45Denial Code (CARC)Active
CO/PR 45 Denial Code - Exceeds Fee Schedule Fixes
Code 45 indicates that the submitted charge exceeds the fee schedule, maximum allowable amount, or contracted/legislated fee arrangement. This means that the payer has determined the charge is higher than what they are willing to pay based on their established rates.
Who Pays: Group Code Liability
For code 45, the group code can be CO or PR. CO applies when the excess charge is a contractual obligation, meaning the provider must write it off and cannot bill the patient. PR applies when the patient is responsible for the excess charge, allowing the provider to bill the patient for the difference.
Why Claims Get Code 45
- The charge submitted is higher than the payer's fee schedule or maximum allowable amount.
- The billing office used an outdated contracted rate or fee schedule.
- The payer's system has incorrect fee schedule data for the provider.
- The service was billed at a non-contracted rate due to a missed contract update.
- A coding error resulted in an inflated charge amount.
How to Fix & Resubmit
- Verify the contracted rate or fee schedule with the payer to ensure accurate billing.
- Check if the charge was calculated correctly based on the current contract terms.
- If the charge is correct per contract, contact the payer to verify their fee schedule data is up-to-date.
- Submit a corrected claim if the original charge was billed incorrectly.
- If the payer's data is incorrect, initiate an appeal with supporting documentation of the contracted rate.
Corrected Claim or Appeal?
Submit a corrected claim when the original charge was billed incorrectly. Appeal if the payer's fee schedule data is incorrect or if the contracted rate is not honored.
Preventing Future 45 Denials
- Regularly update and verify fee schedules and contracted rates in the billing system.
- Ensure coding accuracy and correct charge entry to prevent inflated charges.
- Maintain open communication with payers regarding contract updates.
- Train billing staff on interpreting and applying contracted rates accurately.