Claim Adjustment Reason Codes CARC

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Jemima Shelton
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1 Claim Adjustment Reason Codes CARC 1 Deductible Amount 2 Coinsurance Amount 3 Co-payment Amount 4 The procedure code is inconsistent with the modifier used or a required modifier is missing. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Last Modified: 09/20/ The procedure code/bill type is inconsistent with the place of service. Note: Refer to the 835 Healthcare Policy Last Modified: 09/20/ The procedure/revenue code is inconsistent with the patient's age. Note: Refer to the 835 Healthcare Policy Last Modified: 09/20/ The procedure/revenue code is inconsistent with the patient's gender. Note: Refer to the 835 Healthcare Policy Last Modified: 09/20/ The procedure code is inconsistent with the provider type/specialty (taxonomy). Note: Refer to the 835 Healthcare Policy Last Modified: 09/20/ The diagnosis is inconsistent with the patient's age. Note: Refer to the 835 Healthcare Policy Last Modified: 09/20/ The diagnosis is inconsistent with the patient's gender. Note: Refer to the 835 Healthcare Policy Last Modified: 09/20/ The diagnosis is inconsistent with the procedure. Note: Refer to the 835 Healthcare Policy Last Modified: 09/20/ The diagnosis is inconsistent with the provider type. Note: Refer to the 835 Healthcare Policy Last Modified: 09/20/ The date of death precedes the date of service. 14 The date of birth follows the date of service. 15 The authorization number is missing, invalid, or does not apply to the billed services or provider. Last Modified: 09/30/ Claim/service lacks information or has submission/billing error(s) which is needed for adjudication. Do not use this code for claims attachment(s)/other documentation. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.) Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Last Modified: 11/01/ Requested information was not provided or was insufficient/incomplete. At least one Remark Code must be provided (may be comprised of either the Remittance Advice Remark Code or NCPDP Reject Reason Code.) Last Modified: 09/21/2008 Stop: 07/01/2009

2 18 Exact duplicate claim/service (Use only with Group Code OA except where state workers' compensation regulations requires CO) Last Modified: 06/02/ This is a work-related injury/illness and thus the liability of the Worker's Compensation Carrier. Last Modified: 09/30/ This injury/illness is covered by the liability carrier. Last Modified: 09/30/ This injury/illness is the liability of the no-fault carrier. Last Modified: 09/30/ This care may be covered by another payer per coordination of benefits. Last Modified: 09/30/ The impact of prior payer(s) adjudication including payments and/or adjustments. (Use only with Group Code OA) Last Modified: 09/30/ Charges are covered under a capitation agreement/managed care plan. Last Modified: 09/30/ Payment denied. Your Stop loss deductible has not been met. Stop: 04/01/ Expenses incurred prior to coverage. 27 Expenses incurred after coverage terminated. 28 Coverage not in effect at the time the service was provided. Stop: 10/16/2003 Notes: Redundant to codes 26& The time limit for filing has expired. 30 Payment adjusted because the patient has not met the required eligibility, spend down, waiting, or residency requirements. Stop: 02/01/ Patient cannot be identified as our insured. Last Modified: 09/30/ Our records indicate that this dependent is not an eligible dependent as defined. 33 Insured has no dependent coverage. Last Modified: 09/30/ Insured has no coverage for newborns. Last Modified: 09/30/ Lifetime benefit maximum has been reached. Last Modified: 10/31/ Balance does not exceed co-payment amount. Stop: 10/16/ Balance does not exceed deductible. Stop: 10/16/ Services not provided or authorized by designated (network/primary care) providers. Last Modified: 06/02/2013 Stop: 01/01/2013

