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.
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 |
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 |
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 |
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.