Monday, May 31, 2010

Medicare denial codes - OA : Other adjustments, CARC and RARC list


Medicare contractors are permitted to use the following group codes:

CO Contractual Obligation (provider is financially liable);
CR Correction and Reversal (no financial liability);
OA Other Adjustment (no financial liability); and

PR Patient Responsibility (patient is financially liable).

MCR - 835 Denial Code List 


OA : Other adjustments

OA Group Reason code applies when other Group reason code cant be applied. Its mostly like that payment is not considered due to coverage problem and some other party is responsible for that claim like the below reason.

Benefits were not considered by the other payer because patient is not covered.

Or the claim was adjusted based on failure to follow prior payer’s coverage rules.

The charge was already considered by a previous payer


What are CARCs and RARCs?

Answer:
CARCs and RARCs are codes used on the Medicare provider remittance advice (RA) to explain any adjustment(s) made to the payment.

CARCs, or Claim Adjustment Reason Codes, explain financial adjustments, such as denials, reductions or increases in payment. CARCs explain why a claim (or service line) was paid differently than it was billed.  CARCs are used in the RA with group codes that shows the liability for amounts not covered by Medicare for a claim or service. Group codes include CO (contractual obligations), OA (other adjustments) and PR (patient responsibility). CARCs can be reported at the service-line level or the claim level.

Example:

CO-16: 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.

RARCs, or Remittance Advice Remark Codes, are used in the RA in conjunction with CARCs to further explain an adjustment or relay informational messages that cannot be expressed with a claim adjustment reason code. Most RARCs are supplemental and further explain an adjustment already described by a CARC. Other remark codes are 'informational' and do not further explain a specific adjustment but provide general adjudication information. Informational remark codes start with the word 'Alert.' RARCs can be reported at the service-line level or the claim level.

Examples:

RARC MA120 - Missing/incomplete/invalid CLIA certification number. RARC MA120 could be used to further explain CARC/Group Code CO-16.

Informational RARC MA15 - Alert: Your claim has been separated to expedite handling. You will receive a separate notice for the other services reported


Indian Health Service — patient coinsurance or deductible

Per Section 630 of the Medicare Modernization Act (MMA), which permits Indian Health Service (IHS) facilities to directly bill Medicare for durable medical equipment, prosthetics, orthotics and supplies (DMEPOS), federal government agencies do not permit providers to collect coinsurance or deductible payments from IHS patients. This new reason code enables Medicare to communicate the message that coinsurance or deductible cannot be collected from the patient.


OA 4 The procedure code is inconsistent with the modifier used or a required modifier is missing.

OA 5 The procedure code/bill type is inconsistent with the place of service.

OA 6 The procedure/revenue code is inconsistent with the patient's age.

OA 7 The procedure/revenue code is inconsistent with the patient's gender.

OA 8 The procedure code is inconsistent with the provider type/specialty (taxonomy).

OA 9 The diagnosis is inconsistent with the patient's age.

OA 10 The diagnosis is inconsistent with the patient's gender.

OA 11 The diagnosis is inconsistent with the procedure.

OA 12 The diagnosis is inconsistent with the provider type.

OA 13 The date of death precedes the date of service.

OA 14 The date of birth follows the date of service.

OA 16 Claim/service lacks information which is needed for adjudication. At least one Remark Code must be provided (may be comprised of either the Remittance Advice Remark Code or NCPDP Reject Reason Code.)

OA 18 Duplicate claim/service.

OA 19 Claim denied because this is a work-related injury/illness and thus the liability of the Worker's Compensation Carrier.

OA 20 Claim denied because this injury/illness is covered by the liability carrier.

OA 21 Claim denied because this injury/illness is the liability of the no-fault carrier.

OA 40 Charges do not meet qualifications for emergent/urgent care.

OA 44 Prompt-pay discount.

OA 53 Services by an immediate relative or a member of the same household are not covered.

OA 59 Charges are adjusted based on multiple or concurrent procedure rules. (For example multiple surgery or diagnostic imaging, concurrent anesthesia.)

OA 61 Charges adjusted as penalty for failure to obtain second surgical opinion.

OA 74 Indirect Medical Education Adjustment.

OA 75 Direct Medical Education Adjustment.

OA 87 Transfer amount.

OA 90 Ingredient cost adjustment.

OA 95 Benefits adjusted. Plan procedures not followed.

OA 100 Payment made to patient/insured/responsible party.

OA 104 Managed care withholding.

OA 105 Tax withholding.

OA 106 Patient payment option/election not in effect.

OA 109 Claim not covered by this payer/contractor. You must send the claim to the correct payer/contractor.

OA 116 Payment denied. The advance indemnification notice signed by the patient did not comply with requirements.

OA 118 Charges reduced for ESRD network support.

OA 121 Indemnification adjustment.

OA 122 Psychiatric reduction.

OA 130 Claim submission fee.

OA 131 Claim specific negotiated discount.

OA 132 Prearranged demonstration project adjustment.

OA 133 The disposition of this claim/service is pending further review.

OA 134 Technical fees removed from charges.

OA 136 Claim adjusted based on failure to follow prior payer’s coverage rules. (Use Group Code OA).

OA 137 Payment/Reduction for Regulatory Surcharges, Assessments, Allowances or Health Related Taxes.

OA 141 Claim adjustment because the claim spans eligible and ineligible periods of coverage.

