AGAR Guide
CARC1ReferenceCurrentVerified Aug 15, 2026

CARC 1

AR Guide workflow

Step-by-step: Patient Responsibility

✓ Workflow verified Aug 15, 2026 · Verified via review of official sources and AR Guide practice testing — not payer policy. View the full guide

  1. VerifySteps 1–11

    1. Cost-sharing terms in the patient's benefit plan

    2. Allowed amount used in the calculation

    3. Deductible / coinsurance / copay status

    4. Patient-billing rules for non-covered services

    5. ABN or waiver where required

    6. Group code (PR) + CARC from the ERA/EOB

    7. Confirm the deductible, coinsurance, or copay matches the patient's benefit plan

    8. Verify the allowed amount used for the calculation

    9. Check the plan's patient-billing rules for non-covered services

    10. Confirm the patient received proper notice where required (e.g., ABN)

    11. Reconcile the member's payments against the adjustment

  2. ActSteps 12–14

    1. Bill the patient per the plan's patient-responsibility rules

    2. If the calculation looks wrong, request the claim calculation detail

    3. Do not bill the patient for amounts the plan or regulation says the provider cannot collect

  3. Document & QASteps 15–20

    1. The patient's benefit plan showing cost-sharing terms

    2. The claim calculation detail if the amount is disputed

    3. ABN or waiver documentation where applicable

    4. Verify deductible and cost-sharing at the time of service

    5. Document patient notifications where required

    6. Confirm the calculation before billing the patient

Not a denial — bill the patient per the plan: Note

Deductibles, coinsurance and copays are the patient's responsibility under the plan, not appealable denials. Verify the calculation against the plan, then bill the patient where the plan allows.

If you take the wrong path: Appealing a patient-responsibility amount is denied. Billing the patient without verifying the calculation causes disputes and potential write-offs.

AR Guide explanation

What it means

The amount was applied toward the patient's deductible before the plan paid its share.

AR Guide knowledge

Common denial category

Patient Responsibility — The amount is the patient's responsibility under the plan — deductible, coinsurance, copayment, or a non-covered amount the patient may be billed.

AR Guide knowledge

Most common causes

  • Patient's annual deductible not yet met at time of service
  • Deductible applied per the benefit plan design

AR Guide knowledge

Action in your PM/EMR system

In your PM system: verify the deductible/coinsurance/copay against the patient's benefit plan, confirm the allowed amount used, then generate the patient statement. Do not route to appeals.

Illustrative scenario

Real-world example

The balance was applied to the patient's deductible (CARC 1). The calculation matched the plan, so the correct action was to bill the patient — not to appeal.

Example — not a claim about any specific payer or account.

AR Guide knowledge

What AR should verify

  1. Verify the patient's deductible status for the plan year
  2. Confirm the deductible is satisfied for the correct benefit period

AR Guide knowledge

Recommended action

  1. Bill the patient per the plan's patient-responsibility rules

Appeal template

No code-specific template yet

No downloadable template targets CARC 1 specifically. Browse all appeal letter templates — or follow the recommended workflow above.

AR Guide knowledge

QA checkpoint

  • Confirm deductible was verified at the time of service
  • Check for coordination-of-benefits impact on the deductible

About this guidance: Note

AR Guide knowledge is general reference content written by our team — it is not payer-specific policy and never replaces the payer’s documentation or your contract. Always confirm specifics with the payer.

Priority 2

Commonly paired RARCs

RARCs commonly accompany CARC 1 on the ERA/EOB. Select the one on your line to focus the workflow, or use the list as a lookup.

  • RARCN17Per admission deductible.
  • RARCN16Family/member Out-of-Pocket maximum has been met. Payment based on a higher percentage.
  • RARCN130Consult plan benefit documents/guidelines for information about restrictions for this service.Pull the specific plan benefit document and quote the exact restriction in your appeal — a general appeal without the plan language rarely succeeds here.

Priority 3

Payer-specific nuance

How major payers handle this denial — what AR Guide has verified, and what you must confirm with the payer. We never publish payer handling we have not verified.

Medicare

Patient liability depends on the member's specific benefit design and applicable regulations. Verify the calculation against the plan before billing, and never bill the patient for amounts the plan or law says the provider cannot collect.

Medicaid

Patient liability depends on the member's specific benefit design and applicable regulations. Verify the calculation against the plan before billing, and never bill the patient for amounts the plan or law says the provider cannot collect.

UnitedHealthcare

Patient liability depends on the member's specific benefit design and applicable regulations. Verify the calculation against the plan before billing, and never bill the patient for amounts the plan or law says the provider cannot collect.

Aetna

Patient liability depends on the member's specific benefit design and applicable regulations. Verify the calculation against the plan before billing, and never bill the patient for amounts the plan or law says the provider cannot collect.

Cigna

Patient liability depends on the member's specific benefit design and applicable regulations. Verify the calculation against the plan before billing, and never bill the patient for amounts the plan or law says the provider cannot collect.

Anthem (BCBS)

Patient liability depends on the member's specific benefit design and applicable regulations. Verify the calculation against the plan before billing, and never bill the patient for amounts the plan or law says the provider cannot collect.

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