Question 1

What does denial code CARC 45 mean?

Accepted Answer

CARC 45 — Charge exceeds fee schedule/maximum allowable or contracted fee arrangement. The provider billed an amount exceeding the contracted payer allowable fee schedule (CO-45), or the fee was discounted per participation contract. How to work it: Audit against the negotiated payer fee schedule. If the payer underpaid the contracted rate or processed under an incorrect fee schedule tier, file a formal underpayment appeal. If the contractual adjustment matches your agreement, write off the variance — do not balance-bill the patient.

Question 2

What does denial code CARC 204 mean?

Accepted Answer

CARC 204 — Service/equipment/drug is not covered under the patient’s current benefit plan. The service is explicitly excluded from the patient’s insurance policy, benefit frequency is exhausted, or the plan has a non-covered rider (commonly PR-204). How to work it: Confirm 270/271 eligibility on date of service. If secondary coverage or commercial rider exists, submit COB claim with primary EOB. If the service is genuinely non-covered and a signed Advance Beneficiary Notice (ABN) or financial consent is on file, bill patient responsibility.

Question 3

What does denial code CARC 16 mean?

Accepted Answer

CARC 16 — Claim/service lacks information needed for adjudication. A required data element is missing or incomplete — rendering/billing NPI, diagnosis pointers, units, or a required modifier. The accompanying RARC tells you exactly which element. How to work it: Read the paired RARC to find the missing field, correct it, and submit a corrected claim. N290/N257 point to provider identifiers; M51 to a missing/invalid procedure code; MA27/N382 to subscriber/member ID issues.

Question 4

What does denial code CARC 50 mean?

Accepted Answer

CARC 50 — These are non-covered services — not deemed a medical necessity. The diagnosis on the claim doesn't support medical necessity for the procedure under the payer's LCD/NCD policy. How to work it: Compare the billed ICD-10 against the payer LCD/NCD for that CPT. If the record supports a covered diagnosis, submit a corrected claim; otherwise appeal with documentation or route to patient responsibility via ABN.

Question 5

What does denial code CARC 11 mean?

Accepted Answer

CARC 11 — The diagnosis is inconsistent with the procedure. The linked diagnosis doesn't clinically justify the procedure performed. How to work it: Re-check diagnosis-to-procedure linkage against the documentation, point each CPT to the diagnosis that supports it, and submit corrected.

Question 6

What does denial code CARC 97 mean?

Accepted Answer

CARC 97 — Benefit is included in the payment for another service/procedure (bundled). The procedure is a component of another billed procedure — an NCCI PTP edit or a service inside the global period. How to work it: Run the NCCI PTP edit pair. If the column-2 service was truly separate and documented, append the appropriate modifier (59/XE/XS/XP/XU) and resubmit; otherwise the bundling is correct.

Question 7

What does denial code CARC 4 mean?

Accepted Answer

CARC 4 — Procedure code is inconsistent with the modifier, or a required modifier is missing. A required modifier is absent, or a modifier conflicts with the procedure code. How to work it: Apply the correct modifier per NCCI/payer rules (25 for a separate E/M, 59/X{EPSU}, 26/TC, 50, 51, RT/LT), remove any conflicting modifier, and submit a corrected claim.

Question 8

What does denial code CARC 18 mean?

Accepted Answer

CARC 18 — Exact duplicate claim/service. The same service/date/provider was already submitted, or repeated units were billed as separate lines. How to work it: Check claim history. If it is a true duplicate, no action. If it was a legitimately repeated service, bill correct units or append modifier 76/77/91 and resubmit.

Question 9

What does denial code CARC 197 mean?

Accepted Answer

CARC 197 — Precertification / authorization / notification absent. The service required prior authorization that was not obtained or not attached. How to work it: Check for an auth on file. If one exists, submit a corrected claim with the authorization number. If not, request a retro-authorization where the payer allows it, then appeal.

Question 10

What does denial code CARC 96 mean?

Accepted Answer

CARC 96 — Non-covered charge(s). The service is not a covered benefit under the patient's plan. How to work it: Verify the benefit. If covered, correct the coding/POS that triggered the denial and resubmit. If genuinely non-covered, bill the patient when an ABN/agreement is on file.

Denial Code Lookup

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