedure rules. | CO | Yes |
| CARC 60 | Charges for outpatient services are not covered when performed within a period of time prior to or after inpatient services. | CO | Yes |
| CARC 96 | Non-covered charge(s). | CO, PR | Yes |
| CARC 97 | The benefit for this service is included in the payment/allowance for another service/procedure that has been adjudicated. | CO | Yes |
| CARC 100 | Payment made to patient/insured/responsible party. | OA | No |
| CARC 101 | Predetermination — anticipated payment upon completion of services or claim adjudication. | OA | No |
| CARC 102 | Major Medical Adjustment. | OA | No |
| CARC 103 | Provider promotional discount. | OA | No |
| CARC 104 | Managed care withholding. | OA | No |
| CARC 105 | Tax withholding. | OA | No |
| CARC 107 | The related or qualifying claim/service was not identified on this claim. | CO | Yes |
| CARC 109 | Claim/service not covered by this payer/contractor. You must send the claim/service to the correct payer/contractor. | CO | No |
| CARC 110 | Billing date predates service date. | CO | No |
| CARC 111 | Not covered unless the provider accepts assignment. | CO | Yes |
| CARC 114 | Procedure/product not approved by the FDA. | CO | Yes |
| CARC 115 | Procedure postponed, canceled, or delayed. | CO | No |
| CARC 116 | The advance indemnification notice signed by the patient did not comply with requirements. | CO | Yes |
| CARC 117 | Transportation is only covered to the closest facility that can provide the necessary care. | CO | Yes |
| CARC 118 | ESRD network support adjustment. | OA | No |
| CARC 119 | Benefit maximum for this time period or occurrence has been reached. | CO | Yes |
| CARC 125 | Submission/billing error(s). | CO | Yes |
| CARC 129 | Prior processing information appears incorrect. | CO | Yes |
| CARC 131 | Claim specific negotiated discount. | OA | No |
| CARC 132 | Prearranged demonstration project adjustment. | OA | No |
| CARC 133 | The disposition of the claim/service is pending further review. | OA | No |
| CARC 134 | Technical fees removed from charges. | OA | No |
| CARC 135 | Interim bills cannot be processed. | CO | No |
| CARC 136 | Failure to follow prior payer's coverage rules. | CO | Yes |
| CARC 137 | Regulatory surcharges, assessments, allowances, or health-related taxes. | OA | No |
| CARC 139 | Contracted funding agreement — subscriber is employed by the provider of services. | CO | No |
| CARC 140 | Patient/Insured health identification number and name do not match. | CO | Yes |
| CARC 142 | Monthly Medicaid patient liability amount. | PR | No |
| CARC 143 | Portion of payment deferred. | OA | No |
| CARC 144 | Incentive adjustment, e.g. preferred product/service. | OA | No |
| CARC 146 | Diagnosis was invalid for the date(s) of service reported. | CO | Yes |
| CARC 147 | Provider contracted/negotiated rate expired or not on file. | CO | Yes |
| CARC 150 | Payer deems the information submitted does not support this level of service. | CO | Yes |
| CARC 151 | Payment adjusted because the payer deems the information submitted does not support this many/frequency of services. | CO | Yes |
| CARC 152 | Payer deems the information submitted does not support this length of service. | CO | Yes |
| CARC 153 | Payer deems the information submitted does not support this dosage. | CO | Yes |
| CARC 154 | Payer deems the information submitted does not support this day's supply. | CO | Yes |
| CARC 155 | Patient refused the service/procedure. | CO | No |
| CARC 157 | Service/procedure was provided as a result of an act of war. | CO | Yes |
| CARC 158 | Service/procedure was provided outside of the United States. | CO | Yes |
| CARC 159 | Service/procedure was provided as a result of terrorism. | CO | Yes |
| CARC 160 | Injury/illness was the result of an activity that is a benefit exclusion. | CO | Yes |
| CARC 163 | Attachment/other documentation referenced on the claim was not received. | CO | Yes |
| CARC 164 | Attachment/other documentation referenced on the claim was not received in a timely fashion. | CO | Yes |
| CARC 165 | Referral absent or exceeded. | CO | Yes |
| CARC 166 | These services were submitted after this payer's responsibility for processing claims under this plan ended. | CO | No |
| CARC 167 | This (these) diagnosis(es) is (are) not covered. | CO | Yes |
| CARC 170 | Payment is denied when performed/billed by this type of provider. | CO | Yes |
| CARC 171 | Payment is denied when performed/billed by this type of provider in this type of facility. | CO | Yes |
| CARC 172 | Payment is adjusted when performed/billed by a provider of this specialty. | CO | Yes |
| CARC 173 | Service/equipment was not prescribed by a physician. | CO | Yes |
| CARC 174 | Service was not prescribed prior to delivery. | CO | Yes |
| CARC 175 | Prescription is incomplete. | CO | Yes |
| CARC 176 | Prescription is not current. | CO | Yes |
| CARC 177 | Patient has not met the required eligibility requirements. | CO | Yes |
| CARC 178 | Patient has not met the required spend down requirements. | PR | No |
| CARC 179 | Patient has not met the required waiting requirements. | CO | Yes |
