CARC 119 appeal letter template — Benefit Maximum Reached
CARC 119 indicates the payer determined that the patient's plan benefit maximum (visit count, dollar amount, or occurrence limit) for this time period has already been met. This template helps challenge the denial when the benefit limit appears to have been miscounted or misapplied.
When to appeal vs. correct & resubmit
Appeal when you believe the benefit maximum was miscalculated, applied to the wrong plan year/benefit period, counted services that should not accrue toward the cap, or when the patient's accumulator/eligibility data on file with the payer appears incorrect. Correct and resubmit instead if the claim truly exceeds a documented, verified plan limit (e.g., visit count or dollar cap confirmed by the payer's benefit summary) — in that case an appeal is unlikely to change the outcome and the balance may be patient responsibility per the plan terms.
Appeal letter template
Copy the template, replace every [bracketed] field with your details, and keep only the paragraph that fits your situation.
[Date] [Payer Name] Appeals Department [Payer Address] Re: Appeal of Claim Denial — CARC 119 (Benefit Maximum Reached) Patient Name: [Patient Name] Member ID: [Member ID] Claim #: [Claim #] Date(s) of Service: [DOS] Provider: [Provider Name, NPI] CPT/HCPCS: [CPT/HCPCS] Dear Appeals Review Team, We are writing to formally appeal the denial of the above-referenced claim, which was denied under CARC 119, indicating that the benefit maximum for this time period or occurrence has been reached. We respectfully request a review of this determination for the following reason(s): [Explain basis for appeal — e.g., benefit accumulator appears inaccurate, service should not count toward the cited limit, benefit period/plan year was misapplied, or prior services were miscounted]. Enclosed is documentation supporting our position, including the plan's benefit summary, prior claim history, and/or accumulator records showing [describe discrepancy]. We ask that the payer re-verify the member's benefit utilization for the applicable period and reprocess this claim accordingly. Please reconsider this claim in light of the enclosed information. If additional documentation is needed, please contact our office at [Phone] or [Email]. Thank you for your prompt attention to this matter. Sincerely, [Provider Name, NPI] [Practice Name] [Phone] [Email]
What to attach
- EOB/ERA showing the CARC 119 denial
- Plan benefit summary or Summary of Benefits and Coverage (SBC)
- Member benefit accumulator/utilization history
- Prior claims history for the same benefit period
- Proof of authorization or medical necessity documentation, if applicable
- Any payer correspondence regarding the patient's benefit limits
Frequently asked questions
What does CARC 119 mean?
It means the payer's records show that the patient's plan benefit maximum — such as a visit count, dollar cap, or occurrence limit — for the applicable time period has already been met, so the claim was denied.
Should I always appeal a CARC 119 denial?
Not always. If the benefit limit is accurate and verified by the plan documents, appealing is unlikely to change the outcome. Appeal only when there is a reasonable basis to believe the accumulator, benefit period, or counted services were misapplied.
What documentation helps most with this appeal?
The plan's benefit summary, the member's utilization/accumulator history, and prior claims records are typically the most useful documents to show whether the limit was correctly applied.
Is the patient responsible for the balance if the appeal is denied?
This depends on the plan's terms and applicable billing agreements. Review the payer contract and patient coverage documents to determine responsibility, as this template does not address billing determinations.
More free billing tools: all appeal letters · denial codes · NCCI edits · Medicare fees
This template is for informational purposes only and does not constitute legal, billing, or medical advice. It is intended as a general starting point for drafting an appeal letter and must be customized to the specific claim, payer policy, and plan documents. Submitting an appeal does not guarantee reconsideration, reversal, or payment of the claim. Consult your organization's compliance, billing, or legal resources as needed.
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