CARC 45: Charge exceeds fee schedule/maximum allowable
The provider billed more than the contracted or allowed rate. You're only responsible for your share of the allowed amount — not the billed amount.
What this means for your claim
This is one of the most common codes on an EOB. The 'write-off' is the difference between the billed charge and what the insurer and plan agreed is the maximum allowable. In-network providers cannot bill you for this difference (balance billing protection).
What to do next
- 1
Verify your patient responsibility is calculated against the allowed amount, not the billed charge.
- 2
If an in-network provider bills you for the difference between what they charged and what was allowed, that is a contract violation — contact your insurer.
- 3
Review your EOB to confirm the allowed amount, insurer payment, and your share all add up correctly.
How to handle a contractual-obligation adjustment
Contractual Obligation (CO) codes describe the part of a claim that is governed by the contract between your insurer and the provider. In most cases the adjustment itself is legitimate — it reflects the agreed network discount, your deductible, your coinsurance, or your copay. The money you should focus on is the patient-responsibility line, because that is the amount you can actually verify, dispute, or have reprocessed.
Confirm the math against your plan documents
Pull your Summary of Benefits and Coverage and your member-portal accumulators. Check that the allowed amount matches the in-network contracted rate and that your deductible, coinsurance, or copay was applied at the correct stage. A surprising number of patient-responsibility errors come from accumulators that didn't update after a prior claim.
Check whether your out-of-pocket maximum was reached
Once you hit your annual out-of-pocket maximum, your coinsurance and copays for covered, in-network services should drop to $0. If an EOB still shows patient responsibility after you've met that limit, call member services and ask for the claim to be reprocessed against your accumulator.
Make sure the service was coded the way it actually happened
A visit coded as a higher-complexity level, or a preventive screening miscoded as a diagnostic (sick) visit, can shift cost onto you. Request an itemized bill, compare the CPT codes to what you actually received, and ask the provider's billing office to correct and rebill any mismatch before you pay.
Your appeal rights for CARC 45
If you believe a contractual adjustment was applied incorrectly — wrong network status, wrong accumulator, or a coding error — start with the provider's billing office for coding issues and your insurer's member services for benefit-application issues. If they disagree, you have the right under the Affordable Care Act to a formal internal appeal, and if that's denied, an independent external review.
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