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PR-119 Denial Code: Benefit Maximum Reached

PR-119 means the patient has reached the benefit maximum for this time period or occurrence, such as an annual visit limit or a dollar cap. The payer will not pay more for this benefit until the period resets, and under PR the patient is responsible for the charge.

Quick facts

Code
PR-119 (CARC 119)
Status
Active In use since January 1, 1995; last modified February 29, 2004.
Code set
Claim Adjustment Reason Codes (CARC)
Group codes
  • PR (Patient Responsibility): The patient is responsible because the plan's benefit limit is exhausted. You can bill the patient, subject to your contract and any rules on patient notice.
  • CO (Contractual Obligation): The payer holds the provider responsible, often because the contract requires verification of limits or prohibits billing members for services beyond them. Write off unless your contract says otherwise.
Official description
Benefit maximum for this time period or occurrence has been reached.
X12 Claim Adjustment Reason Codes, retrieved September 25, 2026
Last verified
against the official X12 list.

What PR-119 means

CARC 119 says the benefit maximum for this time period or occurrence has been reached. Many plans cap certain benefits: a set number of therapy or chiropractic visits per year, a dollar limit on a category of equipment, or a maximum per episode or occurrence. Once the patient uses it up, the payer stops paying for that benefit until it resets.

With the PR group, the payer is telling you the charge is the patient’s responsibility. The service is covered in principle, but the benefit is exhausted for now.

Example: a plan covers a fixed number of outpatient therapy visits per calendar year. The patient’s claim for the visit after the limit comes back PR-119 with remark N640. The practice bills the patient, having told them in advance they were near the limit.

Common causes

  • Annual visit limits for therapy, chiropractic, acupuncture, or similar services.
  • Dollar maximums on categories such as hearing aids, DME, or dental services.
  • Per-occurrence or per-episode limits, for example a cap on services per injury.
  • Visits from other providers counting toward the same shared limit (PT and OT visits often share one).
  • The payer counting visits that were later denied or that belong to a different benefit year.
  • The patient moved to a new plan mid-year with a lower limit.

How to fix it

  1. Confirm the count. Ask the payer for the visit or dollar history for the benefit period, including other providers’ claims.
  2. If the count is wrong, request reprocessing or appeal with evidence, such as claims that should not have counted or dates in a different benefit year.
  3. Check for exceptions. Some plans allow additional visits based on medical necessity or specific diagnoses. If so, submit the request with documentation.
  4. If the limit is correct, bill the patient for the PR amount per your financial policy. Tell them when the benefit resets.
  5. If the group is CO, check your contract. The payer may be saying you should have verified the limit, and the amount may need to be written off.
  6. Consider secondary coverage. If the patient has another plan, bill it with the primary’s remittance.

How to prevent it

  • Check remaining visits or dollars during eligibility verification, and record the count in the patient account.
  • Track visits against limits in your scheduling system and alert staff before the limit is reached.
  • Give patients a written financial notice when they are near or past a limit, so they can decide whether to continue.
  • Coordinate with other providers treating the same patient when limits are shared.
  • For verification workflows, see eligibility and COB denials.

Specialty notes

PT/OT and chiropractic see PR-119 most. Many plans combine PT, OT, and sometimes speech therapy into a single visit limit, so a patient seeing more than one therapist can exhaust it quickly. Behavioral health practices should check whether a visit limit is consistent with mental health parity rules for that plan type before accepting it.

Remark codes that may appear with PR-119

  • N587 (Policy benefits have been exhausted.): Policy benefits have been exhausted.
  • N640 (Exceeds number/frequency approved/allowed within time period.): The service exceeds the number or frequency approved or allowed within the time period.
  • N362 (The number of Days or Units of Service exceeds our acceptable maximum.): The number of days or units of service exceeds the payer's acceptable maximum.
  • N130 (Consult plan benefit documents/guidelines for information about restrictions for this service.): The limit is defined in the plan's benefit documents.
  • CO-35 (Lifetime benefit maximum has been reached.): Lifetime benefit maximum reached, rather than a limit that resets each period.
  • CO-149 (Lifetime benefit maximum has been reached for this service/benefit category.): Lifetime benefit maximum reached for a specific service or benefit category.
  • CO-273 (Coverage/program guidelines were exceeded.): Coverage or program guidelines were exceeded, sometimes used for frequency limits.
  • CO-198 (Precertification/notification/authorization/pre-treatment exceeded.): Services exceeded what the authorization approved, not the plan's benefit limit.
  • CO-151 (Payment adjusted because the payer deems the information submitted does not support this many/frequency of services.): The information does not support this many services or this frequency.

PR-119 FAQ

Can I bill the patient for PR-119?

Generally yes, because the PR group assigns the amount to the patient. Check your payer contract, and give patients advance notice when you know they are close to a limit.

Can I appeal a benefit maximum denial?

Sometimes. Appeal when the payer miscounted visits, counted another provider's visits wrongly, or applied a limit that should not apply, such as one waived for certain diagnoses. Some plans also allow extensions for medical necessity.

Do benefit limits apply to mental health visits?

Federal parity law restricts plans from applying stricter visit limits to mental health and substance use disorder benefits than to comparable medical benefits. How it applies depends on the plan type.

When does the benefit reset?

It depends on the plan: calendar year, plan year, rolling period, or per occurrence. Check the plan documents or call the payer.