CARC 166 Denial Code - Resolve & Prevent
CARC 166 indicates that the claim was filed after the payer's responsibility for processing claims under the specified plan had ended. This typically means that the service date was outside the plan coverage period or the plan itself was no longer active at the time of service.
Who Pays: Group Code Liability
With CARC 166, the group code is generally CO, meaning the provider must write off the amount, and the patient cannot be billed. However, if the issue is due to late filing, the group code might be PR, making the patient responsible for payment.
Why Claims Get Code 166
- The patient's insurance coverage ended before the date of service.
- The claim was submitted after the plan's termination date.
- The payer's responsibility ended due to a change in the patient's insurance carrier.
- The claim was incorrectly filed to an inactive plan.
- The patient's policy was canceled or not renewed.
How to Fix & Resubmit
- Verify the patient's insurance coverage dates to ensure they were active during the service date.
- Check if the claim was submitted to the correct payer and plan.
- Confirm if there was a recent change in the patient's insurance carrier that affects coverage.
- If coverage was active, contact the payer to discuss potential errors in their records.
- If the issue was a late filing, consider resubmitting the claim with appropriate documentation if allowed by the payer.
Corrected Claim or Appeal?
If the claim was submitted to the wrong payer or plan, submit a corrected claim to the correct one. If the coverage ended legitimately, an appeal is unlikely to succeed. Resubmitting is only viable if there was an error in the payer's records.
Preventing Future 166 Denials
- Always verify the patient's insurance coverage dates before filing claims.
- Establish a process to check for recent insurance carrier changes before claims submission.
- Ensure claims are submitted promptly to avoid late filing issues.
- Regularly update patient insurance information in the billing system.