CARC 97 appeal letter template — Benefit Included in Payment for Another Service (Bundling Denial)
CARC 97 means the payer determined the billed service's value is already bundled into the payment for another procedure/service on the claim. This template helps you argue that the service was separately identifiable, distinct, and billable.
When to appeal vs. correct & resubmit
Appeal when the service performed was separately identifiable, used a different session/site/organ system, required significant additional work, or was incorrectly bundled by the payer's edits despite appropriate modifier use (e.g., 59, XE, XS, XP, XU). Correct and resubmit instead if the service is, in fact, a component of the primary procedure, if required modifiers were omitted in error, or if documentation does not support separate reporting.
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] Attn: Appeals Department [Payer Address] Re: Appeal of Claim Denial — CARC 97 Patient Name: [Patient Name] Member ID: [Member ID] Claim #: [Claim #] Date(s) of Service: [DOS] Billed CPT/HCPCS: [CPT/HCPCS] Rendering Provider: [Provider Name, NPI] Dear Appeals Reviewer, This letter formally appeals the denial of the above-referenced claim under CARC 97, which indicates that "the benefit for this service is included in the payment/allowance for another service/procedure already adjudicated." We respectfully disagree that this denial applies in this instance and request reconsideration. The service billed under [CPT/HCPCS] was performed as a separately identifiable, medically necessary procedure distinct from the other service(s) processed on this claim. [Explain here: different anatomical site, separate session, distinct diagnosis, unrelated procedure, or significant additional physician work beyond the primary service.] Supporting documentation is enclosed to demonstrate that this service was not inherently part of, nor adequately reimbursed by, the payment for the other adjudicated procedure. If applicable, modifier [Modifier, e.g., 59/XU/XS] was appended to CPT/HCPCS [CPT/HCPCS] to indicate that this was a distinct procedural service, and we ask that the claim be re-evaluated with this distinction in mind. Enclosed medical records and procedure notes further substantiate that separate reimbursement is warranted. We request that [Payer Name] reprocess this claim and issue payment for [CPT/HCPCS] as a separately billable service. Please contact our office at [Phone] or [Email] if additional information or clarification is needed. If prior authorization [Authorization #] was obtained and is relevant to this determination, it is referenced/attached for your review. Thank you for your prompt attention to this appeal. Sincerely, [Provider Name, NPI] [Practice/Facility Name] [Phone] [Email]
What to attach
- Explanation of Benefits (EOB) / Electronic Remittance Advice (ERA) showing the CARC 97 denial
- Complete medical record and chart notes for the date(s) of service
- Operative report or procedure note documenting the distinct service
- Documentation supporting modifier use (e.g., separate site, session, or diagnosis)
- National Correct Coding Initiative (NCCI) edit reference or payer bundling policy, if available
- Copy of the original claim as submitted
- Prior authorization documentation, if applicable
Frequently asked questions
What does CARC 97 mean?
It means the payer considers the billed service's reimbursement already included in the payment for another procedure or service on the same claim, rather than being separately payable.
When should I appeal a CARC 97 denial instead of just rebilling?
Appeal when you can document that the service was distinct, separately identifiable, and medically necessary beyond the bundled procedure. If the service truly is a component of the other procedure, correcting coding or accepting the bundle may be more appropriate.
Does adding a modifier guarantee the appeal will succeed?
No. Modifiers like 59 or the X{EPSU} series can support separate reporting, but payers review documentation independently, and no appeal outcome is guaranteed.
What documentation strengthens a CARC 97 appeal?
Operative or procedure notes clearly describing distinct sites, sessions, or diagnoses, along with any applicable modifier justification and payer-specific bundling policies, help support the case for separate payment.
More free billing tools: all appeal letters · denial codes · NCCI edits · Medicare fees
This template is provided for general informational and administrative purposes only. It is not legal, medical, or billing advice, and does not guarantee any particular outcome, payment, or reversal of a denial. Review payer-specific policies and consult qualified billing or legal professionals as needed before submitting an appeal.
Run visits, billing, and appeals in one place
Join providers across the country delivering modern virtual care with CareNiva. Free to start, ready in minutes.
100% Satisfaction Guaranteed — try it risk-free