119: Benefit maximum for this time period or occurrence has been reached.
The patient has used up the maximum number of visits, dollar amount, or occurrences the plan allows for this benefit in the current period, whether annual, lifetime, or per-episode.
What the group code means
- PR
- Patient Responsibility. The amount may be billed to the patient.
- CO
- Contractual Obligation. The provider is responsible and the amount cannot be billed to the patient.
This CARC is reported under more than one group code depending on the payer and the circumstances: PR, CO.
Why it fires
- The patient already received the maximum allowed visits or units for this benefit category this year
- A lifetime maximum for a benefit, such as certain therapies or devices, has been reached
- Multiple providers billed against the same shared benefit maximum, exhausting it before this claim arrived
Corrective actions, ranked
- 1
Verify the benefit maximum and usage
Call the payer or check the portal for the exact maximum and how much has been used to date.
- 2
Check for other providers
If other providers or facilities also billed against this same maximum, confirm the count is accurate and no overlap or coding error caused a premature max-out.
- 3
Bill the patient if the maximum is confirmed
If the max is accurately reached, this becomes patient responsibility per plan terms.
Is it worth appealing
Appeal only if you can show the benefit count was miscalculated, such as the wrong service category or another provider's units incorrectly counted here. A genuinely exhausted benefit maximum is not appealable.
Related remark codes
Retrieved 2026-07-18.
Do not let this happen again
Scrub the claim against NCCI PTP and MUE edits before you submit, free and in your browser.
DenialPath provides billing and administrative guidance based on published CMS and X12 sources. It is not medical advice, not a coverage determination, and not a guarantee of payment. NCCI and MUE edits are republished quarterly and payer policies vary by contract. Always confirm against the payer's own current policy before submitting or appealing.