CARC 119: Benefit maximum for this time period or occurrence has been reached.
You've hit your annual or lifetime maximum for this benefit category (visits, dollars, units). ACA bans lifetime maximums on essential health benefits.
CARC 119 is the code your insurance company used to explain why your claim was reduced, denied, or paid less than expected. It appears on your Explanation of Benefits (EOB) — the statement your plan sends after a claim is processed. Here's what it means for you and what you can do about it.
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
What to do next 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.
DenialHelp helps organize a source-linked draft from the denial notice and confirmed case facts. The patient and treating clinician must verify the governing review rule, current payer policy, clinical sources, attachments, destination, and deadline.
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.
Frequently asked questions
What does CARC 119 mean?
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.
Is CARC 119 appealable?
Yes — CARC 119 is one of the codes that commonly supports an appeal. 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.
Which group code does CARC 119 appear under?
CARC 119 most often appears under: CO (Contractual Obligation) — Contractual write-off. The provider agreed to the rate. Patient does NOT owe this amount.
When does CARC 119 typically appear on a denial?
Common scenarios: Annual PT/OT cap; Mental health session cap; Chiropractic cap; Vision exam annual limit.
How do I appeal a CARC 119 denial?
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.
Related resources
Sources
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