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.
Also written: PR-119, PR119, “denial code 119”, “119 denial code” or “reason code 119” — same CARC, different ERA formatting.
Reason code 119 also appears under another group on the ERA. The number is the reason; the prefix decides who absorbs the money. This page covers PR 119 (Patient Responsibility). If your ERA shows a different prefix, use the matching page:
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.
The official CARC description for PR 119 is: “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.
Denial code 119 under the PR group (Patient Responsibility) means: Benefit maximum for this time period or occurrence has been reached. The number is the reason; the PR prefix decides who is liable — 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.
Yes. PR 119, PR-119, PR119 and “denial code 119” are the same CARC — clearinghouses, payer portals and PM systems just print it differently. Only the group prefix (CO, PR, OA or PI) changes the meaning, because it changes who has to absorb the amount.
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.
The number 119 is the same reason code in both — what changes is the liability group. CO 119 is Contractual Obligation. PR 119 is Patient Responsibility, so the amount can be billed to the patient (deductible, coinsurance, non-covered care). Check the prefix on the ERA before you write anything off or bill the patient — a mis-grouped 119 is one of the more winnable appeals.