Denial Code CO 119

What is denial code CO 119 – Maximum benefit exhausted/met

It is the benefit limits. It may be either the “Benefit amount” or individual lifetime visits for certain services as per the patient plan and insurance company will start denying those services once the maximum amount paid or maximum number of visits exhausted with the denial code CO 119 – Maximum benefit exhausted/met.

Whenever you come across this denial code CO 119 – Maximum benefit exhausted/met, a very first step is to verify the benefit limits of the patient plan and claim submitted beyond these limits is patient responsibility.

Services for a maximum benefit denial may include:

• Mental Health Services
• Physical Therapy
• Routine Exams
• Specialist Services

For examples: consider patient’s policy benefits limit for that particular calendar year is $2000

In this example insurance company will pay the benefits to provider till $2000 is met for that particular calendar year. Once it reaches paying $2000 for that particular calendar year, then insurance company will start denying the future claims submitted with following denial code CO 119 – Maximum benefit exhausted/met in that particular calendar year.

consider patient’s policy benefits limit is 3 visits per month for physical therapy.

In this example insurance company will pay the benefits till 3 visits are met for that particular month for physical therapy. If provider submit the physical therapy claims beyond 3 visits per month, then insurance company will start denying those beyond claims with following denial code CO 119 – Maximum benefit exhausted/met.

Denial Analysis:

We can resolve this denial without calling the insurance company. First, we need to check eligibility and benefit limits of the patient plan through website and then verify the patient account for the total amount paid or total number of visits paid respectively for that particular service by the insurance company.

If the benefit limit not met, then call insurance company to reprocess the claim.

If the benefit limit met, then check for the other active insurance for patient. If found then submit the claim with primary denied EOB.

If not found, go ahead and bill the patient.

Action on Denial Code CO 119 – Maximum benefit exhausted/met:

1. Call the insurance company and get the denial date.
2. Verify the reason for denial, is it “Benefit amount” or “number of visits”?

If its “Benefit amount”:

• Check how much benefit amount paid as per patient plan?
• Verify when the amount met (DOS)?
• Check the billing software application for the same.
• If it’s not met, ask representative to reprocess the claim and get the reprocessing time.
• If met, then check with representative or patient account for other active insurances available for this patient.
• If active insurance found, then submit those claims with denied EOB.
• If no active insurance available, then bill the insurance allowed amount to patient.

If its “Visit”:

• Check that particular service how many visits payable as per patient plan?
• Verify when the visits exhausted?
• Cross check the same in the billing software application.
• If it’s not met, ask representative to reprocess the claim and get the reprocessing time.
• If met, then check with rep or patient account for other active insurances available for this patient.
• If active insurance found, then submit those claims with denied EOB.
• If no active insurance available, then go ahead and the bill patient.

• Get Claim number and Cal reference number.

Notes Format:

DOS 07/10/2023 called payer BCBS @ 888-824-3120 spoke with Chris stated that the claim was received on 08/20/2023 and denied on 08/28/2023 as Maximum benefit exhausted/met. Verified about maximum benefits in terms of dollar amount or visits, rep said max benefits reached in terms of visits. Asked the rep how many visits were allowed as per patient plan, the rep said 6 visits were allowed per calendar year and the maximum visits were met on DOS 13/6/2023. (Please mention action part here) Claim# 20118719183. Call reference# 897398743.

Note: If you don’t have denied EOB then Requested the EOB through fax and mention the same in the notes.

In the above notes format action part is not mentioned:

For example, if suppose patient is having other active UHC insurance, then include the following notes:” Checked application found patient is having active UHC insurance, hence submitted the claim to UHC insurance along with BCBS denied EOB.

If patient don’t have any other active insurance, then include the following comments: “Checked application no other active insurance found, hence billed the claim to patient.

Medical Billing Denials and actions – Top Denial codes Solutions (medicalbillingcycle.com)