CARC 222 Active

PR-222: Exceeds Contracted Maximum Hours/Days/Units

TL;DR

The patient owes for units beyond the contract maximum. Collect from the patient.

Action
Review & Decide
Who Pays
Patient
Appeal
No
Patient Impact
Direct Financial
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 PR-222 Mean?

With PR (Patient Responsibility), the patient is responsible for services exceeding the contract maximum. Collect from the patient.

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.

How to Resolve

  1. Communicate with the patient Inform the patient of the charges for services beyond the contract limit.
  2. Collect from the patient Send a statement and collect.
Do Not Appeal This Code

Exceeds Contracted Maximum Hours/Days/Units reflects a fee-schedule or contracted-rate reduction — the difference between billed charges and the negotiated allowed amount. The reduction is the contracted rate itself, not a denial of coverage, so an appeal isn't the right action. Confirm the contracted rate was applied correctly and accept the adjustment.

How to Prevent PR-222

Also Filed As

The same CARC 222 may appear with different Group Codes:

CO-222 OA-222

Related Denial Codes

PR-45 — Charge Exceeds Fee Schedule/Maximum Allowable PR-139 — Contracted Funding Agreement — Subscriber Employed by Provider PR-260 — Processed Under Medicaid ACA Enhanced Fee Schedule PR-308 — Contracted Funding Agreement Adjustment PR-P12 — Workers' Compensation Jurisdictional Fee Schedule 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.