CO-119 denial code: benefit maximum for this time period reached

Claim adjustment reason code 119 says: benefit maximum for this time period or occurrence has been reached. The patient's plan limits how much of this service it covers, by visits, units, dollars or frequency, and this claim is past the limit.

Payers send it with group code CO or PR. With CO, the practice carries the balance; with PR, the patient does. Which one applies depends on the plan and on whether the patient was told in advance.

• Visit caps, such as a set number of therapy or behavioral health visits per plan year.
• Frequency limits, such as a preventive service covered once every 12 months.
• Dollar maximums on a type of benefit.
• Lifetime limits on specific services.

• Check the dates. If the plan year reset before the date of service, the limit may not apply.
• Check the count. A visit billed by another provider, or a denied claim counted as used, can make the payer's count wrong.
• Ask about an exception. Some plans approve additional visits when they are medically necessary, often through a prior authorization.
• For Medicare frequency limits, an Advance Beneficiary Notice given before the service lets you bill the patient if Medicare denies it.

1. Confirm the limit and how many uses the payer has counted.
2. Appeal if the count is wrong, with the visit dates.
3. Request an exception or extension if the plan allows one and the care is medically necessary.
4. Otherwise, bill the patient only if they were told in advance and agreed, under your financial policy.

• Check benefit limits at booking, not just whether coverage is active.
• Count visits against the limit across the plan year.
• Request extensions before the last covered visit.
• Give the patient notice in writing before a service that may be past the limit.

CO-119 is decided by the patient's benefits, so it is prevented at booking and before the visit.

Claira Health's AI agents confirm coverage and the right payer before the visit, so this denial is stopped at the front desk instead of coming back weeks later. Your team sees only what needs a decision, and approves every step. On a 20-minute call, we’ll walk through it using one of your own denials.

Book a 20-minute call and bring a CO-119 you've had recently.