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1 | CCRS.zip\CCRS\CCRS-BUSRULES-v1.5.3.zip\CCRS-BUSRULES-v1.5.3-436e6fff1115001d614ccd45b469ad60a9bdb27b\docs | VA Standard Reasons CARC.RARC.CAGC-092016.xlsx | Tue Apr 10 06:18:41 2018 UTC |
2 | CCRS.zip\CCRS\CCRS-BUSRULES-v1.5.3.zip\CCRS-BUSRULES-v1.5.3-436e6fff1115001d614ccd45b469ad60a9bdb27b\docs | VA Standard Reasons CARC.RARC.CAGC-092016.xlsx | Fri Jun 15 15:34:05 2018 UTC |
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1 | SHEET: Cle an Copy fo r Dev Team | |
2 | TYPE*,FBCS Descripti on,PFRAR/V eteran Let ter Descri ption, | |
3 | Suspend,13 58 Funding Needed,13 58 Funding Needed, | |
4 | Denial,38 USC 1703 C laim Past 6-Year Ti mely Filin g,Claim De nied - The claim was filed out side the 6 -year time ly filing limitation . 31 USC 3 702 (b), | |
5 | Denial,38 USC 1703 V eteran Ref used Trans fer,Claim Denied - V eteran cou ld have be en safely transferre d to a VA facility f or continu ed treatme nt, but de clined to transfer. 38 CFR 17. 53, | |
6 | Denial,38 USC 1725 A mbulance T ransport D isapproved ,Claim De nied - Amb ulance cla im did not meet all required c riteria. The non-VA facility must be ap proved and paid befo re payment can be ma de for the emergency transport ation. 38 CFR 17.100 3, | |
7 | Denial,38 USC 1725 C laim Past 90-Day Tim ely Filing ,Claim Den ied - The claim was filed outs ide the 90 -day timel y filing l imitation. 38 CFR 1 7.1004 (d) , | |
8 | Denial,38 USC 1725 N o VA Treat ment in Pa st 24 Mont hs,Claim D enied - At the time the emerge ncy treatm ent was pr ovided, Ve teran had not receiv ed VA trea tment with in the pas t 24 month s prior to the emerg ency treat ment. 38 C FR 17.1002 (d), | |
9 | Denial,38 USC 1725 N on-Emergen cy Dept.,C laim Denie d - Servic es were no t provided in an eme rgency dep artment. 3 8 CFR 17.1 002 (a), | |
10 | Denial,38 USC 1725 N on-Emergen t Care,Cla im Denied - The trea tment prov ided did n ot meet th e Prudent Layperson definition of an eme rgency. 38 CFR 17.10 02 (b), | |
11 | Denial,38 USC 1725 P atient Not Enrolled, Claim Deni ed - The c laim was s ubmitted f or a patie nt who is not enroll ed in a VA Health Ca re System. 38 CFR 1 7.1002 (d) , | |
12 | Denial,38 USC 1725 S table for Transfer,C laim Denie d - Vetera n was stab le to safe ly transfe r to a VA facility f or continu ed treatme nt. 38 CFR 17.1005 ( c), | |
13 | Denial,38 USC 1725 S upporting Documentat ion Not Re ceived Tim ely,Claim Denied - T he claim i s consider ed abandon ed and pay ment is pr ohibited w hen the su pporting d ocumentati on needed to conside r the clai m was not received w ithin 30 d ays from t he date re quested. 3 8 CFR 17.1 004 (e ), | |
14 | Denial,38 USC 1725 V A Facility Available ,Claim Den ied - VA o r other Fe deral faci lity was a vailable t o provide the servic es. 38 CFR 17.1002 ( c), | |
15 | Denial,38 USC 1725 V eteran has Other Ins urance Ben efit,Claim Denied - Veteran ha s other co verage und er a healt h plan con tract. 38 CFR 17.10 02 (f), | |
16 | Denial,38 USC 1725 V eteran has Third Par ty Liabili ty,Claim D enied - Ve teran has a contract ual or leg al recours e against a third pa rty that i n whole ex tinguishes the Veter an's liabi lity. 38 CFR 17.100 2 (g), | |
17 | Denial,38 USC 1725 V eteran Ref used Trans fer,Claim Denied - V eteran cou ld have sa fely trans ferred to a VA facil ity for co ntinued tr eatment, b ut decline d to trans fer. 38 CF R 17.1005 (d), | |
18 | Denial,38 USC 1728 C laim Past 2-Year Ti mely Filin g,Claim De nied - The claim was filed out side the t wo-year ti mely filin g limitati on. 38 CF R 17.126, | |
