CARC 109 Denial Appeal

Not covered by this payer/contractor (misrouted)

Claim/service not covered by this payer/contractor. You must send the claim/service to the correct payer/contractor.

The winning argument

The claim was misrouted due to ambiguous coordination-of-benefits / carve-out instructions from the plan; it has been resubmitted to the correct payer and any resulting timely-filing denial should be waived because the original timely submission was made in good faith.

• Verification of benefits directed the original routing.
• Integrated behavioral health delivered in a primary-care setting may be payable by the medical payer.

Sample appeal letter body

Replace the {{placeholders}} with your own information before sending.

This letter appeals the denial of {{service_name}} for {{patient_reference}} under CARC 109 (not covered by this payer). On {{date_of_vob}}, our verification of benefits directed us to submit behavioral-health claims for this member to {{primary_payer_name}}. Because the carve-out arrangement between the medical plan and the managed behavioral-health organization was not clearly documented, the claim was misrouted; it has now been routed to {{correct_mbho_name}}. We request that any timely-filing denial for this date of service be waived, as the original good-faith submission occurred within the required window on {{original_submission_date}}.