3 Claim Status codes Supplemental Acknowledgements A0 Acknowledgement/Forwarded-The claim/encounter has been forwarded to another entity. A1 Acknowledgement/Receipt-The claim/encounter has been received. This does not mean that the claim has been accepted for adjudication. A2 Acknowledgement/Acceptance into adjudication system-the claim/encounter has been accepted into the adjudication system. A3 Acknowledgement/Returned as unprocessable claim-the claim/encounter has been rejected and has not been entered into the adjudication system. A4 Acknowledgement/Not Found-The claim/encounter can not be found in the adjudication system. A5 Acknowledgement/Split Claim-The claim/encounter has been split upon acceptance into the adjudication system. Start: 02/28/2002 A6 Acknowledgement/Rejected for Missing Information - The claim/encounter is missing the information specified in the Status details and has been rejected. Start: 10/31/2002 A7 Acknowledgement/Rejected for Invalid Information - The claim/encounter has invalid information as specified in the Status details and has been rejected. Start: 10/31/2002 A8 Acknowledgement / Rejected for relational field in error. Start: 10/31/2004 Pending P0 Pending: Adjudication/Details-This is a generic message about a pended claim. A pended claim is one for which no remittance advice has been issued, or only part of the claim has been paid. P1 Pending/In Process-The claim or encounter is in the adjudication system. P2 Pending/Payer Review-The claim/encounter is suspended and is pending review (e.g. medical review, repricing, Third Party Administrator processing). Last Modified: 01/27/2008 P3 Pending/Provider Requested Information - The claim or encounter is waiting for information that has already been requested from the provider. (Note: A Claim Status Code identifying the type of information requested, must be reported) Last Modified: 01/27/2008 P4 Pending/Patient Requested Information - The claim or encounter is waiting for information that has already been requested from the patient. (Note: A status code identifying the type of information requested must be sent) Last Modified: 01/27/2008 P5 Pending/Payer Administrative/System hold Start: 10/31/2006 Finalized F0 Finalized-The claim/encounter has completed the adjudication cycle and no more action will be taken. F1 Finalized/Payment-The claim/line has been paid. F2 Finalized/Denial-The claim/line has been denied. F3 Finalized/Revised - Adjudication information has been changed Start: 02/28/2001 F3F Finalized/Forwarded-The claim/encounter processing has been completed. Any applicable payment has been made and the claim/encounter has been forwarded to a subsequent entity as identified on the original claim or in this payer's records. F3N Finalized/Not Forwarded-The claim/encounter processing has been completed. Any applicable payment has been made. The claim/encounter has NOT been forwarded to any subsequent entity

4 Schedule The Remittance Advice Remark Code List is updated tri-annually in March, July, and November. Remittance Advice RARC M1 X-ray not taken within the past 12 months or near enough to the start of treatment. M2 Not paid separately when the patient is an inpatient. M3 Equipment is the same or similar to equipment already being used. M4 Alert: This is the last monthly installment payment for this durable medical equipment. Last Modified: 04/01/2007 M5 Monthly rental payments can continue until the earlier of the 15th month from the first rental month, or the month when the equipment is no longer needed. M6 Alert: You must furnish and service this item for any period of medical need for the remainder of the reasonable useful lifetime of the equipment. Last Modified: 03/01/2009 Notes: (Modified 4/1/07, 3/1/2009) M7 No rental payments after the item is purchased, or after the total of issued rental payments equals the purchase price. M8 We do not accept blood gas tests results when the test was conducted by a medical supplier or taken while the patient is on oxygen. M9 Alert: This is the tenth rental month. You must offer the patient the choice of changing the rental to a purchase agreement. Last Modified: 04/01/2007 M10 Equipment purchases are limited to the first or the tenth month of medical necessity. M11 DME, orthotics and prosthetics must be billed to the DME carrier who services the patient's zip code. M12 Diagnostic tests performed by a physician must indicate whether purchased services are included on the claim. M13 Only one initial visit is covered per specialty per medical group. Last Modified: 06/30/2007 Notes: (Modified 6/30/03) M14 No separate payment for an injection administered during an office visit, and no payment for a full office visit if the patient only received an injection. M15 Separately billed services/tests have been bundled as they are considered components of the same procedure. Separate payment is not allowed. M16 Alert: Please see our web site, mailings, or bulletins for more details concerning this policy/procedure/decision. Last Modified: 04/01/2007 Notes: (Reactivated 4/1/04, Modified 11/18/05, 4/1/07) M17 Alert: Payment approved as you did not know, and could not reasonably have been expected to know, that this would not normally have been covered for this patient. In the future, you will be liable for charges for the same service(s) under the same or similar conditions. Last Modified: 04/01/2007 M18 Certain services may be approved for home use. Neither a hospital nor a Skilled Nursing Facility (SNF) is considered to be a patient's home. Last Modified: 06/30/2003 Notes: (Modified 6/30/03) M19 Missing oxygen certification/re-certification. Last Modified: 02/28/2003 Related to N234 M20 Missing/incomplete/invalid HCPCS. Last Modified: 02/28/2003 M21 Missing/incomplete/invalid place of residence for this service/item provided in a home. Last Modified: 02/28/2003 M22 Missing/incomplete/invalid number of miles traveled. Last Modified: 02/28/2003

