CARC Code
4
The procedure code is inconsistent with the modifier used or a required modifier is missing.
25%
Recovery Rate
30-90 days
Avg. Resolution
Hard
Difficulty
Common
Frequency
Recommended Action
Verify coverage and appeal or bill patient as non-covered service
Step-by-Step Resolution
- 1
Pull the patient's Summary of Benefits and verify the service is truly excluded
- 2
Check if service requires a specific diagnosis code to be covered
- 3
Review if the service is covered under a different procedure code
- 4
If excluded, obtain patient signed ABN (Advance Beneficiary Notice) before billing patient
- 5
If you believe coverage exists, file an appeal with clinical documentation within 30 days
- 6
For recurring services, update the patient's treatment plan to avoid future non-covered claims
Common Remark Codes (RARC)
These RARC codes often appear alongside CARC 4 on remittance advice.
Payer-Specific Notes
How major payers handle CARC 4 in practice.
Delta Dental
Cosmetic procedures (whitening, veneers) are always excluded; verify with patient pre-treatment
MetLife Dental
Implants may be excluded on basic plans; verify missing tooth clause and waiting periods
Cigna Dental
Orthodontic coverage requires specific rider; confirm patient has ortho benefit
Common 835 Combinations
CARC 4 most often appears with these Group Code + RARC combinations on 835 remittances.
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