Providers receive results of reviews on their Electronic Remittance Advice (ERA). Search by selecting categories Claim Adjustment Reason Codes (CARC) or Remittance Advice Remark Codes (RARC) and the corresponding code below.
CARC | RARC | Reason | Corrective Action |
|---|---|---|---|
OA18 | |||
Duplicate service by the same provider on the same date of service | Reconsideration to support payment of duplicate services | ||
Duplicate service by the another provider on the same date of service | Ensure claim is billed with appropriate modifier(s) to indicate duplicate services performed by another provider | ||
| Duplicate service by the same provider or another provider on the same date of service; duplicate modifier present | Request reconsideration to support payment of duplicate services | ||
CO4 | N657 | ||
Service billed with inappropriate modifier or anatomical modifier | Claim correction to change or remove modifier | ||
Service billed with global modifier, but is not within a global period of another procedure | Claim correction to remove modifier | ||
CO16 | MA63 | ||
Diagnosis to modifier comparison; | Claim correction to correct modifier or diagnosis | ||
Diagnosis to Diagnosis Comparison; | Claim correction to remove unspecified diagnosis | ||
Excludes1 Diagnosis; Per ICD-10-CM codes cannot be billed together. | Claim correction to remove Excludes1 diagnosis | ||
Secondary diagnosis is the only diagnosis on the claim; | Claim correction to add appropriate primary diagnosis | ||
Unacceptable principle diagnosis per ICD-10-CM | Claim correction to add appropriate primary diagnosis | ||
Principle diagnosis is on the Outpatient Prospective Payment System (OPPS) unacceptable principle diagnosis list | Claim correction to change principle diagnosis | ||
CO96 | N56 | ||
New patient billed when patient has already received care from the provider | Claim correction to change procedure code to established patient | ||
Individual lab tests billed instead of lab panel | Submit claim correction to void individual tests and replace with panel code | ||
CO97 | N20 | ||
NCCI, Mutually Exclusive, modifier present | Request reconsideration with supporting documentation | ||
NCCI, Non-mutually exclusive, modifier present | Request reconsideration with supporting documentation | ||
NCCI, Non-mutually exclusive, no modifier present | If documentation supports, do a claim correction to add NCCI modifier. If documentation does not support, it is a provider write-off | ||
E/M service same day as a global procedure; modifier present | Request reconsideration with supporting documentation | ||
CO97 | M144 | ||
Revenue codes billed without a HCPCS code | Claim correction to add HCPCS code | ||
CO119 | N362 | ||
Number of daily units billed exceeds the maximum | Refer to MUE section of Correct Coding Policy | ||
COB14 | M86 | ||
Multiple E/M on the same date of service for the same group and same specialty Note: mid-levels are considered same specialty | Billed service should represent level of service for combined visits | ||
Multiple E/M on the same date of service and same revenue code | Claim correction for any modifier changes or additions |
If a provider disagrees with a payment determination and a claim correction is not the next step, request a Reconsideration using the Appeal form. Reconsideration timelines for request align with the respective appeal timelines for commercial and Medicaid Expansion.
A reconsideration is not an appeal as it’s a payment dispute and not an adverse benefit determination; it does not use the member’s appeal rights. A reconsideration of a payment determination is a provider right only. When completing the appeal form, select Provider on behalf of self.
Providers will receive a reconsideration notification within 45 days of receipt of the request. If a provider disagrees with the determination, they will have the option of requesting a second reconsideration within 45 days. Providers will receive a reconsideration notification of their subsequent request within 45 days of receipt of the request.