19 | Denial,38 USC 1728 N on-Emergen t Care,Cla im Denied - The trea tment prov ided does not meet t he Prudent Layperson definitio n of an em ergency. 38 CFR 17. 120 (b), | |
20 | Denial,38 USC 1728 N ot Eligibl e for Bene ficiary Tr avel,Claim Denied - Veteran do es not mee t eligibil ity criter ia for tra vel benefi ts as esta blished un der Title 38 CFR 70. 10., | |
21 | Denial,38 USC 1728 S table for Transfer,C laim Denie d - The da te(s) of s ervice occ urred afte r the poin t at which the Veter an was sta bilized an d could ha ve been di scharged o r safely t ransported to a VA o r other Fe deral faci lity for c ontinued t reatment. 38 CFR 17. 121 (a), | |
22 | Denial,38 USC 1728 S upporting Documentat ion Not Re ceived Tim ely,Claim Denied - T he claim i s consider ed abandon ed and pay ment is pr ohibited w hen the su pporting d ocumentati on needed to conside r the clai m was not received w ithin one year from the date r equested. 38 CFR 17. 131, | |
23 | Denial,38 USC 1728 V A Facility Available ,Claim Den ied - VA o r other Fe deral faci lity was a vailable t o provide the servic es. 38 CFR 17.120 (c ), | |
24 | Denial,38 USC 1728 V eteran Ref used Trans fer,Claim Denied - V eteran was stabilize d and refu sed transf er to a VA facility. 38 CFR 1 7.121 (c), | |
25 | Line Item, Add On Cod e Error,Ad d-on code cannot be billed alo ne., | |
26 | Rejection, Additional Charges D oesn't Cha nge Paymen t,Addition al charges does not change the reimburse ment previ ously paid ., | |
27 | Rejection, Admission Hour Error Medical R ecords,Mis sing/incom plete/inva lid admiss ion hour., | |
28 | Rejection, Ambulance - Forward to Benefic iary Trave l,There is no eviden ce of an a uthorizati on for the invoice s ubmitted. Please co ntact the VA facilit y Benefici ary Travel Office re garding el igible ben eficiaries ., | |
29 | Rejection, Ambulance - Point-of -Pickup Zi p Code Err or Medical Records,T he point-o f-pick-up zip code i s required to proces s this cla im. On a C MS-1500 cl aim the zi p code mus t be prese nt in bloc k 19, 23, or 32. On CMS-1450 t he zip cod e must be present in block 39, 40, or 41 ., | |
30 | Rejection, Anesthesia Time/Unit s Error,Mi ssing/inco mplete/inv alid anest hesia time /units., | |
31 | Rejection, ASC Must B ill on HCF A,Request for additi onal infor mation. Am bulatory S urgical Ce nters Esse ntial clai m requirem ents: 1) S ubmit CMS- 1500 or ED I 837 prof essional c laim. 2) N ame of ASC facility in box 32 3) Place o f Service must be 24 . 4) Must contain th e facility NPI in bl ock 33a. , | |
32 | Rejection, Authorizat ion Absent (Home Hea lth & Cont ractors),A uthorizati on absent. , | |
33 | Suspend,Au thorizatio n Adjustme nt Request ,Authoriza tion Adjus tment Requ est, | |
34 | Suspend,Au thorizatio n Entry Re quest - 17 03,1703 Au thorizatio n Entry Re quest, | |
35 | Suspend,Au thorizatio n Entry Re quest - 17 25,1725 Au thorizatio n Entry Re quest, | |
36 | Suspend,Au thorizatio n Entry Re quest - 17 28,1728 Au thorizatio n Entry Re quest, | |
37 | Suspend,Au thorizatio n Entry Re quest - In patient,In patient Au thorizatio n Entry Re quest, | |
38 | Suspend,Au thorizatio n Entry/Ad justment C omplete,Au thorizatio n Entry/Ad justment C omplete, | |
39 | Rejection, Authorizat ion Exceed ed (Home H ealth & Co ntractors) ,Authoriza tion excee ded., | |
40 | Suspend,Au thorizatio n In Proce ss,A diffe rent claim for this episode wa s forwarde d for auth orization. , | |
41 | Rejection, Authorized as Choice Program,O ur documen tation ind icates thi s claim wa s authoriz ed under t he Choice Program. P lease coor dinate pay ment with the Choice Program c ontractor referenced in the au thorizatio n., | |
