CARC 102 – Major Medical Adjustment

What it means

This code indicates that the payer adjusted the claim because part of the charges fall under a separate 'major medical' benefit component of the patient's insurance plan, rather than the basic medical benefit. It typically shows up when a plan splits coverage into basic and major medical tiers and the payment or patient responsibility was recalculated based on that split.

Common causes

The patient's plan has both basic and major medical benefit tiers, and the claim was processed under the major medical portion
Coordination of benefits between a primary basic plan and a supplemental major medical policy
Deductible or coinsurance tied specifically to the major medical benefit was applied
Legacy or older insurance plan designs that separate coverage this way (more common with certain commercial or union/trust plans)

How to fix it

Review the remittance advice (RA) alongside the patient's plan benefit summary to confirm how basic vs. major medical benefits were split
Verify eligibility and benefit details directly with the payer to understand which services fall under major medical coverage
Check for any secondary insurance or supplemental major medical policy that may need to be billed for the adjusted amount
Confirm patient responsibility amounts (deductible/coinsurance) tied to the major medical tier are billed correctly to the patient if applicable
If the adjustment appears incorrect, contact the payer for a detailed benefit breakdown before resubmitting or appealing

Appeal / resubmit

If you believe the adjustment misapplies major medical benefit rules, request a written benefit breakdown from the payer showing how the basic and major medical portions were calculated. Compare this against the patient's plan documents. Include any supporting documentation, such as the plan's summary of benefits, when submitting a reconsideration or appeal.

Related codes

Frequently asked

Does CARC 102 mean the claim was denied?

Not necessarily. It usually reflects an adjustment in how the payment was calculated based on a major medical benefit split, rather than an outright denial of the service.

Who is responsible for the adjusted amount?

This depends on the patient's specific plan design. It may shift to patient responsibility, a secondary payer, or remain a contractual adjustment—review the plan details and RA carefully.

Is this code common with all insurance plans?

No, it is more often seen with plans that structure benefits into separate basic and major medical tiers, which is less common with many modern commercial plans.

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This content is for informational purposes only and does not constitute billing, coding, or legal advice. Verify all denial handling with the specific payer and applicable regulations.