What does CARC 196 mean?

CARC 196 means "Claim/service denied based on prior payer's coverage determination.". The recommended action is: Correct or clarify the diagnosis; appeal with clinical documentation supporting medical necessity.

How do I resolve CARC 196?

Pull the original claim and review the denial reason and any RARC codes Research the payer's policy for CARC 196 to understand the basis for denial Gather supporting documentation addressing the denial reason Submit a formal appeal with the documentation within the plan's appeal window Follow up on the appeal within 30 days and document all communication

Can CARC 196 be appealed?

CARC 196 has a 35% recovery rate and typically resolves in 21-45 days. Resolution difficulty is rated Hard.

CARC Code

196

🔴 Hard Denial

Claim/service denied based on prior payer's coverage determination.

35%

Recovery Rate

21-45 days

Avg. Resolution

Hard

Difficulty

Occasional

Frequency

Recommended Action

Correct or clarify the diagnosis; appeal with clinical documentation supporting medical necessity

Step-by-Step Resolution

1
Pull the original claim and review the denial reason and any RARC codes
2
Research the payer's policy for CARC 196 to understand the basis for denial
3
Gather supporting documentation addressing the denial reason
4
Submit a formal appeal with the documentation within the plan's appeal window
5
Follow up on the appeal within 30 days and document all communication

Payer-Specific Notes

How major payers handle CARC 196 in practice.

MetLife Dental

MetLife provides detailed denial reason codes — check EOB for supplemental information.

Common 835 Combinations

CARC 196 most often appears with these Group Code + RARC combinations on 835 remittances.

COCO-196Appealable COCO-196+N115Appealable

Look up any combination →

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