Currently viewingDenial Management

Active Denial Code Directory & Lookup Tool

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Notice

Looking for inactive or deprecated codes? View our List of Excluded Denials to see codes that are intentionally kept outside the active lookup directory because they were retired, expired, replaced, or removed from active use in the maintained code-set structure.

Active Denials Search Tool

Use the search bar below to look up active Claim Adjustment Reason Code / denial codes topics and related remittance keywords. You can search by keyword, group-code example, CARC code, or description given on EOB / ERA.

Search by keyword, CARC code, or description

Search checks code, description, and hidden keywords. Click any linked code to open its detail page. Total active searchable rows: 8.

Active Denial Codes

Code	Description
CARC-04	The procedure code is inconsistent with the modifier used or a required modifier is missing.
CARC-05	The procedure code or bill type is inconsistent with the place of service.
CARC-06	The procedure or revenue code is inconsistent with the patient age.
CARC-07	The procedure code is inconsistent with the patient gender.
CARC-08	The procedure code is inconsistent with the provider type or specialty.
CARC-09	The diagnosis code is inconsistent with the patient's age.
CARC-10	The diagnosis is inconsistent with the patient's gender.
CARC-11	The diagnosis is inconsistent with the procedure billed.

Understanding PR 1, PR 2, and PR 3 CARC Codes

PR stands for Patient Responsibility. When a claim adjustment is tagged with the PR group code, the financial responsibility is assigned to the patient instead of the insurance payer.

PR 1 – Deductible Amount: A portion of the allowed claim amount was applied to the patient's annual deductible. The payer does not pay this amount because the patient must satisfy the deductible first.
PR 2 – Coinsurance Amount: The patient owes a percentage-based share of the allowed amount after the plan calculates benefits according to the patient's policy.
PR 3 – Co-payment Amount: The patient owes a fixed copay amount required by the health plan for a specific visit, service, or benefit category.

Excluded Denials

The denial codes listed below are intentionally excluded from our active lookup directory. They are kept here for learning, cleanup, and historical reference so students do not confuse old or inactive codes with current active denial-code lessons.

X12 code-set maintenance may retire, expire, remove, replace, or split a code when a newer or more precise code is available. For production billing work, always follow the active code shown on the current ERA/EOB and verify the latest payer or X12 guidance when needed.

List of Excluded Denials

Total excluded codes: 63.

