PR-119: Benefit Maximum Reached
The patient owes this benefit maximum reached amount. Verify the balance and collect from the patient.
What Does PR-119 Mean?
With PR (Patient Responsibility), the benefit maximum reached is the patient's financial obligation. The insurer processed the claim, applied the patient's plan benefits, and this amount is owed directly by the patient. The most common scenario is the patient has exhausted their covered benefit amount and is responsible for charges beyond the maximum per their plan terms.
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.
Common Causes
| Cause | Frequency |
|---|---|
| Patient responsible for services beyond benefit maximum The patient has exhausted their covered benefit amount and is responsible for charges beyond the maximum per their plan terms | Most Common |
| Patient elected to continue treatment beyond benefit limit The patient was informed that their benefit maximum was reached and chose to continue receiving services at their own expense | Common |
How to Resolve
- Verify the benefit maximum reached amount Cross-reference the adjusted amount against the patient's benefits summary or eligibility response to confirm the benefit maximum reached amount was applied correctly per plan terms.
- Confirm plan benefit details Review the patient's specific plan structure. Confirm the correct amount was applied for this service type.
- Generate a patient statement Prepare a clear statement showing the service rendered, the allowed amount, the benefit maximum reached amount, and the balance the patient owes.
- Collect from the patient Send the statement and follow your practice's collection workflow. Offer payment plan options for substantial balances.
- Track and follow up Record payments received, update the account balance, and follow up on outstanding amounts per your collection policy.
The patient has exhausted their benefit maximum for this service category. The charges are correctly assigned as patient responsibility. Collect from the patient.
Common RARC Pairings
The RARC code tells you exactly what triggered the PR-119:
| RARC | Description |
|---|---|
| N381 | The patient is responsible for charges beyond the benefit maximum Bill the patient for services rendered after the benefit maximum was reached → |
How to Prevent PR-119
- Notify patients of their benefit limits during scheduling and at each visit
- Provide written cost estimates when patients are approaching their benefit maximum
- Collect financial responsibility acknowledgment before providing services beyond the benefit maximum
- Offer alternative treatment options that may be covered under different benefit categories
Also Filed As
The same CARC 119 may appear with different Group Codes:
Related Denial Codes
Sources
- https://www.cms.gov/medicare/coverage/coverage-general-information
- https://www.aapc.com/resources/claim-adjustment-reason-code-carc
- https://www.mdclarity.com/denial-code/119
- Codes maintained by X12. Visit x12.org for official definitions.