835 Denial Combination
CO-119
Contractual Obligation · Claim-Level Adjustment
What This Combination Means
Benefit maximum has been reached. The patient has exhausted their plan benefit for this type of service (e.g., maximum visit count, dollar maximum, or day limit). This is a limitation of the patient's plan design, not a clinical or coding error.
N/A
Appeal Success
7-14 days
Avg. Resolution
Medium
Difficulty
No
Appealable
Step-by-Step Resolution
Steps tailored specifically to this CO-119 combination — not generic advice.
- 1
Confirm the benefit limit by running an eligibility/benefit check on the payer portal — confirm the remaining benefit for this service type.
- 2
If the maximum is correct, inform the patient they are responsible for services beyond the benefit limit.
- 3
For behavioral health: evaluate whether the visit limit violates MHPAEA — if so, file a parity complaint with the state Department of Insurance or Department of Labor.
- 4
Offer the patient a self-pay rate or payment plan for services beyond the benefit limit.
- 5
Consider tracking patients' benefit utilization throughout the year to proactively discuss remaining benefits before treatment.
Specialty Context
How CO-119 typically presents across different practice types.
Dental
Annual dental plan maximums (commonly $1,000–$2,500) are frequently hit mid-year. Proactive benefit tracking before treatment prevents unexpected patient balance surprises.
Medical
Physical therapy visit limits (e.g., 20 visits/year), chiropractic limits, and out-of-pocket maximums can all trigger CO-119. Confirm which benefit type is exhausted.
Behavioral Health
Mental Health Parity and Addiction Equity Act (MHPAEA) prohibits day/visit limits on behavioral health services that are more restrictive than medical/surgical limits. If the patient's plan has a BH visit cap, it may violate MHPAEA — this is worth challenging.
Individual Code References
View the standalone definition for each code in this combination.
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