CARC 119: Benefit maximum for this time period or occurrence has been reached.

CARC 119 appears on the 835 ERA (Electronic Remittance Advice) that the payer returns after claim adjudication. It explains a reduction, denial, or payment adjustment to your billing team. For your practice, the question is workflow: identify the pattern, route the denial to the right resolution path (rebill, appeal, write-off), and recover what's recoverable without burning RVU time on dead-end fights.

What CARC 119 means

The official X12 description is: “Benefit maximum for this time period or occurrence has been reached.”

In plain language: You've hit your annual or lifetime maximum for this benefit category (visits, dollars, units). ACA bans lifetime maximums on essential health benefits.

Common scenarios

• Annual PT/OT cap
• Mental health session cap
• Chiropractic cap
• Vision exam annual limit

Practice workflow for CARC X 119

If your plan is ACA-compliant, dollar lifetime maximums on essential health benefits are illegal — appeal citing ACA §2711. Visit limits (e.g., 30 PT sessions/year) are still allowed but appealable on medical necessity for additional units.

ApprovalHelp auto-drafts the appeal letter against the right federal appeal-rights regulation (ACA §2719, ERISA §503, NSA §2799A, 42 CFR 422 Subpart M, or 42 CFR 438 Subpart F) for the patient's plan type, the payer's own coverage policy, and the relevant clinical guideline. Drafts route to the clinician for signature in under five minutes.

CARC 119 group codes explained

On the 835 ERA, CARC 119 appears alongside a group code that signals who is financially responsible for the adjustment. CO (Contractual Obligation) — Contractual write-off. The provider agreed to the rate. Patient does NOT owe this amount.