Appendix D: Remittance Advice Claim Adjustment Reason Codes

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APPENDIX D

Remittance Advice Claim Adjustment Reason Codes

Tell Me Why

Claim Adjustment Reason Codes (CARCs) appear on the remittance advice received by your doctor to tell him why his claim for services he provided to you has been rejected and not paid. The rejection reason can determine whether it is appropriate for him to appeal or bill you instead. The reason codes may also appear on the “explanation of benefits” (EOB) you receive. These codes are maintained by the Washington Publishing Company and are updated three times a year.¹ The following table explains some of the most commonly used reason codes and the rejection categories they represent.

Code	Description	Category
4	Procedure code inconsistent with modifier or modifier missing	Modifiers
5	Procedure code or bill type inconsistent with place of service	Place of service
6	Procedure/revenue code inconsistent with patient’s age	Patient age
7	Procedure/revenue code inconsistent with patient’s gender	Patient gender
8	Procedure code inconsistent with provider specialty	Provider
9	Diagnosis inconsistent with patient age	Patient age
10	Diagnosis inconsistent with patient gender	Patient gender
11	Diagnosis inconsistent with procedure	Medical necessity
12	Diagnosis inconsistent with provider type	Provider
13	Date of death precedes date of service	Date of service
14	Date of birth follows date of service	Date of service
15	Payment adjusted because authorization is missing, invalid, or does not apply to service or provider	Prior authorization
16	Claim lacks information needed for adjudication*	Requested information
18	Duplicate claim	Duplicate
19	Claim denied because this is work-related injury/illness	Coverage
20	Claim denied because this injury/illness is covered by the liability carrier	Coverage
24	Charges covered under a capitation agreement	Managed care
26	Expenses incurred prior to coverage	Eligibility
27	Expenses incurred after coverage terminated	Eligibility
29	Time limit for filing has expired	Filing limit
31	Patient cannot be identified as our insured	Eligibility
35	Lifetime benefit maximum reached	Coverage
39	Service denied when preauthorization was requested	Prior authorization
40	Charges do not meet qualifications for emergent or urgent care	Medical necessity
49	Noncovered service because routine exam or screening procedure	Coverage
50	Noncovered because not deemed a medical necessity	Medical necessity
51	Noncovered because preexisting condition	Coverage
55	Procedure deemed experimental or investigational	Coverage
58	Procedure performed in an inappropriate or invalid place of service	Place of service
59	Charges adjusted based on multiple surgery or concurrent anesthesia rules	Information only
60	Outpatient services with this proximity to inpatient services are not covered	Coverage
96	Noncovered charges*	Coverage
97	Payment included in allowance for another service/procedure	Bundling
100	Payment made to patient/insured	Information only
107	Related or qualifying service not previously paid or identified on this claim	Procedure
109	Not covered by this payer; send claim to correct payer	Eligibility
110	Billing date predates service date	Date of service
114	Procedure/product not approved by the Food & Drug Administration	Coverage
115	Procedure postponed, canceled, or delayed	Information only
116	Advance notice signed by patient did not meet requirements	Medical necessity
117	Transportation only covered to the closest facility	Coverage
119	Benefit maximum reached	Coverage
122	Psychiatric reduction	Information only
133	Claim pended for further review	Information only
140	Health insurance number and name do not match	Eligibility
146	Diagnosis invalid for date of service	Diagnosis
149	Lifetime benefit reached	Coverage
150	Information submitted does not support this level of service	Medical necessity
151	Information submitted does not support this many services	Medical necessity
152	Information submitted does not support this length of service	Medical necessity
153	Information submitted does not support this dosage	Medical necessity
154	Information submitted does not support this day’s supply	Medical necessity
155	Patient refused the service	Information only
157	Service provided as a result of an act of war	Coverage
158	Service provided outside the United States	Coverage
159	Service provided as a result of terrorism	Coverage
160	Injury/illness was the result of an activity that is a benefit exclusion	Coverage
163	Attachment referenced on the claim was not received	Information only
164	Attachment referenced on the claim not received in a timely manner	Information only
167	This diagnosis not covered	Diagnosis
181	Procedure code invalid on date of service	Coding
182	Modifier invalid on date of service	Coding
184	Ordering provider not eligible to order services billed	Provider
189	Not otherwise classified or unlisted code when there is a specific code for service billed	Coding
A1	Claim denied*
A6	Prior hospitalization or 30-day transfer requirement not met	Coverage
A8	Ungroupable DRG	Information only
B1	Noncovered visits	Coverage
B6	Payment adjusted when performed by this type of provider, by this type of provider in this type of facility, or by a provider of this specialty	Provider
B7	Provider not certified/eligible to be paid for this service on this date of service	Provider
B8	Alternative services were available and should have been used	Medical necessity
B9	Not covered because patient is enrolled in a hospice	Coverage
B12	Services not documented in patient’s medical record	Information only
B13	Previously paid	Duplicate claim
B14	Only one visit or consultation per physician per day is covered	Coverage
B16	New patient qualification not met	Coding
B22	Payment adjusted based on the diagnosis	Diagnosis

* For reason codes 16, 96, and A1, an additional remarks code is required to fully explain the reason for the rejection.

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¹ Available at: http://www.wpc-edi.com/reference/codelists/healthcare/claim-adjustment-reason-codes/. Accessed January 2, 2014.

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Table of Contents for Appendix D: Remittance Advice Claim Adjustment Reason Codes

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Table of Contents for
Appendix D: Remittance Advice Claim Adjustment Reason Codes