CO-45
The amount billed is higher than the payer's contracted (allowed) rate. The difference is a contractual write-off, not a patient balance.
Look up a CARC or RARC denial code to see what it means, why it happens, and how to fix it.
The amount billed is higher than the payer's contracted (allowed) rate. The difference is a contractual write-off, not a patient balance.
The claim is missing required information or has an error. It is almost always paired with a RARC that names the specific missing field.
This service is bundled into another service that was already paid, so it is not paid separately.
The payer received this exact claim/service already.
Another insurer should be billed first under coordination of benefits.
The claim was submitted after the payer's filing deadline.
The payer decided the service was not medically necessary as billed.
The service is not covered under the plan. Often paired with a RARC explaining why.
The rendering provider's NPI is missing, incomplete, or invalid on the claim.
This is the wrong payer for the claim.
A required prior authorization, precertification, or notification was not obtained.
The item or service is not a covered benefit under this plan.
This amount is applied to the patient's deductible and is the patient's responsibility.
This amount is the patient's coinsurance and is their responsibility.
This amount is the patient's copay and is their responsibility.
The diagnosis code does not match or support the procedure billed.
A modifier is missing or wrong for the procedure billed.
The patient's coverage had ended before the date of service.
The payer cannot match the patient to a member record.
The provider was not credentialed or enrolled with the payer for that date/service.
The billed frequency or quantity exceeds what the payer allows or the documentation supports.
The patient has hit a benefit maximum (visits, dollars, or occurrences) for the period.
The service is covered under a capitation or managed-care arrangement, not fee-for-service.
The procedure is not separately payable; its value is included in another service.
The diagnosis code was not valid for that date of service.
The member ID and patient name on the claim do not match the payer's records.
This provider type is not allowed to bill this service to the payer.
The payer needs supporting documentation before it can process the claim.
A routine or preventive service is not covered (or was billed with a routine exam), and it is patient responsibility.
The procedure billed does not fit the patient's age per payer edits.
The referring provider on the claim is not eligible to make the referral.
The claim is unprocessable due to incomplete/invalid information, so it was not adjudicated (and has no appeal rights until corrected).
The service is subject to plan restrictions; check the benefit documents.
The diagnosis is missing, incomplete, or invalid on the claim.