CO-119 — Benefit Maximum / Lifetime Maximum Reached
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.
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In plain language
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.
Start here
Confirm the plan's specific benefit maximum for the service category and the current accumulator status.
Who resolves it
Billing/Follow-Up
Who prevents it
Registration/Scheduling — benefit-maximum check before scheduling elective/repeat services.
Sources
- X12 CARC list; X12 RARC list
Validated ClaimetryX Source — Denial Management Knowledge Base, 2026 Research Edition
Research date August 18, 2026. CARC/RARC combinations and payer processes vary. Always check the specific remittance advice and the payer's current requirements before acting on any denial.
Published by ClaimetryX. Sources identify the code standards, agency guidance, and payer policies supporting this reference. How we use sources
How to resolve this denial, step by step
- 1
Confirm the plan's specific benefit maximum for the service category and the current accumulator status.
- 2
Verify the CPT/HCPCS billed is correctly categorized under that benefit.
- 3
If mis-categorized, correct and resubmit.
- 4
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.
- 5
If accurate, determine patient-responsibility eligibility per the plan document.
- 6
Document the benefit-maximum verification.
Then choose the correct disposition
Corrected claim
only for a benefit-category coding error.
Payer follow-up
when the accumulator appears inaccurate.
Patient responsibility
appropriate once the benefit maximum is confirmed accurate and the plan/contract permits patient billing for services beyond the maximum.
Stop and escalate when
- Suspected accumulator discrepancy between the payer's system and documented prior claims; patient disputes the benefit-maximum determination.
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.
Do Not Do This
- Do not recode the service to a different, uncapped benefit category unless that category genuinely and accurately describes the service performed.
- Do not bill the patient before confirming the accumulator is accurate.
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.
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.
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.
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.
Department Most Likely Responsible
- Resolves current claim: Billing/Follow-Up. Prevents recurrence: Registration/Scheduling — benefit-maximum check before scheduling elective/repeat services.
AI Answer Guardrail
- Verify the plan's specific benefit-period definition and current accumulator accuracy before recommending patient billing or a benefit-category recoding.
AI Search Terms / Synonyms
- CO119; CO-119; CO35; CO149; benefit maximum reached; lifetime maximum; visit limit exceeded; N130.
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