Predetermination: Anticipated Payment Upon Completion of Services or Claim Adjudication

What it means

This code isn't a denial in the traditional sense—it means the payer processed the submission as a predetermination (a pre-service estimate) rather than an actual claim for services rendered. No payment is issued now because the payer is indicating that payment, if any, will be determined once the actual services are performed and a real claim is submitted, or once the claim goes through full adjudication.

Common causes

A predetermination or pre-authorization request was submitted using claim form fields, and the payer processed it as an estimate rather than a billable claim
The claim was submitted before services were actually rendered
Provider or biller confused a predetermination request with a standard claim submission
Payer system flagged the submission as an inquiry/estimate based on how it was coded or dated
Duplicate submission where an earlier predetermination request is now appearing on a remittance advice

How to fix it

Confirm whether this submission was intended as a predetermination request or an actual claim for completed services
If services have been rendered, resubmit a corrected claim with accurate dates of service and appropriate claim frequency code
Verify the claim was submitted through the correct channel (claims vs. predetermination/pre-authorization requests)
Check the remittance advice for any accompanying RARC codes that clarify next steps
Contact the payer to confirm whether the predetermination was approved, and what documentation is needed for the final claim
Once services are complete, submit the final claim referencing the predetermination number if the payer requires it

Appeal / resubmit

This is typically not an appealable denial since no adverse determination was made—it simply reflects that the payer is treating the item as a pre-service estimate. If you believe the claim was mistakenly processed as a predetermination when it should have been treated as a completed-service claim, contact the payer to clarify the submission type and request reprocessing as a standard claim rather than filing a formal appeal.

Related codes

Frequently asked

Does CARC 101 mean my claim was denied?

Not exactly. It indicates the payer treated the submission as a predetermination or pre-service estimate rather than a final claim, so no payment decision has been made yet on rendered services.

What should I do after receiving CARC 101?

Confirm whether services have been completed. If so, submit (or resubmit) the actual claim with correct dates of service so it can be adjudicated for payment.

Do I need to reference the predetermination in my final claim?

Many payers ask you to include the predetermination or pre-authorization reference number on the final claim—check the specific payer's requirements.

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This content is informational only and does not constitute billing or legal advice. Always verify requirements with the specific payer and consult qualified billing or legal professionals as needed.