CARCContractual Obligation
CARC 11: The diagnosis is inconsistent with the patient's gender
The billed diagnosis doesn't match the gender on file for the patient.
What this means for your claim
Similar to age edits, some diagnoses are gender-specific. A mismatch with the insurer's records (which may be outdated or incorrect) will trigger an adjustment.
What to do next
- 1
Verify that your gender on file with the insurer matches your current identity documentation.
- 2
If the insurer's records are outdated, request a member record update and ask the provider to resubmit.
- 3
If the service is clinically appropriate regardless of the recorded gender, the provider can appeal with supporting clinical notes.
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