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N167 Remark Code: Post-Transplant Coverage Limit Exceeded

N167 means the charges exceed the post-transplant coverage limit. The patient's plan caps what it pays for care after a transplant, and this claim pushed total charges past that cap, so the excess was not paid.

Quick facts

Code
N167 (RARC N167)
Status
Active In use since February 28, 2003.
Code set
Remittance Advice Remark Codes (RARC)
Group codes
  • PR (Patient Responsibility): Amounts beyond the benefit limit are generally the patient's responsibility or go to other coverage.
  • CO (Contractual Obligation): If a contract prevents billing the patient beyond the limit, the excess is a provider write-off.
Official description
Charges exceed the post-transplant coverage limit.
X12 Remittance Advice Remark Codes, retrieved September 25, 2026
Last verified
against the official X12 list.

What N167 means

Transplant benefits are often divided into phases, with separate limits for the transplant itself and for follow-up care. N167 concerns the follow-up phase. The plan has a cap on post-transplant charges, and this claim put the patient over it. Anything above the cap was not paid.

It commonly appears with a benefit-maximum reason code such as CARC 119 or CARC 149.

Common causes

  • The patient has used up the post-transplant benefit through ongoing care.
  • Services unrelated to the transplant were counted toward the limit.
  • Claims from several providers reached the limit at once, and yours was processed last.
  • The patient’s plan changed, and a lower limit applied.

What to do

  1. Ask the payer for the benefit accumulation: the limit, the amount used, and which claims counted.
  2. Check for misapplied services. If unrelated care was counted, request correction.
  3. Look for other coverage and bill it for the excess.
  4. Talk with the patient about the remaining balance and any financial assistance programs the transplant center offers.
  5. Appeal only when the accumulation was wrong.

How to prevent it

Transplant coordinators and financial counselors should track benefit use against the post-transplant limit throughout follow-up and plan for the point when it runs out. Checking accumulators before scheduling high-cost services avoids surprises for the patient.

Codes that may appear with N167

  • PR-119 (Benefit maximum for this time period or occurrence has been reached.): The benefit maximum for this time period or occurrence has been reached.
  • CO-149 (Lifetime benefit maximum has been reached for this service/benefit category.): The lifetime benefit maximum for this service or benefit category has been reached.
  • CO-35 (Lifetime benefit maximum has been reached.): The lifetime benefit maximum has been reached.
  • N806 (Payment is included in the Global transplant allowance.): Payment is included in the global transplant allowance.
  • MA126 (Pancreas transplant not covered unless kidney transplant performed.): Pancreas transplant not covered unless a kidney transplant is performed.
  • M139 (Denied services exceed the coverage limit for the demonstration.): Denied services exceed the coverage limit for a demonstration.

N167 FAQ

What counts toward the post-transplant limit?

The plan documents define it. It may include follow-up care, drugs, and services for a set period after the transplant. Ask the payer for the definition and the amount used.

Could another payer cover the excess?

Possibly. If the patient has secondary coverage, or qualifies for another program, bill it for the amount beyond the limit.

Can I appeal N167?

If the payer applied charges that do not belong to the post-transplant benefit, or miscounted the total, yes. Include an accounting of what should count.