| CARC 180 | Patient has not met the required residency requirements. | CO | Yes |
| CARC 181 | Procedure code was invalid on the date of service. | CO | Yes |
| CARC 182 | Procedure modifier was invalid on the date of service. | CO | Yes |
| CARC 183 | The referring provider is not eligible to refer the service billed. | CO | Yes |
| CARC 184 | The prescribing/ordering provider is not eligible to prescribe/order the service billed. | CO | Yes |
| CARC 185 | The rendering provider is not eligible to perform the service billed. | CO | Yes |
| CARC 186 | Level of care change adjustment. | OA | No |
| CARC 187 | Consumer Spending Account payments (HSA, FSA, HRA). | OA | No |
| CARC 188 | This product/procedure is only covered when used according to FDA recommendations. | CO | Yes |
| CARC 189 | 'Not otherwise classified' or 'unlisted' procedure code (CPT/HCPCS) was billed when there is a specific procedure code for this procedure. | CO | Yes |
| CARC 190 | Payment is included in the allowance for a Skilled Nursing Facility (SNF) qualified stay. | CO | No |
| CARC 192 | Non-standard adjustment code from paper remittance. | OA | No |
| CARC 193 | Original payment decision is being maintained. This claim was processed properly the first time. | OA | No |
| CARC 194 | Anesthesia performed by the operating physician, the assistant surgeon, or the attending physician is not separately payable. | CO | No |
| CARC 195 | Refund issued to an erroneous priority payer for this claim/service. | OA | No |
| CARC 197 | Precertification/authorization/notification/pre-treatment absent. | CO | Yes |
| CARC 198 | Precertification/notification/authorization/pre-treatment exceeded. | CO | Yes |
| CARC 199 | Revenue code and procedure code do not match. | CO | No |
| CARC 200 | Expenses incurred during lapse in coverage. | CO | Yes |
| CARC 201 | Patient is responsible for amount of this claim/service through 'set aside arrangement' or other agreement. | PR | No |
| CARC 203 | Discontinued or reduced service. | CO | No |
| CARC 204 | This service/equipment/drug is not covered under the patient's current benefit plan. | PR | Yes |
| CARC 205 | Pharmacy discount card processing fee. | OA | No |
| CARC 206 | National Provider Identifier (NPI) — missing. | CO | Yes |
| CARC 207 | National Provider Identifier (NPI) — invalid format. | CO | Yes |
| CARC 208 | National Provider Identifier (NPI) — not matched. | CO | Yes |
| CARC 209 | Per regulatory or other agreement. | OA | No |
| CARC 210 | Payment adjusted because pre-certification/authorization not received in a timely fashion. | CO | Yes |
| CARC 211 | National Drug Code (NDC) not eligible for rebate, do not bill. | CO | No |
| CARC 212 | Administrative surcharges are not covered. | CO | No |
| CARC 213 | Non-compliance with the physician self-referral prohibition legislation or payer policy. | CO | Yes |
| CARC 214 | Workers' Compensation claim adjudicated as non-compensable. | CO | Yes |
| CARC 215 | Based on subrogation of a third-party settlement. | OA | No |
| CARC 216 | Based on the findings of a review organization. | CO | Yes |
| CARC 219 | Based on extent of injury. | CO | Yes |
| CARC 222 | Exceeds the contracted maximum number of hours/days/units by this provider for this period. | CO | Yes |
| CARC 223 | Adjustment code for mandated federal, state, or local law/regulation that is not already covered by another code. | OA | No |
| CARC 224 | Patient identification compromised by identity theft. Identity verification required. | CO | Yes |
| CARC 225 | Penalty or interest payment by payer. | OA | No |
| CARC 226 | Information requested from the Billing/Rendering Provider was not provided or was insufficient/incomplete. | CO | Yes |
| CARC 227 | Information requested from the patient/insured/responsible party was not provided or was insufficient/incomplete. | CO | Yes |
| CARC 228 | Denied for failure of this provider, payer, or subscriber to respond to a request for information in a timely manner. | CO | Yes |
| CARC 229 | Partial charge amount not considered by Medicare due to the initial claim type of bill being 12X. | CO | No |
| CARC 231 | Mutually exclusive procedures cannot be done in the same day/setting. | CO | Yes |
| CARC 232 | Institutional Transfer Amount. | OA | No |
| CARC 233 | Services/charges related to the treatment of a hospital-acquired condition or preventable medical error. | CO | Yes |
| CARC 234 | This procedure is not paid separately. | CO | Yes |
| CARC 235 | Sales tax. | OA | No |
| CARC 236 | This procedure or procedure/modifier combination is not compatible with another procedure or procedure/modifier combination provided on the same day according to the National Correct Coding Initiative (NCCI). | CO | Yes |
| CARC 237 | Legislated/Regulatory Penalty. | OA | No |
| CARC 238 | Claim spans eligible and ineligible periods of coverage, this is the reduction for the ineligible period. | PR | Yes |
| CARC 239 | Claim spans eligible and ineligible periods of coverage. | CO | Yes |
| CARC 240 | The diagnosis is inconsistent with the patient's birth weight. | CO | Yes |
