CARC 119 Active

OA-119: Benefit Maximum Reached

TL;DR

Adjustment in a COB or secondary payer context. Review the coordination of benefits details to determine the responsible party.

Action
Review & Decide
Who Pays
Depends
Appeal
No
Patient Impact
Indirect
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 OA-119 Mean?

When paired with Group Code OA, CARC 119 (Benefit Maximum Reached) is processed as an adjustment outside the standard CO/PR classifications. This typically occurs in secondary payer or coordination of benefits scenarios. Review the remittance details and the COB arrangement to determine financial responsibility and appropriate next steps.

CARC 119 indicates benefit maximum reached. The payer determined that the service or a portion of it does not meet coverage criteria under the patient's current plan benefits or the applicable coverage rules.

Common scenarios that trigger this adjustment include: the patient's plan has an annual or lifetime dollar maximum for the service category, and the total claims have reached that limit; The patient has used the maximum number of covered visits or treatments for the service type (e.g., 60 physical therapy visits per year), and additional services are not covered; The patient has exhausted their covered days for a specific benefit (e.g., inpatient psychiatric days, SNF days). The group code paired with CARC 119 determines who bears the financial responsibility — CO places it on the provider as a contractual obligation, PR shifts it to the patient, OA indicates a coordination of benefits or other payer adjustment.

How to Resolve

  1. Review the coordination of benefits Examine the OA-119 adjustment to understand how it fits within the primary/secondary payer relationship or other multi-payer context.
  2. Verify primary payer adjudication Review the primary payer's EOB to understand the basis for the secondary payer's OA adjustment.
  3. Determine the responsible party Based on the COB review, identify whether the adjustment should be absorbed, billed to another payer, or if additional documentation is needed.
  4. Appeal or resubmit if needed If the OA adjustment appears incorrect based on the COB arrangement, submit an appeal or corrected claim with the appropriate documentation.
  5. Follow up Monitor the claim status and take additional action as needed based on the COB determination.
Do Not Appeal This Code

Benefit Maximum Reached grouped under OA is an Other Adjustment that doesn't fall into the standard contractual write-off or patient responsibility categories. Whether action is needed depends on the specific reason — review any accompanying RARC codes and payer guidance to decide whether this is a final adjustment to accept or an issue to resolve through resubmission.

How to Prevent OA-119

Also Filed As

The same CARC 119 may appear with different Group Codes:

CO-119 PR-119

Related Denial Codes

OA-74 — Indirect Medical Education Adjustment OA-75 — Direct Medical Education Adjustment OA-76 — Disproportionate Share Adjustment OA-85 — Patient Interest Adjustment OA-89 — Professional Fees Removed from Charges

Sources

  1. https://www.cms.gov/medicare/coverage/coverage-general-information
  2. https://www.aapc.com/resources/claim-adjustment-reason-code-carc
  3. https://www.mdclarity.com/denial-code/119
  4. Codes maintained by X12. Visit x12.org for official definitions.