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CO-35 Denial Code: Lifetime Benefit Maximum Reached

CO-35 means the patient has reached the lifetime benefit maximum under their plan, so the payer won't pay any more for covered benefits subject to that limit. Confirm the limit applies to this service, then look for other coverage.

Quick facts

Code
CO-35 (CARC 35)
Status
Active In use since January 1, 1995; last modified October 31, 2002.
Code set
Claim Adjustment Reason Codes (CARC)
Group codes
  • CO (Contractual Obligation): Under CO the provider absorbs the amount unless the patient agreed in advance to pay or the payer reassigns it.
  • PR (Patient Responsibility): Often used for this code because the plan's benefit limit, not a provider error, stopped payment. The patient may be billed according to your agreements and applicable law.
Official description
Lifetime benefit maximum has been reached.
X12 Claim Adjustment Reason Codes, retrieved September 25, 2026
Last verified
against the official X12 list.

What CO-35 means

CARC 35 says the lifetime benefit maximum has been reached. Some plans cap the total amount they’ll pay over a member’s lifetime, either for the plan overall or for certain benefits. Once a member reaches that cap, the payer stops paying for services subject to it, and CO-35 appears on the remittance.

Since the Affordable Care Act, most health plans can’t impose lifetime dollar limits on essential health benefits. That makes whole-plan lifetime maximums much less common. CO-35 still shows up on non-essential benefits, on some plan types not subject to those rules, and on international or specialty coverage. It’s worth checking that the limit is actually allowed and actually applies.

For a limit on a specific service or category (for example, a once-in-a-lifetime procedure or a lifetime cap on a particular therapy), payers often use CARC 149 instead.

Common causes

  • Plan with a lifetime limit on a non-essential benefit, such as certain elective or specialty services.
  • Short-term, excepted-benefit, or other plan types not subject to the ACA lifetime-limit ban. Grandfathered group and individual plans are generally still subject to it.
  • Benefit counted incorrectly, for example claims from another member applied to this patient.
  • Service miscategorized into a limited benefit when it belongs to an unlimited one.

How to fix it

  1. Ask the payer which limit was reached, how much has been paid toward it, and which benefit category it covers.
  2. Check whether the service is an essential health benefit under an ACA-compliant plan. If so, request reconsideration.
  3. If the category is wrong, correct coding or place of service and send a corrected claim with resubmission code 7 in box 22.
  4. Look for secondary coverage, Medicaid, or other programs.
  5. Bill the patient only when the payer reports PR or your agreement allows, and explain the limit clearly.

How to prevent it

  • Check benefit limits during verification for services known to carry lifetime caps.
  • Track cumulative use for patients receiving ongoing high-cost care.
  • Discuss financial responsibility before continuing services once a limit is near.
  • Review plan type for short-term or non-ACA plans that may carry limits. See eligibility and COB denials.

Remark codes that may appear with CO-35

  • N130 (Consult plan benefit documents/guidelines for information about restrictions for this service.): Directs you to plan benefit documents for the limit that was applied.
  • N117 (This service is paid only once in a patient's lifetime.): The service is paid only once in a patient's lifetime, a service-specific lifetime limit.
  • CO-149 (Lifetime benefit maximum has been reached for this service/benefit category.): Lifetime maximum reached for a specific service or benefit category, rather than the whole plan.
  • PR-119 (Benefit maximum for this time period or occurrence has been reached.): Benefit maximum for a time period or occurrence, such as an annual visit limit.
  • CO-273 (Coverage/program guidelines were exceeded.): Coverage or program guidelines exceeded.
  • OA-22 (This care may be covered by another payer per coordination of benefits.): Another payer may cover the service under coordination of benefits.

CO-35 FAQ

Are lifetime maximums still allowed?

Under the Affordable Care Act, most group and individual health plans can't impose lifetime dollar limits on essential health benefits. Lifetime limits may still apply to non-essential benefits and to plans not subject to those rules, so CO-35 still appears.

How do I respond to CO-35?

Ask the payer which benefit limit was reached and confirm it applies to this service. If the service is an essential health benefit under an ACA-compliant plan, question the denial. Otherwise, look for secondary coverage.

Can I bill the patient for CO-35?

If the payer reports it as PR, generally yes. Under CO, the provider holds the balance unless your agreement or the patient's written acceptance allows billing.

Does CO-35 mean the patient has no coverage at all?

Not necessarily. The limit may apply to one benefit only, and other services can still be covered. Ask the payer exactly which benefits remain available.