42 | Rejection, Bill to Co ntractor S pecified i n the Auth orization, Services w ere referr ed to you or coordin ated by a VA contrac tor. Plea se submit claim to t he contrac tor specif ied in the authoriza tion or co ntract., | |
43 | Line Item, Billed Cha rge Error, Missing/in complete/i nvalid cha rge., | |
44 | Rejection, Billing Da te Predate s Service Date,Billi ng date pr edates ser vice date. , | |
45 | Suspend,Ce ntral Fee Duplicate, A duplicat e claim or improper payment wa s identifi ed on Cent ral Fee re port., | |
46 | Suspend,Ce ntral Fee Reject,The claim was rejected by Central Fee, | |
47 | Rejection, Claim Lack s Info/Bil ling Error ,Claim/se rvice lack s informat ion or has submissio n/billing error(s) w hich is ne eded for a djudicatio n., | |
48 | Rejection, Claim will be Proces sed Manual ly in Vist a,This cla im will be processed manually in a diffe rent syste m. A Medic al Payment Identific ation Noti ce will be provided when the p ayment is processed. , | |
49 | Suspend,Cl inical Rev iew Comple te,Clinica l Review C omplete, | |
50 | Suspend,Cl inical Rev iew Comple te - Denie d,Clinical Review Co mplete - D enied, | |
51 | Suspend,Cl inical Rev iew Comple te - Inpat ient,Clini cal Review Complete - Inpatien t, | |
52 | Suspend,Cl inical Rev iew In Pro cess,A dif ferent cla im for thi s episode was forwar ded for cl inical rev iew., | |
53 | Suspend,Cl inical Rev iew Reques t,Clinical Review Re quest, | |
54 | Suspend,Co ding Revie w Complete ,Coding Re view Compl ete, | |
55 | Suspend,Co ding Revie w Request, Coding Rev iew Reques t, | |
56 | Rejection, Contract I nclusive C harges,Cha rges are i nclusive o f a contra cted/negot iated rate or are se parately b illable ch arges that required pre-author ization. The patien t is not l iable for these char ges., | |
57 | Line Item, Contract I nclusive C harges,Cha rges on th is line ar e inclusiv e of a con tracted/ne gotiated r ate or are separatel y billable charges t hat requir ed pre-aut horization . The pat ient is no t liable f or these c harges., | |
58 | Suspend,Co ntracting Rep Review Needed,Co ntracting Rep Review Needed, | |
59 | Rejection, Contractor Billed to VA in Err or,Service s were not authorize d under VA contract and should be billed to VA dir ectly by t he provide r. , | |
60 | Line Item, CPT Code N eeds Recor ds,This CP T/HCPCS co de needs s upporting documentat ion in ord er to be c onsidered for paymen t., | |
61 | Rejection, CPT/HCPCS Error,Miss ing/incomp lete/inval id CPT or HCPCS code (s)., | |
62 | Line Item, CPT/HCPCS Error,Miss ing/incomp lete/inval id procedu re code(s) ., | |
63 | Rejection, Date of Se rvice Outs ide Author ization Ra nge,Date(s ) on autho rization d oes not in clude date (s) on cla im. Author ization da te may be extended, pending ve rification from faci lity. Plea se contact the refer ring VA fa cility for approval. , | |
64 | Line Item, Date of Se rvice Outs ide Author ization Ra nge,Date(s ) on autho rization d oes not in clude date (s) on cla im. Author ization da te may be extended, pending ve rification from faci lity. Plea se contact the refer ring VA fa cility for approvals ., | |
65 | Rejection, Device Cod e Error,Th is claim c ontains a device cod e but no p rocedure i s billed. , | |
66 | Line Item, Device Cod e Error,Th is line co ntains a d evice code but no pr ocedure is billed. , | |
67 | Rejection, Diagnosis Code Error Medical R ecords,Thi s claim co ntains one or more i nvalid dia gnosis cod es or is m issing a d iagnosis c ode., | |
