CARC Code

167

🔴 Hard Denial

This (these) diagnosis(es) is (are) not covered.

75%

Recovery Rate

7-14 days

Avg. Resolution

Medium

Difficulty

Common

Frequency

Recommended Action

Verify diagnosis code accuracy and coverage; correct and resubmit

Step-by-Step Resolution

  1. 1

    Verify the ICD-10 code is valid and fully specified (not truncated)

  2. 2

    Confirm the diagnosis code is covered for this payer and procedure

  3. 3

    Check if the diagnosis code has a coverage limitation (LCD/NCD for Medicare)

  4. 4

    Correct the diagnosis code based on clinical documentation if coded incorrectly

  5. 5

    Ensure the primary diagnosis supports medical necessity for the billed procedure

  6. 6

    Resubmit with corrected diagnosis codes within timely filing window

Common Remark Codes (RARC)

These RARC codes often appear alongside CARC 167 on remittance advice.

RARC N1·Alert: Refer to provider manual for additional guidance

→ Check LCD/NCD for covered diagnosis codes for this procedure

RARC M51·Missing/incomplete/invalid procedure code(s)

→ Ensure diagnosis and procedure code combination is valid

Payer-Specific Notes

How major payers handle CARC 167 in practice.

Delta Dental

Dental claims using medical diagnosis codes (ICD-10) for medical billing require valid codes

Cigna Dental

Oral surgery billed to medical requires supported diagnosis; ensure specificity

Common 835 Combinations

CARC 167 most often appears with these Group Code + RARC combinations on 835 remittances.

COCO-167+N362Appealable

Look up any combination →

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