Claim adjustment reason code · X12
CARC 119: benefit maximum reached.
CARC 119 says the plan's limit for this benefit has been used up for the period or occurrence. Check the accumulator and the plan year before you accept it. The service itself was not judged unnecessary.
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What X12 says CARC 119 means
Benefit maximum for this time period or occurrence has been reached.
CARC 119 · Start 01/01/1995, last modified 02/29/2004.
The words "time period or occurrence" cover both annual or lifetime dollar caps and visit limits per year or per episode.
Check the limit is real
- Is the benefit period a calendar year, a plan year or a rolling window? A date of service just after a reset should not hit last year's cap.
- Do the visits or dollars on the payer's tally match your own records? Another provider's claims count too.
- Is the limit combined across services, such as therapy types sharing one visit count?
- Was a claim from earlier in the period reprocessed, which frees up units?
Who owes the balance
Group code decides. Under PR, X12's Patient Responsibility, the patient may owe it, and the payer's explanation of benefits should show the limit. Under CO the provider writes it off. Many contracts and some plans require a patient notice before billing for services past a limit; check yours.
What to do next
Request the accumulator detail from the payer. If it is correct, bill the patient only where permitted. If the tally is wrong, ask the payer to reprocess with the correct count. Related: if the plan says the service is not part of the benefit at all, the code is CARC 109 or CARC 204 rather than 119.
Sources
- X12: Claim Adjustment Reason Codes — code text, start and last-modified dates (list dated 10/30/2026, retrieved 2026-11-01)
- X12: Claim Adjustment Group Codes — CO, OA, PI, PR names (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
Is CARC 119 a medical necessity denial?
No. It means a plan limit was reached. CARC 50 is the medical necessity code.
Can the patient be billed after CARC 119?
Often yes when the group code is PR, but check the contract and any required patient notice.
How do I check the visit count?
Ask the payer for the accumulator or benefit summary for the plan year and compare it with your own visit log.
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.