| CARC 241 | Low Income Subsidy (LIS) Co-payment Amount. | PR | No |
| CARC 242 | Services not provided by network/primary care providers. | CO | Yes |
| CARC 243 | Services not authorized by network/primary care providers. | CO | Yes |
| CARC 245 | Provider performance program withhold. | OA | No |
| CARC 246 | This non-payable code is for required reporting only. | OA | No |
| CARC 247 | Deductible for Professional service rendered in an Institutional setting and billed on an Institutional claim. | PR | No |
| CARC 248 | Coinsurance for Professional service rendered in an Institutional setting and billed on an Institutional claim. | PR | No |
| CARC 249 | This claim has been identified as a readmission. | CO | Yes |
| CARC 250 | The attachment/other documentation that was received was the incorrect attachment/document. | CO | Yes |
| CARC 251 | The attachment/other documentation that was received was incomplete or deficient. | CO | Yes |
| CARC 252 | An attachment/other documentation is required to adjudicate this claim/service. | CO | Yes |
| CARC 253 | Sequestration — reduction in federal payment. | CO | No |
| CARC 254 | Claim received by the dental plan, but benefits not available under this plan. | CO | Yes |
| CARC 256 | Service not payable per managed care contract. | CO | Yes |
| CARC 257 | The disposition of the related Property & Casualty claim has not yet been finalized. | OA | No |
| CARC 258 | Claim/service not covered when patient is in custody/incarcerated. | CO | Yes |
| CARC 259 | Additional payment for Dental/Vision service utilization. | OA | No |
| CARC 260 | Processed under Medicaid ACA Enhanced Fee Schedule. | OA | No |
| CARC 261 | The procedure or service is inconsistent with the patient's history. | CO | Yes |
| CARC 262 | Adjustment for delivery cost. | OA | No |
| CARC 263 | Adjustment for shipping cost. | OA | No |
| CARC 264 | Adjustment for postage cost. | OA | No |
| CARC 265 | Adjustment for administrative cost. | OA | No |
| CARC 266 | Adjustment for compound preparation cost. | OA | No |
| CARC 267 | Claim/service spans multiple months. | CO | Yes |
| CARC 268 | The Claim spans two calendar years. Please resubmit one claim per calendar year. | CO | No |
| CARC 269 | Anesthesia not covered for this procedure/clinical situation. | CO | Yes |
| CARC 270 | Claim received by the medical plan, but benefits not available under this plan. Submit these services to the patient's dental plan for further consideration. | CO | Yes |
| CARC 271 | Prior contractual reductions related to a current periodic payment as part of a contractual payment schedule when deferred amounts have been previously reported. | OA | No |
| CARC 272 | Coverage/program guidelines were not met. | CO | Yes |
| CARC 273 | Coverage/program guidelines were exceeded. | CO | Yes |
| CARC 274 | Fee/Service not payable per patient Care Coordination arrangement. | CO | Yes |
| CARC 275 | Prior payer's (or payers') patient responsibility (deductible, coinsurance, co-payment) not covered. | PR | No |
| CARC 276 | Services denied by the prior payer(s) are not covered by this payer. | CO | Yes |
| CARC 286 | Appeal procedures not followed. | CO | Yes |
| CARC 287 | Referral exceeded. | CO | Yes |
| CARC 288 | Referral absent. | CO | Yes |
| CARC 289 | Services considered under the dental and medical plans, benefits not available. | CO | Yes |
Codes here cover the most common CARC entries published by ASC X12. A handful of recently-added or rarely-used codes may not have a dedicated page yet. If a code you're looking for is missing, the X12 master list at x12.org is authoritative.
Frequently asked questions
What is a CARC code?
A Claim Adjustment Reason Code (CARC) is a standardised numeric code published by ASC X12 that explains why a health-insurance carrier reduced, denied, or adjusted a claim. CARC codes appear on the 835 Electronic Remittance Advice that carriers send to providers and on the EOB (Explanation of Benefits) sent to patients.
How do CARC codes differ from RARC codes?
CARC codes are the primary reason for the adjustment. RARC (Remittance Advice Remark Codes) are supplementary — they add detail to a CARC. A claim might be denied with CARC 197 (precertification absent) and a RARC like N4 (missing/incomplete/invalid prior authorization number) providing the specific gap.
Which CARC codes are appealable?
Codes that imply a clinical judgement (medical necessity, experimental, prior-auth absent, level of service downcoded, frequency exceeded) are typically appealable with the right documentation. Codes that reflect contractual write-offs, patient responsibility (deductible, copay, coinsurance), or routine accounting are usually not. DenialHelp flags the 119 codes here that typically support an appeal.
Where does this list come from?
ASC X12 publishes the master CARC list via the Washington Publishing Company (WPC). CMS, HIPAA-covered carriers, and clearinghouses use this standard. DenialHelp's editorial process re-verifies the descriptions against the current X12 publication monthly and updates any code descriptions that have been amended.
Sources
Contact: hello@approvalhelp.com