CO-222: Exceeds Contracted Maximum Hours/Days/Units
Units exceed the contract maximum. Appeal with medical necessity documentation or request a contract exception.
What Does CO-222 Mean?
With CO (Contractual Obligation), the excess units are denied per the contract. Appeal if the services were medically necessary, or request a contract exception for future cases.
CARC 222 indicates that the service billed exceeds the contractual limit for hours, days, or units established between the provider and the payer. Unlike CARC 198 (which relates to authorization limits), this code specifically refers to contractual maximums — the ceiling defined in the provider agreement rather than a per-patient authorization.
This is common in home health, physical therapy, occupational therapy, and other services where contracts specify maximum units per day, visits per episode, or hours per treatment period. The excess services are denied because they fall outside the provider's contractual arrangement.
Common Causes
| Cause | Frequency |
|---|---|
| Provider exceeded contracted maximum hours for the period The provider has billed for more hours of service than their contract allows for the specified time period | Most Common |
| Maximum days of service exceeded The number of treatment days billed exceeds the contractual maximum days allowed per patient or per period | Common |
| Unit cap reached for the service type The provider has reached the maximum number of units allowed under their contract for this service type during the billing period | Common |
| Volume cap triggered by provider-level aggregate billing The total volume of services billed by this provider across all patients has exceeded a contractual aggregate cap | Occasional |
How to Resolve
- Verify contract limits Check the specific contract maximum for this service.
- Appeal if medically necessary Submit clinical documentation supporting the need for additional units.
- Request contract amendment For recurring issues, negotiate higher contractual limits.
Appeal with documentation demonstrating the medical necessity for services beyond the contracted maximum. Include clinical notes, treatment plans, and physician justification. Request a single-case agreement or contract amendment for the additional services. Reference the specific contract provision and demonstrate why the maximum is insufficient for the patient's clinical needs.
Common RARC Pairings
The RARC code tells you exactly what triggered the CO-222:
| RARC | Description |
|---|---|
| N362 | The number of Days or Units of Service Exceeds our acceptable maximum. Verify your contracted maximum and request an increase if medically necessary → |
| N381 | Alert: Consult your contractual agreement for restrictions, billing, and payment information. Review your contract for the specific maximum hours/days/units allowed → |
How to Prevent CO-222
- Track utilization against contractual limits before billing
- Set up alerts when approaching contract maximums
- Negotiate adequate contract limits during payer contracting
- Document medical necessity thoroughly when approaching contract limits
General Prevention
- Track service utilization against contracted maximums throughout each billing period
- Set up automated alerts when approaching 80% of the contracted maximum hours, days, or units
- Request contract amendments proactively when patient volume trends suggest the maximum will be exceeded
- Negotiate adequate contracted maximums during initial contract negotiations and renewals
- Distribute caseload among multiple providers when approaching individual provider caps
Also Filed As
The same CARC 222 may appear with different Group Codes:
Related Denial Codes
Sources
- https://x12.org/codes/claim-adjustment-reason-codes
- 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
- https://www.aapc.com/resources/claim-adjustment-reason-codes
- Codes maintained by X12. Visit x12.org for official definitions.