Claim Denied – Work-Related Injury/Illness (Workers' Compensation Liability)

What it means

The payer is denying this claim because they believe the condition being treated resulted from a work-related injury or illness. Under this determination, the Workers' Compensation carrier—not the health insurance plan—is responsible for covering these services.

Common causes

Diagnosis codes or documentation suggest an occupational injury or illness
Patient's intake or claim history indicates the injury occurred at work
Employer or payer records show an open Workers' Compensation claim for this patient
Claim was submitted to the wrong payer instead of the Workers' Compensation carrier
Incorrect or missing information about the nature of the injury on the claim

How to fix it

Verify with the patient whether the injury or illness occurred at work
Contact the patient's employer to confirm if a Workers' Compensation claim exists
Obtain the correct Workers' Compensation carrier name, claim number, and billing address
Resubmit the claim directly to the Workers' Compensation carrier with appropriate documentation
If the injury was not work-related, gather supporting documentation and appeal the denial with the original payer
Update patient intake records to reflect accurate injury details for future claims

Appeal / resubmit

If you believe the denial is incorrect and the injury or illness is not work-related, submit a clear statement from the patient along with supporting medical documentation indicating the cause of the condition. Include any relevant history, incident reports, or physician notes that clarify the injury did not occur on the job. Appeals should be submitted within the payer's specified timeframe with all supporting evidence attached.

Related codes

Frequently asked

What does CARC 19 mean on my remittance advice?

It means the payer has determined that the service was for a work-related injury or illness, making the Workers' Compensation carrier responsible for payment instead of the health plan.

What should I do if the patient says the injury wasn't work-related?

Collect documentation from the patient and treating provider confirming the non-occupational nature of the injury, then file an appeal with the original payer.

Can I bill the patient if this code appears?

Generally, you should not bill the patient until the correct liable party (Workers' Compensation or the health plan) is identified. Billing practices should follow applicable state and payer rules.

How do I find the correct Workers' Compensation carrier?

Contact the patient's employer or state Workers' Compensation board to identify the carrier and obtain claim filing details.

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

This content is for informational purposes only and does not constitute billing or legal advice. Always verify current payer policies and consult appropriate professionals for specific claim decisions.