Excluded Denial Code	Previous Description	Replacement / Superseding Status
CARC 15	Authorization number missing, invalid, or not applicable.	Review CARC 197, 284, 296, or 302 based on the payer message.
CARC 17	Requested information was not provided or was incomplete.	Review CARC 16, 226, 227, 250, 251, or 252.
CARC 25	Stop-loss deductible was not met.	Verify current payer remark and use the current CARC/RARC shown on the ERA.
CARC 28	Coverage was not in effect on the service date.	Use CARC 26 for before coverage or CARC 27 for after termination.
CARC 30	Eligibility, spend-down, waiting, or residency requirement not met.	Review CARC 177, 178, 179, or 180.
CARC 36	Balance did not exceed the co-payment amount.	Use PR group code with CARC 3 when the issue is patient copayment.
CARC 37	Balance did not exceed the deductible.	Use PR group code with CARC 1 when the issue is patient deductible.
CARC 38	Services not provided or authorized by network/primary care providers.	Use CARC 242 for network provider or CARC 243 for network authorization.
CARC 41	Preferred provider contract discount.	Review CARC 45 or payer contract adjustment guidance.
CARC 42	Charge exceeded fee schedule or maximum allowable amount.	Use CARC 45.
CARC 43	Gramm-Rudman reduction.	Review current payer/federal reduction guidance; CARC 253 may apply for sequestration when appropriate.
CARC 46	Service was not covered.	Use CARC 96.
CARC 47	Diagnosis was not covered, missing, or invalid.	Review CARC 146 or 167 based on whether diagnosis is invalid or non-covered.
CARC 48	Procedure was not covered.	Use CARC 96.
CARC 52	Referring, prescribing, ordering, or rendering provider was not eligible.	Review CARC 183, 184, or 185.
CARC 57	Submitted information did not support level, frequency, length, dosage, or days supply.	Use CARC 150, 151, 152, 153, or 154.
CARC 62	Pre-certification or authorization was absent or exceeded.	Review CARC 197, 198, 210, 284, 296, or 302.
CARC 63	Correction to a prior claim.	Use the current reversal/correction process required by the payer and implementation guide.
CARC 64	Denial reversed per medical review.	Use the current reversal/correction process required by the payer and implementation guide.
CARC 65	Procedure code was incorrect and payment reflected the corrected code.	Use current coding/edit CARCs or submit a corrected claim as directed by the payer.
CARC 67	Lifetime reserve days.	Handled in QTY segment where applicable.
CARC 68	DRG weight.	Handled in CLP12 where applicable.
CARC 71	Primary payer amount.	Use CARC 23.
CARC 72	Coinsurance day.	Handled in QTY segment where applicable.
CARC 73	Administrative days.	Verify payer-specific ERA guidance.
CARC 77	Covered days.	Handled in QTY segment where applicable.
CARC 79	Cost report days.	Handled in MIA15 where applicable.
CARC 80	Outlier days.	Handled in QTY segment where applicable.
CARC 81	Discharges.	Verify payer-specific ERA guidance.
CARC 82	PIP days.	Verify payer-specific ERA guidance.
CARC 83	Total visits.	Verify payer-specific ERA guidance.
CARC 84	Capital adjustment.	Handled in MIA where applicable.
CARC 86	Statutory adjustment.	Use CARC 45 when it represents fee schedule/allowed amount adjustment.
CARC 87	Transfer amount.	Verify payer-specific ERA guidance.
CARC 88	Collection against receivable created by a prior overpayment.	Review current overpayment recovery/PLB reporting guidance.
CARC 92	Claim paid in full.	No active denial replacement; verify payment posting details.
CARC 93	No claim-level adjustments.	Follow current 835 implementation guide reporting.
CARC 98	Hospital must file the Medicare claim for this inpatient non-physician service.	Verify current Medicare/payer-specific billing guidance.
CARC 99	Medicare Secondary Payer adjustment amount.	Review CARC 23 or current COB/MSP reporting guidance when applicable.
CARC 113	Service was outside the United States or resulted from war.	Use CARC 157, 158, or 159.
CARC 120	Patient is covered by a managed care plan.	Use CARC 24.
CARC 123	Payer refund due to overpayment.	Follow current reversal/overpayment handling in the implementation guide.
CARC 124	Payer refund amount for non-patient situation.	Follow current reversal/overpayment handling in the implementation guide.
CARC 125	Submission or billing error.	Review CARC 16 or more specific request-for-information codes.
CARC 126	Major medical deductible.	Use PR group code with CARC 1.
CARC 127	Major medical coinsurance.	Use PR group code with CARC 2.
CARC 138	Appeal procedures not followed or time limits not met.	Use CARC 285 or 286.
CARC 141	Claim spans eligible and ineligible coverage periods.	Review CARC 238 or 239.
CARC 145	Premium payment withholding.	Use Group Code CO and CARC 45 when applicable.
CARC 156	Flexible spending account payments.	Use CARC 187.
CARC 162	State-mandated requirement for property and casualty.	Use code P1.
CARC 165	Referral absent or exceeded.	Use CARC 287 for exceeded referral or CARC 288 for absent referral.
CARC 168	Dental plan benefits not available after medical plan consideration.	Review CARC 254, 270, 280, 289, 290, 291, or 292 based on plan routing.
CARC 191	Not work-related injury or illness for workers compensation liability.	Use code P2.
CARC 196	Claim denied based on prior payer coverage determination.	Use CARC 136.
CARC 214	Workers compensation claim adjudicated as non-compensable.	Use code P4.
CARC 217	Payer reasonable and customary fees; no maximum allowable defined.	Use code P5.
CARC 218	Adjustment based on entitlement to benefits.	Use code P6.
CARC 220	Fee schedule/database does not contain the billed code.	Use code P7.
CARC 221	Claim is under investigation.	Use code P8.
CARC 230	No available or correlating CPT/HCPCS code describes the service.	Use code P9.
CARC 244	Payment reduced to zero due to litigation.	Use code P10.
CARC 255	Related property and casualty claim disposition pending due to litigation.	Use code P11.

Educational note: payer remittance files may still show old language in internal notes or converted legacy data. For live claim follow-up, rely on the current payer ERA/EOB code, any attached RARC, and the payer's current policy instructions.

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