Official CARC description: “Benefit maximum for this time period or occurrence has been reached.” Here’s what it actually means, why it fires, and how to get the claim paid.
PR twin of CO 119 — the cap is hit and the rest lands on the patient. Verify the accumulator before the patient statement, and know the exception paths for medically necessary overage.
Liability group: PR = Patient Responsibility — the amount can be billed to the patient (deductible, coinsurance, non-covered care) — but only after you verify the denial is correct. Mis-grouped PR denials are a common appeal win.
Request the accumulator detail before conceding
Medicare therapy: KX modifier with documented necessity continues payment
Dispute inflated accumulators with a claims-level count
Genuinely exhausted: pre-service estimates and consent for continued care
Appeal accumulator errors and medical-necessity exceptions (KX pathway, plan exception processes). A corrected count regularly reverses these.
Fill in the denial facts — use placeholders, never real patient data (the letter keeps [PATIENT NAME]-style fields so you can merge real details privately). A payer-ready draft with an enclosure checklist comes back in ~20 seconds.
Your appeal letter draft will appear here.
Benefit maximum for this time period or occurrence has been reached. In practice: PR twin of CO 119 — the cap is hit and the rest lands on the patient. Verify the accumulator before the patient statement, and know the exception paths for medically necessary overage.
PR stands for Patient Responsibility — the amount can be billed to the patient (deductible, coinsurance, non-covered care) — but only after you verify the denial is correct. Mis-grouped PR denials are a common appeal win.
Appeal accumulator errors and medical-necessity exceptions (KX pathway, plan exception processes). A corrected count regularly reverses these.