CARC 167 — The specific diagnosis code(s) on this claim aren't covered under the patient's

CARC 167PR · Patient Responsibility

The specific diagnosis code(s) on this claim aren't covered under the patient's plan.

Common causes: The plan explicitly excludes coverage for conditions related to this diagnosis, such as certain cosmetic or non-covered condition categories.
Suggested fix: Confirm the plan's exclusions for this diagnosis; if a more accurate, covered diagnosis applies, correct and resubmit with supporting documentation.

Related Patient Responsibility codes

1The billed amount was applied to the patient's plan deductible instead of being paid by the payer.119The patient has used up the maximum benefit allowed for this service within the applicable time period, such as an annual visit limit.177The patient doesn't currently meet the plan's eligibility criteria for this benefit.187This amount was or should be paid from the patient's consumer-directed spending account, such as an HSA or FSA, rather than by the payer.2This portion of the claim represents the patient's coinsurance share, the percentage of the allowed amount they are responsible for under their plan.200The service date falls within a period when the patient's coverage had lapsed.201The patient is responsible for this amount under a legal set-aside arrangement, commonly seen in workers' compensation Medicare Set-Aside cases, rather than the payer.202This charge is for a personal comfort or convenience item or service that isn't covered by the plan.

Frequently asked questions

What does CARC 167 mean?

The specific diagnosis code(s) on this claim aren't covered under the patient's plan.

How do I resolve CARC 167?

Confirm the plan's exclusions for this diagnosis; if a more accurate, covered diagnosis applies, correct and resubmit with supporting documentation.

Why does CARC 167 happen?

The plan explicitly excludes coverage for conditions related to this diagnosis, such as certain cosmetic or non-covered condition categories.

CARC codes maintained by X12 (x12.org). Descriptions on this site are original reference interpretations. Always verify codes with authoritative sources before making billing decisions.