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CO-P6 Denial Code: Based on Entitlement to Benefits

CO-P6 means a property and casualty carrier adjusted or denied the bill based on the claimant's entitlement to benefits, meaning whether and how much the injured person is entitled to under the policy or jurisdiction's rules. The cited regulation explains the specific reason.

Quick facts

Code
CO-P6 (CARC P6)
Status
Active In use since November 1, 2013; last modified July 1, 2017.
Code set
Claim Adjustment Reason Codes (CARC)
Group codes
  • CO (Contractual Obligation): The usual group. The carrier isn't paying because of entitlement limits; state rules govern whether the claimant can be billed.
  • PR (Patient Responsibility): Used when the carrier indicates the claimant is responsible, for example after benefits are exhausted. Check state law before billing.
Official description
Based on entitlement to benefits. Usage: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier 'IG') for the jurisdictional regulation. If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF). To be used for Property and Casualty only.
X12 Claim Adjustment Reason Codes, retrieved September 25, 2026
Last verified
against the official X12 list.

What CO-P6 means

CARC P6 says based on entitlement to benefits. X12 limits it to property and casualty claims and requires the carrier to cite the jurisdictional regulation in the 835 (loop 2100 REF qualifier IG at claim level, or loop 2110 REF at line level). It replaced deactivated CARC 218.

P&C benefits depend on who the injured person is and what the policy provides. An auto PIP policy covers specific people (for example, the named insured, household members, or vehicle occupants) up to a set limit. A workers’ comp claim covers a qualifying employee for an accepted injury. When the carrier decides the claimant isn’t entitled, or is no longer entitled, to benefits for this service, it adjusts the bill with P6.

Common causes

  • Benefits exhausted, such as a PIP or medical payments limit reached (N587).
  • Claimant not an eligible injured person under the policy.
  • Benefits suspended pending the claimant’s cooperation, such as a missed examination under oath or required application.
  • Coverage not in effect on the date of loss.
  • Maximum medical improvement reached in a workers’ comp claim, limiting further treatment benefits.

How to fix it

  1. Read the remark codes and cited regulation to understand the entitlement issue.
  2. Contact the adjuster to confirm whether the issue is temporary, like a suspension, or final, like exhaustion.
  3. For suspensions, work with the claimant to complete what’s required, then resubmit.
  4. For exhaustion or ineligibility, get written confirmation and bill the next payer, such as the health plan or another auto policy.
  5. Dispute through the state’s process if you believe the entitlement decision was wrong.
  6. Check state rules before billing the claimant.

How to prevent problems

  • Ask the carrier for remaining benefits at the start of treatment and periodically.
  • Keep the patient’s health plan on file for when P&C benefits run out.
  • Tell claimants about their obligations, such as completing applications and attending exams.

Specialty notes

Chiropractic and PT practices that provide many visits under auto PIP often reach policy limits, triggering CO-P6 once benefits are exhausted.

Remark codes that may appear with CO-P6

  • N587 (Policy benefits have been exhausted.): Policy benefits have been exhausted.
  • N586 (The injured party does not qualify for benefits.): The injured party doesn't qualify for benefits.
  • N583 (Patient was not an occupant of our insured vehicle and therefore, is not an eligible injured person.): The patient wasn't an occupant of the insured vehicle, so isn't an eligible injured person under the policy.
  • CO-218Deactivated (Based on entitlement to benefits.): The deactivated code that CARC P6 replaced.
  • CO-P21 (Payment denied based on the Medical Payments Coverage (MPC) and/or Personal Injury Protection (PIP)): Denied based on MPC or PIP jurisdictional regulations.
  • CO-P27 (Payment denied based on the Liability Coverage Benefits jurisdictional regulations and/or payment policies.): Denied based on liability coverage jurisdictional regulations.
  • PR-119 (Benefit maximum for this time period or occurrence has been reached.): Benefit maximum reached for a time period, the general health-plan equivalent.

CO-P6 FAQ

What does entitlement to benefits mean?

Whether the injured person qualifies for benefits under the policy or law, and how much remains. Examples include PIP limits being exhausted, the person not being an eligible insured, or benefits suspended for non-cooperation.

Where do I find the specific reason?

The carrier must cite the jurisdictional regulation in the 835: loop 2100 REF qualifier IG at claim level, or loop 2110 REF at line level. Remark codes usually add detail.

What do I do if benefits are exhausted?

Get the carrier's exhaustion letter and bill the next payer, often the patient's health plan or another auto policy, with that documentation.

Is CO-P6 used by health plans?

No. It's for property and casualty claims only.

Can a CO-P6 decision be reversed?

Yes, in some cases. A suspension ends once the claimant cooperates, and a wrongly applied eligibility decision can be disputed. Exhausted policy limits, however, generally stay exhausted.