5 M23 Missing invoice. Last Modified: 08/01/2005 Notes: (Modified 8/1/05) M24 Missing/incomplete/invalid number of doses per vial. Last Modified: 02/28/2003 M25 The information furnished does not substantiate the need for this level of service. If you believe the service should have been fully covered as billed, or if you did not know and could not reasonably have been expected to know that we would not pay for this level of service, or if you notified the patient in writing in advance that we would not pay for this level of service and he/she agreed in writing to pay, ask us to review your claim within 120 days of the date of this notice. If you do not request an appeal, we will, upon application from the patient, reimburse him/her for the amount you have collected from him/her in excess of any deductible and coinsurance amounts. We will recover the reimbursement from you as an overpayment. Last Modified: 11/01/2010 Notes: (Modified 10/1/02, 6/30/03, 8/1/05, 11/5/07, 11/1/10) M26 The information furnished does not substantiate the need for this level of service. If you have collected any amount from the patient for this level of service /any amount that exceeds the limiting charge for the less extensive service, the law requires you to refund that amount to the patient within 30 days of receiving this notice. The requirements for refund are in 1824(I) of the Social Security Act and 42CFR The section specifies that physicians who knowingly and willfully fail to make appropriate refunds may be subject to civil monetary penalties and/or exclusion from the program. If you have any questions about this notice, please contact this office. Last Modified: 11/05/2007 Notes: (Modified 10/1/02, 6/30/03, 8/1/05, 11/5/07. Also refer to N356) M27 Alert: The patient has been relieved of liability of payment of these items and services under the limitation of liability provision of the law. The provider is ultimately liable for the patient's waived charges, including any charges for coinsurance, since the items or services were not reasonable and necessary or constituted custodial care, and you knew or could reasonably have been expected to know, that they were not covered. You may appeal this determination. You may ask for an appeal regarding both the coverage determination and the issue of whether you exercised due care. The appeal request must be filed within 120 days of the date you receive this notice. You must make the request through this office. Last Modified: 08/01/2007 Notes: (Modified 10/1/02, 8/1/05, 4/1/07, 8/1/07) M28 This does not qualify for payment under Part B when Part A coverage is exhausted or not otherwise available. M29 Missing operative note/report. Last Modified: 07/01/2008 Notes: (Modified 2/28/03, 7/1/2008) Related to N233 M30 Missing pathology report. Last Modified: 08/01/2004 Notes: (Modified 8/1/04, 2/28/03) Related to N236 M31 Missing radiology report. Last Modified: 08/01/2004 Notes: (Modified 8/1/04, 2/28/03) Related to N240 M32 Alert: This is a conditional payment made pending a decision on this service by the patient's primary payer. This payment may be subject to refund upon your receipt of any additional payment for this service from another payer. You must contact this office immediately upon receipt of an additional payment for this service. Last Modified: 04/01/2007 M36 This is the 11th rental month. We cannot pay for this until you indicate that the patient has been given the option of changing the rental to a purchase. M37 Not covered when the patient is under age 35. Last Modified: 03/08/2011 Notes: (Modified 3/8/11) M38 Alert: The patient is liable for the charges for this service as they were informed in writing before the service was furnished that we would not pay for it and the patient agreed to be responsible for the charges. Last Modified: 07/01/2015 Notes: (Modified 7/1/15) M39 Alert: The patient is not liable for payment of this service as the advance notice of non-coverage you provided the patient did not comply with program requirements. Last Modified: 07/01/2015 Notes: (Modified 2/1/04, 4/1/07, 11/1/09, 11/1/12, 7/1/15) Related to N563 M40 Claim must be assigned and must be filed by the practitioner's employer. M41 We do not pay for this as the patient has no legal obligation to pay for this. M42 The medical necessity form must be personally signed by the attending physician. M44 Missing/incomplete/invalid condition code. Last Modified: 02/28/2003 M45 Missing/incomplete/invalid occurrence code(s). Last Modified: 12/02/2004 Notes: (Modified 12/2/04) Related to N299

Code Adjustment Reason 1 Deductible Amount 2 Coinsurance Amount 3 Co-payment Amount

Code Adjustment Reason 1 Deductible Amount 2 Coinsurance Amount 3 Co-payment Amount 4 5 6 7 8 9 10 11 12 The procedure code is inconsistent with the modifier used or a required modifier is missing. Note: