CARC 215 Active

CO-215: Based on Subrogation of a Third Party Settlement

TL;DR

Payment was reduced due to a third-party settlement. Review the settlement terms and accept or negotiate.

Action
Review & Decide
Who Pays
Provider
Appeal
Yes
Patient Impact
None
Disclaimer
This content is for informational purposes only and does not constitute professional billing advice. Always verify information against your payer contracts and current coding guidelines. Consult a certified billing specialist for specific claim issues.

What Does CO-215 Mean?

With CO (Contractual Obligation), the subrogation adjustment is contractual. The payer is exercising its right to reduce payment based on the third-party settlement.

CARC 215 indicates that the payer's payment was reduced or denied because a third-party settlement (such as an auto insurance settlement, workers compensation settlement, or personal injury settlement) includes funds designated for the medical expenses billed on this claim. The payer is exercising its subrogation rights to recover or reduce payment because the patient has already received compensation for these services from another source.

Subrogation is the legal right of the insurance company to seek reimbursement from a third party that caused the injury or from settlement funds designated for medical costs. This is common in auto accident cases, slip-and-fall injuries, and workers compensation claims where a third party is financially responsible.

Common Causes

Cause Frequency
Third party liability settlement received The patient received a settlement from a third party (auto insurance, workers comp, liability) that covers the medical expenses, and the health insurer is exercising subrogation rights Most Common
Auto accident claim with third party recovery The patient was involved in an auto accident and the at-fault party's insurance has settled or is expected to settle the medical claims Common
Workers compensation subrogation Workers compensation has been identified as the responsible payer for the services and the health insurer is subrogating the claim Common
Liability insurance recovery in progress The payer has identified that a third party may be liable for the medical costs and is pursuing subrogation Occasional

How to Resolve

  1. Review settlement documentation Obtain the settlement agreement and allocation details.
  2. Verify the adjustment amount Confirm the subrogation amount matches the settlement allocation for medical expenses.
  3. Negotiate if incorrect If the adjustment amount is wrong, submit documentation showing the correct allocation.
Appeal Guide

Appeal if no third party settlement has been received and no third party liability exists. Include documentation demonstrating the absence of third party involvement, such as a statement from the patient confirming no accident or liability claim. If the subrogation amount is incorrect, provide documentation of the actual settlement amount.

Common RARC Pairings

The RARC code tells you exactly what triggered the CO-215:

RARC Description
N381 Alert: Consult your contractual agreement for restrictions, billing, and payment information. Review the subrogation terms in your payer contract and coordinate with the third party insurer →

How to Prevent CO-215

General Prevention

Also Filed As

The same CARC 215 may appear with different Group Codes:

OA-215 PR-215

Related Denial Codes

CO-101 — Predetermination: Anticipated Payment CO-106 — Patient Payment Option Not in Effect CO-109 — Claim Not Covered by This Payer CO-115 — Procedure Postponed, Canceled, or Delayed CO-132 — Prearranged Demonstration Project Adjustment

Sources

  1. https://x12.org/codes/claim-adjustment-reason-codes
  2. https://portal.ct.gov/-/media/ohs/health-it-advisory-council/apcd-advisory-group/data-submission-guide-workgroup/meeting-materials/6-30-22/carc-codes_final.pdf
  3. https://www.aapc.com/resources/claim-adjustment-reason-codes
  4. Codes maintained by X12. Visit x12.org for official definitions.