CARC 97: The benefit for this service is included in the payment/allowance for another service/procedure
This charge was bundled into a payment that already covered another related service.
What this means for your claim
Bundling rules prevent double payment for related services. For example, a follow-up note may be considered part of a surgical global period and not separately billable.
What to do next
- 1
Ask your provider whether this service falls within a global surgical period or another bundling rule.
- 2
If the service was genuinely separate and distinct (different clinical problem, different anatomical site), a modifier and appeal may allow separate payment.
- 3
Confirm you aren't being billed by the provider for a charge that was correctly bundled.
How to handle a non-covered or denied service
Non-covered codes mean the insurer is declining to pay — either because the plan excludes the service, because medical necessity wasn't established, or because a requirement like prior authorization or timely filing wasn't met. These are the adjustments most worth contesting, because a denial is not the final word: a large share of denials are overturned on appeal when the patient or provider supplies the right documentation.
Find the exact reason for the denial in writing
"Not covered" is a category, not an explanation. Call your insurer and ask specifically why: Is the service excluded from your plan? Was it deemed not medically necessary? Was prior authorization missing? Was the claim filed late by the provider? The precise reason determines who fixes it and how.
Decide whether it's the provider's error or a true plan exclusion
If the problem is a missing prior authorization, a coding error, or late filing, that is usually the provider's responsibility — and in many states they cannot bill you for their own administrative mistakes. If the service is genuinely excluded from your plan, your path is an appeal or financial assistance, not a billing correction.
Gather support for medical necessity before you appeal
When a denial is based on medical necessity, ask your treating physician for a letter of medical necessity and the clinical notes that justify the service. Insurers overturn a meaningful portion of these denials once the supporting documentation is in front of a reviewer.
Your appeal rights for CARC 97
You have a federally protected right to appeal a denial. Request the insurer's full reason and your plan's appeal deadline in writing, then file an internal appeal with your supporting documents. If the internal appeal is denied, you can request an independent external review — a reviewer with no financial stake in the outcome. If the service was an emergency or from an out-of-network provider at an in-network facility, the federal No Surprises Act may also protect you from balance billing.
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