Getting CARC 45 constantly on 835s from one payer — is this normal?
Asked by billing_lead_rms (EDI Practitioner) on 2026-07-28 · 980 views
We bill a specific payer regularly and almost every claim comes back with a CAS segment using group code CO and reason code 45. Payment is still coming through but always less than billed. Is this expected behavior or a sign something's wrong with our contracted rates setup?
1 Answer
CARC 45 ("Charge exceeds fee schedule/maximum allowable or contracted/legislated fee arrangement") showing up consistently for one payer is actually normal and expected if your billed charge amounts are set higher than that payer's contracted allowable rate — which is a common practice (billing your standard rate card, letting contractual adjustments true it down). It only becomes a problem if the allowed amount itself looks wrong relative to your actual contract terms. I'd sample a handful of these claims and compare the CLP03 (billed) minus the CAS-45 amount against your signed fee schedule for that payer and CPT code. If the resulting allowed amount matches your contract, this is just routine contractual adjustment, not an error.
healthit_denise · EDI Expert · 2026-07-28