Claim adjustment reason code · X12
CARC 109: not covered by this payer, send it elsewhere.
CARC 109 means this payer is not the one responsible for the claim. X12 says you must send the claim to the correct payer or contractor. Find out who that is, then file with them.
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What X12 says CARC 109 means
Claim/service not covered by this payer/contractor. You must send the claim/service to the correct payer/contractor.
CARC 109 · Start 01/01/1995, last modified 01/29/2012.
Typical reasons
These are common patterns, not an official list. The remark code or the payer's letter is what confirms yours.
- The patient is enrolled in a different plan or product from the one you billed.
- The service belongs to a program that pays separately, for example workers' compensation or an auto policy.
- The plan carves the service out to a separate vendor.
- Coverage was a different plan on the date of service.
CARC 109 versus coordination of benefits
CARC 109 sends the claim away to another payer. CARC 22 is different: X12 words it as "This care may be covered by another payer per coordination of benefits", meaning another plan may be involved, often as primary. If a remittance shows 22, look for other coverage and bill the primary first. If it shows 109, the payer does not cover this claim and wants it filed elsewhere.
Steps
- Run a fresh eligibility check for the date of service and note the plan name and ID.
- Ask the patient about other coverage, including employer, spouse, auto and work-related injury.
- Ask the payer, if the remittance does not say, which payer or contractor it believes is responsible.
- File with the correct payer, keeping the original denial as proof of timely attempt. Watch the new payer's filing limit; see CARC 29.
Sources
- X12: Claim Adjustment Reason Codes — code text, start and last-modified dates (list dated 10/30/2026, retrieved 2026-11-01)
Every code description and rule above was retrieved from these pages on November 1, 2026. Payers revise code lists, contracts and policies, so confirm anything that affects a claim or a deadline with the payer.
Frequently asked questions
What is the difference between CARC 109 and CARC 22?
CARC 109 says the payer does not cover the claim and it should go to another payer. CARC 22 says the care may be covered by another payer under coordination of benefits.
Should I bill the patient after CARC 109?
Not before you find the correct payer. Bill the patient only after the responsible payer has processed the claim, or as your contract and the patient's notice allow.
Is CARC 109 an appeal situation?
Usually not. The fix is filing with the right payer. If you believe this payer is responsible, ask it to review with proof of coverage.
Not legal, billing or medical advice
This page explains published code lists and rules and runs a lookup in your browser. It cannot see your claim, your contract or any payer's policy. Confirm with the payer or your Medicare Administrative Contractor before you resubmit, appeal or bill a patient.