CARC 216: Based on the findings of a review organization.
Based on the findings of a review organization.
CARC 216 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 216 means
The official X12 description is: “Based on the findings of a review organization.”
In plain language: Based on the findings of a review organization.
What to do next 216
Appeal with documentation specific to this code. The provider's billing office can help clarify what the carrier wants.
DenialHelp drafts the appeal letter for you in about five minutes. We cite the federal appeal-rights regulation that applies to your plan type (ACA §2719, ERISA §503, NSA §2799A, 42 CFR 422 Subpart M, or 42 CFR 438 Subpart F), the insurer's own coverage policy, and the relevant clinical guideline.
CARC 216 group codes explained
On the 835 ERA, CARC 216 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 216 mean?
Based on the findings of a review organization. In plain language: Based on the findings of a review organization.
Is CARC 216 appealable?
Yes — CARC 216 is one of the codes that commonly supports an appeal. Appeal with documentation specific to this code. The provider's billing office can help clarify what the carrier wants.
Which group code does CARC 216 appear under?
CARC 216 most often appears under: CO (Contractual Obligation) — Contractual write-off. The provider agreed to the rate. Patient does NOT owe this amount.
How do I appeal a CARC 216 denial?
Appeal with documentation specific to this code. The provider's billing office can help clarify what the carrier wants.
Related resources
Sources
Appeal a CARC 216 denial
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