CARC 222 Denial Appeal

Exceeds contracted maximum hours/days/units for the period

Exceeds the contracted maximum number of hours/days/units by this provider for this period. This is not patient specific. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

The winning argument

Where the claimed 'contracted maximum' functions as a numerical cap on hours, days, or units of mental-health treatment, it operates as a quantitative treatment limitation: under MHPAEA, treatment limitations on MH/SUD benefits may be no more restrictive than the predominant limitations applied to substantially all medical/surgical benefits in the same classification, and separate limits that apply only to MH/SUD benefits are prohibited. The payer must produce the specific contract or plan provision establishing the cap and the unit-accumulation record showing how it was applied — absent that, the denial is unsupported.

• The remittance does not identify the specific contractual or plan provision establishing the maximum. Under the ERISA claims-procedure regulation (29 CFR 2560.503-1), an adverse benefit determination must reference the specific plan provisions on which it is based, and the claimant is entitled, free of charge, to all documents and records relevant to the claim — including the accumulation data used to count units against the cap.
• Unit-counting errors are common in behavioral health: time-based psychotherapy and ABA codes accumulate across rendering clinicians in a group practice, telehealth and in-person claims can double-count, and payers sometimes apply the wrong accumulation period. Demand the unit-accumulation report and reconcile it against the practice's own billing records.
• If the limit being enforced is actually a per-patient session or benefit cap rather than a provider-level contract maximum, CARC 222 is miscoded (the official wording says it 'is not patient specific'; CARC 119 is the benefit-maximum code) — and a per-patient visit/unit cap on mental-health services is squarely a quantitative treatment limitation subject to MHPAEA's no-more-restrictive rule.
• If the payer cannot demonstrate that comparable hour/unit caps apply to medical/surgical benefits, a parity complaint can be filed with the state insurance commissioner, DOL, or HHS depending on plan type — the American Psychiatric Association publishes template complaint letters for each.

Sample appeal letter body

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We are appealing the adjustment of behavioral health services for {{patient_reference}} under CARC 222 (exceeds the contracted maximum number of hours/days/units by this provider for this period). The remittance does not identify the contract or plan provision establishing this maximum, and our records show {{units_billed_in_period}} units of {{service_description}} billed during {{period_in_question}} — {{basis_for_dispute}}. Consistent with the ERISA claims-procedure regulation (29 CFR 2560.503-1), which requires that an adverse determination reference the specific provisions on which it is based and entitles the claimant to receive, free of charge, all records relevant to the claim, we formally request the exact contractual or plan provision imposing this maximum and a complete unit-accumulation report showing how it was applied to this claim. To the extent the denial rests on a numerical cap on hours, days, or units of mental-health treatment, that cap operates as a quantitative treatment limitation; under the Mental Health Parity and Addiction Equity Act, such limitations may be no more restrictive than the predominant limitations applied to substantially all medical/surgical benefits in the same classification, and limitations that apply only to mental-health benefits are prohibited. We request that this claim be reprocessed or that the requested documentation be provided within the timeframe applicable to this appeal.