OA 143 Portion of payment deferred.

OA 147 Provider contracted/negotiated rate expired or not on file.

OA 148 Claim/service rejected at this time because information from another provider was not provided or was insufficient/incomplete.

OA 155 This claim is denied because the patient refused the service/procedure.

OA 156 Flexible spending account payments

OA 161 Provider performance bonus

OA 186 Payment adjusted since the level of care changed

OA 187 Health Savings account payments

OA 189 "Not otherwise classified" or "unlisted" procedure code (CPT/HCPCS) was billed when there is a specific procedure code for this procedure/service

OA 192 Non standard adjustment code from paper remittance advice.

OA 199 Revenue code and Procedure code do not match.

OA 206 NPI denial - missing

OA 208 NPI denial - not matched

OA 209 Per regulatory or other agreement. The provider cannot collect this amount from the patient. However, this amount may be billed to subsequent payer. Refund to patient if collected. (Use Group code OA)

This new reason code enables Medicare to communicate the message that coinsurance or deductible cannot be collected from the patient. Refund to patient if collected. This is mainly would come with QMB patients.


OA A1 Claim/Service denied. At least one Remark Code must be provided (may be comprised of either the Remittance Advice Remark Code or NCPDP Reject Reason Code.)

OA A6 Prior hospitalization or 30 day transfer requirement not met.

OA A8 Claim denied; ungroupable DRG

OA B11 The claim/service has been transferred to the proper payer/processor for processing. Claim/service not covered by this payer/processor.

OA B12 Services not documented in patients' medical records.

OA B13 Previously paid. Payment for this claim/service may have been provided in a previous payment.

OA B15 Payment adjusted because this service/procedure requires that a qualifying service/procedure be received and covered. The qualifying other service/procedure has not been received/adjudicated.

OA B18 Payment adjusted because this procedure code and modifier were invalid on the date of service

OA B20 Payment adjusted because procedure/service was partially or fully furnished by another provider.

OA B22 This payment is adjusted based on the diagnosis.

A0 Patient refund amount.

A1 Claim denied charges.

A2 Contractual adjustment.

A3 Medicare Secondary Payer liability met.

A4 Medicare Claim PPS Capital Day Outlier Amount.

A5 Medicare Claim PPS Capital Cost Outlier Amount.

A6 Prior hospitalization or 30 day transfer requirement not met.

A7 Presumptive Payment Adjustment.

A8 Claim denied; ungroupable DRG.

B1 Non-covered visits.

B2 Covered visits.

B3 Covered charges.

B4 Late filing penalty.

B5 Payment adjusted because coverage/program guidelines were not met or were exceeded.

B6 This payment is adjusted when performed/billed by this type of provider, by this type of provider in this type of facility, or by a provider of this specialty.

B7 This provider was not certified/eligible to be paid for this procedure/service on this date of service.

B8 Claim/service not covered/reduced because alternative services were available, and should not have been utilized.

B9 Services not covered because the patient is enrolled in a Hospice.

B10 Allowed amount has been reduced because a component of the basic procedure/test was paid. The beneficiary is not liable for more than the charge limit for the basic procedure/test.

B11 The claim/service has been transferred to the proper payer/processor for processing. Claim/service not covered by this payer/processor.

B12 Services not documented in patient’s medical records.

B13 Previously paid. Payment for this claim/service may have been provided in a previous payment.

B14 Payment denied because only one visit or consultation per physician per day is covered.

B15 Payment adjusted because this service/procedure is not paid separately.

B16 Payment adjusted because "new patient" qualifications were not met.

B17 Payment adjusted because this service was not prescribed by a physician, not prescribed prior to delivery, the prescription is incomplete, or the prescription is not current.

B18 Payment denied because this procedure code/modifier was invalid on the date of service or claim submission.

B19 Claim/service adjusted because of the finding of a Review Organization.

B20 Payment adjusted because procedure/service was partially or fully furnished by another provider.

B21 The charges were reduced because the service/care was partially furnished by another physician.

B22 This payment is adjusted based on the diagnosis.

B23 Payment denied because this provider has failed an aspect of a proficiency testing program.

D1 Claim/service denied. Level of subluxation is missing or inadequate.

D2 Claim lacks the name, strength, or dosage of the drug furnished.

D3 Claim/service denied because information to indicate if the patient owns the equipment that requires the part or supply was missing.

D4 Claim/service does not indicate the period of time for which this will be needed.

D5 Claim/service denied. Claim lacks individual lab codes included in the test.

D6 Claim/service denied. Claim did not include patient's medical record for the service.

D7 Claim/service denied. Claim lacks date of patient's most recent physician visit.

D8 Claim/service denied. Claim lacks indicator that "x-ray is available for review”.

D9 Claim/service denied. Claim lacks invoice or statement certifying the actual cost of the lens, less discounts or the type of intraocular lens used.

D10 Claim/service denied. Completed physician financial relationship form not on file.

D11 Claim lacks completed pacemaker registration form.

D12 Claim/service denied. Claim does not identify who performed the purchased diagnostic test or the amount you were charged for the test.

D13 Claim/service denied. Performed by a facility/supplier in which the ordering/referring physician has a financial interest.

D14 Claim lacks indication that plan of treatment is on file.

D15 Claim lacks indication that service was supervised or evaluated by a physician.

W1 Workers Compensation State Fee Schedule Adjustment.



For full list of Medicare denial codes.

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