Denial Code CO 119

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

When it comes to insurance and healthcare coverage, benefit limits play a crucial role in determining the extent of services a patient can receive under their plan. These limits can be defined by either a maximum benefit amount or a set number of lifetime visits for specific services, as outlined in the patient’s plan. Once the maximum benefit amount has been reached or the allowable number of visits has been exhausted, the insurance company may start denying further services. This denial typically comes with a specific code- denial code CO 119 – Maximum benefit exhausted/met.

Understanding benefit limits is essential for patients to make informed decisions about their healthcare and financial planning. It is important for individuals to review their insurance plans and be aware of these limitations to avoid surprises or unexpected costs down the line. Additionally, healthcare providers should be proactive in communicating benefit limits to their patients to ensure transparency and help patients navigate their coverage effectively.

Denial code CO 119 – Maximum benefit exhausted/met indicates that the claim submitted has reached or exceeded the maximum benefit limit set by the patient’s insurance plan. When encountering this denial code, the initial step is to confirm the benefit limits outlined in the patient’s plan. Claims that surpass these limits become the responsibility of the patient to cover.

Such denial codes often pertain to a variety of services, including Mental Health Services, Physical Therapy, Routine Exams, and Specialist Services.

For examples:

Example 1: Consider patient’s policy benefits limit for that particular calendar year is $2000

In the scenario provided, the insurance company will cover benefits up to $2000 for a particular calendar year. Once this threshold is reached, the insurance company will begin denying future claims with the denial code CO 119, indicating that the maximum benefit for the calendar year has been exhausted or met

Example 2: Consider patient’s policy benefits limit is 3 visits per month for physical therapy.

In the scenario described, it is important to understand the insurance company’s benefit limitation for physical therapy visits. The insurance policy stipulates that benefits will be provided for up to 3 visits per month for physical therapy. If the provider submits claims for physical therapy sessions beyond the 3-visit limit in a given month, the insurance company will start denying those claims using denial code CO 119 – Maximum benefit exhausted/met.

How to resolve the denial code CO 119

• Resolving the denial code CO 119 can be done, before directly contacting the insurance company. To start, it is crucial to review the patient’s plan eligibility and benefit limits on the insurance company’s website. This will provide insight into whether the claim denial could be due to benefit limits being exceeded.
• Next, it is important to verify the patient’s account for the total amount paid or the total number of visits paid for that particular service by the insurance company. If the benefit limit has not been met, reaching out to the insurance company to request reprocessing of the claim may be necessary.
• If the benefit limit has been met, it is essential to check if there are any other active insurances for the patient. If another primary insurance is found, the claim can be resubmitted with the primary denied explanation of benefits (EOB).
• If no other active insurance is found, the next step would be to directly bill the patient for the services.

By following these steps, it is possible to resolve the denial code CO 119 without immediately contacting the insurance company, saving time and streamlining the process for both the provider and the patient.

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

When encountering a denial from an insurance company, it is imperative to follow a structured process to address the issue. Start by contacting the insurance company to ascertain the denial date and reason for denial, whether it is related to “Benefit amount” or “number of visits”.

Benefit amount – Denial code CO 119

• If the denial is due to “Benefit amount”, determine the benefit amount paid as per the patient’s plan and verify when this amount was exhausted. Utilize the billing software application to access this information.
• If the benefit amount has not been met, request the representative to reprocess the claim and obtain the reprocessing time.
• If the amount has been met, explore other active insurances available for the patient. Submit claims with the denied Explanation of Benefits (EOB) for any active insurances found. If no active insurance is available, bill the insurance allowed amount to the patient.

Number of Visits – Denial code CO 119

• In the case of denial due to “number of visits”, review how many visits of that particular service are payable as per the patient’s plan and confirm when these visits were exhausted. Validate this data in the billing software application as well.
• If the visits have not been met, request the representative to reprocess the claim and seek the reprocessing time.
• If the visits have been exhausted, check for other active insurances for the patient. Submit claims with denied EOBs for any active insurances identified.
• If no active insurance is present, proceed to bill the patient accordingly.

This systematic approach ensures thorough management of insurance denial code CO 119 and optimizing reimbursement for healthcare services provided.

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