CO-119 — Benefit Maximum / Lifetime Maximum Reached

Denial Identifier

• Primary CARCs: CO-119 — "Benefit maximum for this time period or occurrence has been reached." CO-35 — "Lifetime benefit maximum has been reached." CO-149 — "Lifetime benefit maximum has been reached for this service/benefit category." (X12)
• Common RARC: N130 — "Consult plan benefit documents/guidelines for information about restrictions for this service."; N356 (not covered when performed with/subsequent to a noncovered service) may apply if the maximum relates to a service category already exhausted.

Plain-Language Meaning

• The patient's plan only covers a set amount/number of this service per period (CO-119) or ever (CO-35/CO-149), and that limit has already been used up.

Why the Claim Was Denied

• Registration/Eligibility: benefit maximum not checked before the service was scheduled/performed
• Payer processing: payer's benefit-accumulator count may be outdated or include services from a different provider not yet reflected to this office
• Patient/COB information: patient received the same benefit-category service elsewhere in the same benefit period

Information the Biller Must Review

• Plan benefit document/summary of benefits for the specific service category, benefit period (calendar year, plan year, lifetime), payer portal benefit-accumulator/utilization screen, prior claims history for the same benefit category.

What Needs to Be Corrected

• Claim correction: Rarely applicable; verify the code billed actually falls in the maxed-out benefit category (a coding error placing the wrong category could be corrected).
• Upstream correction: Registration/Scheduling should check benefit accumulators before scheduling elective or repeat services subject to a known plan maximum.

Resolution Workflow

• Confirm the plan's specific benefit maximum for the service category and the current accumulator status.
• Verify the CPT/HCPCS billed is correctly categorized under that benefit.
• If mis-categorized, correct and resubmit.
• If the maximum has genuinely been reached, confirm whether the payer's accumulator reflects all prior payer-paid services accurately, and dispute if there is a documented discrepancy.
• If accurate, determine patient-responsibility eligibility per the plan document.
• Document the benefit-maximum verification.

Department Most Likely Responsible

• Resolves current claim: Billing/Follow-Up. Prevents recurrence: Registration/Scheduling — benefit-maximum check before scheduling elective/repeat services.

Prevention Control

• Benefit-accumulator check integrated into scheduling for known benefit-capped service lines (e.g., therapy visit limits, certain DME); patient financial counseling before the service when a maximum is close to being reached.

Escalation Trigger

• Suspected accumulator discrepancy between the payer's system and documented prior claims; patient disputes the benefit-maximum determination.

Sample Scenario

• Scenario: Therapy visit denied CO-119/N130.
• Finding: Payer's system correctly shows the plan's annual visit maximum was reached two visits earlier with the same provider.
• Action: Patient counseled on benefit exhaustion and self-pay options per plan terms; no further claim action.

Resolution path at a glance

AI Search Terms / Synonyms

• CO119; CO-119; CO35; CO149; benefit maximum reached; lifetime maximum; visit limit exceeded; N130.

AI Answer Guardrail

• Verify the plan's specific benefit-period definition and current accumulator accuracy before recommending patient billing or a benefit-category recoding.

Sources

• X12 CARC list; X12 RARC list