CARC 109: Claim/Service Not Covered by This Payer/Contractor

What it means

The payer you billed is saying they are not the right entity to process this claim. This usually means the patient has different or additional coverage, the claim was sent to the wrong plan, or the payer's contractor jurisdiction doesn't match where the service was rendered.

Common causes

Patient has other primary or supplemental insurance that should have been billed first or instead
Claim was sent to the wrong Medicare Administrative Contractor (MAC) or jurisdiction
Patient recently changed insurance plans and the old payer information was used
Coordination of benefits (COB) information on file with the payer is outdated or incorrect
Service was rendered under a different plan type (e.g., Medicare Advantage vs. Original Medicare)
Claim submitted to a subcontracted or carved-out benefit administrator instead of the correct one

How to fix it

Contact the payer to confirm why they believe they are not responsible and ask for the correct payer name and address
Re-verify patient eligibility and coverage details, including COB, through the payer portal or clearinghouse
Check with the patient to confirm current insurance information and any recent plan changes
For Medicare claims, confirm the correct MAC jurisdiction based on place of service and provider location
Correct the payer information in your practice management system and resubmit the claim to the correct payer
Update the patient's insurance record to prevent the same routing error on future claims

Appeal / resubmit

This is typically not an appeal situation but a resubmission issue. Gather documentation confirming the correct payer (such as an eligibility response or COB update) and submit the claim to that payer within their timely filing limit. Keep a copy of the original denial in case the new payer requests proof of the redirect.

Related codes

Frequently asked

Does this denial mean the patient has no coverage?

No. It means this specific payer isn't the correct one to process the claim, not that coverage doesn't exist. The patient likely has coverage through another plan or contractor.

Can I just resubmit to the same payer with corrections?

No. You need to identify and bill the correct payer or contractor, since the current one has indicated they are not responsible for this claim.

How do I find the correct payer?

Check with the patient, verify eligibility through official payer resources, or ask the denying payer for guidance on where the claim should be sent.

More free billing tools: all denial codes · denial lookup · Medicare fee calculator

This content is informational only and does not constitute billing or legal advice. It does not guarantee any specific claim outcome or reimbursement.