PR 119: Benefit Maximum Reached
The benefit maximum for this period has been reached.
Check for a KX modifier or a medical-necessity exception before writing it off.
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What PR 119 means
PR: Patient responsibility. This one goes on the patient statement.
So the balance is billable to the patient, provided your advance notice was in order. Check that before the statement goes out. Billing a patient for something you contractually agreed to absorb is the expensive mistake on this code.
The same code, a different prefix. 119 also arrives as CO 119. The reason for the denial is the same. The prefix decides who pays for it, so the next step is not the same. If your remit says CO 119, read that page instead.
Is It Worth Appealing?
Usually lost. Recoverable only with unusual evidence. Triage by dollar value.
Why It Fires
In the order we see it.
The patient has reached the benefit maximum for the period.
For therapy, the annual threshold was reached without a KX modifier.
How to Appeal PR 119, Step by Step
Check for a KX modifier or a medical-necessity exception before writing it off.
- 1Step 1: Read the remark code. Find the remark code printed next to PR 119 on the 835 or EOB. It says what the payer wants back. The usual ones are N362.
- 2Step 2: Find the cause. Match the denial to one of the 2 causes in Why It Fires above, and fix that one.
- 3Step 3: Take the first action. Check for a KX modifier or a medical-necessity exception before writing it off.
- 4Step 4: Attach the documentation. A KX modifier where continued therapy is medically necessary and documented. Documentation supporting a medical-necessity exception.
- 5Step 5: Send the appeal before the deadline. Send it to the payer with the claim, the denial and the documentation, inside the payer's appeal window. See what an appeal letter must contain and the filing limits by payer.
The common mistake. Do not write this off before checking whether a KX modifier or an exception applies. On therapy claims that is the most common recoverable version of this denial.
Free: the Denial Code Appeal Playbook. 53 codes on one sheet: appeal, fix and resubmit, or let it go, and what to attach. Get the playbook
PR 119 description
The benefit maximum for this period has been reached.
The benefit maximum for this period has been reached. So the balance is billable to the patient, provided your advance notice was in order. Check that before the statement goes out. Billing a patient for something you contractually agreed to absorb is the expensive mistake on this code.
This is our plain-English wording, not the official X12 text. X12 asserts copyright over the published descriptions, so we write our own and say what it means for the money rather than restating the code.
Where this comes from. This is our own reading of the code, not the payer's and not a copy of the standards text. We classify it from how these denials actually resolve. Where we are unsure, we say so rather than guessing.
The Remark Code Beside It
The adjustment code says the claim was reduced. The remark code printed next to it says why, and it is the one that tells you what to send back.
| Remark | What it means |
|---|---|
| N362 | More days or units were billed than the payer will accept for that code. |
Related Codes
Your Questions Answered
What does PR 119 mean?
The benefit maximum for this period has been reached. Patient responsibility. This one goes on the patient statement.
Can you appeal PR 119?
Usually lost. Check for a KX modifier or a medical-necessity exception before writing it off.
Why does PR 119 happen?
The patient has reached the benefit maximum for the period. For therapy, the annual threshold was reached without a KX modifier.
What documentation wins a PR 119 appeal?
A KX modifier where continued therapy is medically necessary and documented. Documentation supporting a medical-necessity exception.
How do I appeal a PR 119 denial?
Step 1: Read the remark code. Find the remark code printed next to PR 119 on the 835 or EOB. It says what the payer wants back. Step 2: Find the cause. Match the denial to one cause: The patient has reached the benefit maximum for the period. For therapy, the annual threshold was reached without a KX modifier. Step 3: Take the first action. Check for a KX modifier or a medical-necessity exception before writing it off. Step 4: Attach the documentation. A KX modifier where continued therapy is medically necessary and documented. Documentation supporting a medical-necessity exception. Step 5: Send the appeal before the deadline. Send it to the payer with the claim, the denial and the documentation, inside the payer's appeal window.
Most searched: CO 97 · CO 96 · OA 23 · PR 204 · CO 109 · CO 197 · CO 45 · CO 50
How Much of This Is Sitting in Your Write-Off Pile?
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