68 | Rejection, Dialysis F acility Cl aim Error Medical Re cords,Requ est for ad ditional i nformation . Dialysis Claims Es sential cl aim requir ements: 1) Submit on CMS-1450 or EDI 837 Instituti onal forma t. 2) Must contain t he facilit y NPI in b lock 56 3) ESRD rela ted drugs and labora tory tests or separa tely billa ble drugs or laborat ory test m ust append modifiers CD, CE, C F, AY, or 91, to eac h CPT/HCPC S code. 4) Appropria te value a nd conditi on codes m ust be on the CMS-14 50, includ ing height and weigh t. 5) Type of Bill ( TOB) in bl ock 4 must be 72X. , | |
69 | Rejection, Dialysis I ndependent Laborator y - Modifi er AY Paya ble Only,E ffective J anuary 1, 2011, all ESRD-relat ed lab tes ts must be billed by the renal dialysis facility, whether pr ovided dir ectly or u nder arran gements wi th an inde pendent la boratory. In the ev ent the la b tests we re furnish ed for rea sons other than ESRD treatment , the prov ider may s ubmit a cl aim for se parate pay ment using modifier AY., | |
70 | Rejection, Discharge Status Err or Medical Records,M issing/inc omplete/in valid disc harge stat us informa tion., | |
71 | Rejection, DoD Arrear s,This cla im has bee n identifi ed as part of the VA /DoD FY11- 14 Arrear s Reconcil iation and will be a djudicated according to that a greement. This clai m is rejec ted to fac ilitate th is effort. , | |
72 | Rejection, DRG Error Medical Re cords,Miss ing/incomp lete/inval id DRG cod e., | |
73 | Rejection, Duplicate Claim,Dupl icate of a claim pro cessed, or to be pro cessed., | |
74 | Line Item, Duplicate Line,The s ame servic e is repor ted on two or more l ine items without a modifier; line item appears to be duplic ate of a s econd proc edure., | |
75 | Suspend,Er ror - Foll ow-Up Need ed,Error - Follow-Up Needed, | |
76 | Denial,Exc eeds Month ly Fee ID Limit,Clai m Denied - Fee ID ca rd amount exceeds th e current authorized monetary limit., | |
77 | Line Item, Exceeds Mo nthly Fee ID Limit,L ine Denied - Fee ID card amoun t exceeds the curren t authoriz ed monetar y limit., | |
78 | Line Item, Exceeds Nu mber/Frequ ency Appro ved,Exceed s number/f requency a pproved/al lowed with in time pe riod., | |
79 | Denial,Fug itive Felo n Prohibit ed Benefit s,Claim De nied - Vet eran is no t entitled to benefi ts for any period in which Vet eran is a Fugitive F elon. 38 U SC 5313B, | |
80 | Line Item, Global Per iod Inclus ive,Servic e appears to be with in a globa l period. , | |
81 | Rejection, ICD-10 Req uired Afte r 9/30/15, ICD-10 is required f or dates o f service after 9/30 /15., | |
82 | Line Item, IHS-Ins pa id above A ll Inclusi ve Rate / V20,Line D enied - In surance pa id more th en all-inc lusive rat e., | |
83 | Rejection, IHS-Ins pa id above A ll-Inclusi ve Rate / V20,Insura nce paid m ore than a ll-inclusi ve rate., | |
84 | Line Item, Incidental Services, Procedure code incid ental to p rimary pro cedure., | |
85 | Rejection, Incorrect VA facilit y (Do NOT use for ED I),This in voice was submitted to the inc orrect VA facility. Another VA Facility has jurisd iction ove r this cla im. We hav e forwarde d the clai m to the r esponsible VA Facili ty., | |
86 | Line Item, Lab Panel Required,A lab panel code shou ld be code d in lieu of the ind ividual la b codes fo r this dat e of servi ce., | |
87 | Line Item, Lack of Me dical Nece ssity,Line item non- covered be cause this is not de emed a "me dical nece ssity.", | |
88 | Line Item, Line Item Not Author ized,This line item is not aut horized. , | |
89 | Line Item, Line Item Previously Paid,This line was previously paid and the origin al payment decision is being m aintained. , | |
90 | Suspend,Me dical Docu mentation Needed,Med ical Docum entation N eeded, | |
