Denial Codes - Healthcare

CO 119 Denial Code – Benefit maximum for this time period or occurrence has been reached or exhausted

Channagangaiah

Insurances will deny the claim as Denial Code CO 119 – Benefit maximum for this time period or occurrence has been reached or exhausted, whenever the maximum amount or maximum number of visits or units for the time dated under the plans policy is reached.

To understand the denial code 119 consider the following example:

Assume as per the John plan policy End Stage Related Services are allowed only once per month.

Let us assume John has taken ESRD related health care services on 12/02/2019 and received a payment for the claim from insurance. Again on the same month John received ESRD related health care services i.e. on 12/24/2019.

In this case, Do insurance company pay the date of service 12/24/2019?

Answer: No, insurance will deny the claim with Denial Code CO 119 – Benefit maximum for this time period or occurrence has been reached or exhausted. Because this End stage related healthcare service is allowed only once per month as per the patient policy and John has already received payment for the similar End stage related service on 12/02/2019, so insurance company will deny the claim as per the his plan policy.

What is Maximum benefit Exhausted in Medical Billing?

Maximum Benefit exhausted in medical billing refers to the maximum amount of money/maximum number of visits/maximum number of units met as per the patient plan policy (specific time period).

When the Claim denied as Maximum Benefits Met or Maximum benefit Exhausted, then we need to follow the below steps to resolve the denial (CO 119 denial code):
  • Review the other claims billed after the date of service in question, if found paid in the application. Call the claims department of carrier and have the claim reprocessed by referencing the paid claim.
  • If the procedure code is an office visit/ consultation, check if the patient has referrals to cover those visits, if yes, reprocess the claim.

If above information not available,

  • Reach out insurance company to find out whether it’s maximum amount or unit or visit?
  • Get the maximum amount or visit or units under the patient plans policy and benefit met date?
  • Bill the patient if the benefits met or benefits exhausted (Before you do, check the client specifications).
Call the claims department and ask the following question when claim denied with CO 119 – Benefit maximum for this time period or occurrence has been reached or exhausted:

If Benefit Maximum for this time period or occurrence has reached, then ask the following questions:

  • Get the Claim received date and denial date of the Claim?
  • Check with rep and get the maximum benefit amount for the patient and the date when the maximum benefit amount reached?
  • Get the Claim number and Cal reference number

If Maximum frequency (Units) reached, then check with the following questions:

  • Get the received and denial date?
  • Get the maximum frequency for the procedure code and the date when the maximum frequency reached?
  • Get the Claim number and Cal reference number.

If Maximum visits reached, then with the following questions:

  • May I know the maximum visit for the patient and the date when the maximum visit met?