91 | Rejection, Medical Re cords - M ill Bill - All Recor ds,Medical records h ave not be en receive d or are i nsufficien t to deter mine decis ion of pay ment. If a pplicable, please su bmit the a mbulance t rip notes, ER Report , H&P note s, physici an orders, progress notes, sur gery opera tive notes , and disc harge summ ary within 30 days. If records are not r eceived yo ur claim w ill be con sidered ab andoned. Y ou may req uest addit ional time , which ma y extend t his time l imit as re asonably n ecessary., | |
92 | Rejection, Medical Re cords - M ill Bill - Ambulance Trip Note s,Request for additi onal infor mation. Me dical reco rds have n ot been re ceived or are insuff icient to determine decision o f payment. If applic able, plea se submit the ambula nce trip n otes withi n 30 days. If record s are not received your claim will be c onsidered abandoned. You may r equest add itional ti me, which may extend this time limit as reasonably necessary ., | |
93 | Rejection, Medical Re cords - M ill Bill - Discharge Summary,M edical rec ords have not been r eceived or are insuf ficient to determine decision of payment . If appli cable, ple ase submit the disch arge summa ry within 30 days. I f records are not re ceived you r claim wi ll be cons idered aba ndoned. Yo u may requ est additi onal time, which may extend th is time li mit as rea sonably ne cessary., | |
94 | Rejection, Medical Re cords - M ill Bill - ER Report ,Medical r ecords hav e not been received or are ins ufficient to determi ne decisio n of payme nt. If app licable, p lease subm it the eme rgency roo m report w ithin 30 d ays. If re cords are not receiv ed your c laim will be conside red abando ned. You m ay request additiona l time, wh ich may ex tend this time limit as reason ably neces sary., | |
95 | Rejection, Medical Re cords - M ill Bill - H&P,Medic al records have not been recei ved or are insuffici ent to det ermine dec ision of p ayment. If applicabl e, please submit the History & Physical notes with in 30 days . If recor ds are not received your clai m will be considered abandoned . You may request ad ditional t ime, which may exten d this tim e limit as reasonabl y necessar y., | |
96 | Rejection, Medical Re cords - M ill Bill - Progress Notes,Medi cal record s have not been rece ived or ar e insuffic ient to de termine de cision of payment. I f applicab le, please submit th e progress notes wit hin 30 day s. If reco rds are no t received your cla im will be considere d abandone d. You may request a dditional time, whic h may exte nd this ti me limit a s reasonab ly necessa ry., | |
97 | Rejection, Medical Re cords - Al l Records, Medical re cords have not been received o r are insu fficient t o determin e decision of paymen t. If appl icable, pl ease submi t the ambu lance trip notes, ER Report, H &P notes, physician orders, pr ogress not es, surger y operativ e notes, a nd dischar ge summary ., | |
98 | Rejection, Medical Re cords - Am bulance Tr ip Notes,M edical rec ords have not been r eceived or are insuf ficient to determine decision of payment . If appli cable, ple ase submit the ambul ance trip notes., | |
99 | Rejection, Medical Re cords - Di scharge Su mmary,Medi cal record s have not been rece ived or ar e insuffic ient to de termine de cision of payment. P lease subm it the dis charge sum mary. , | |
100 | Rejection, Medical Re cords - ER report,Me dical reco rds have n ot been re ceived or are insuff icient to determine decision o f payment. If applic able, plea se submit the emerge ncy room r eport. , | |
101 | Rejection, Medical Re cords - H& P Notes,Me dical reco rds have n ot been re ceived or are insuff icient to determine decision o f payment. If applic able, plea se submit the Histor y & Physic al Notes., | |
102 | Rejection, Medical Re cords - Pr ogress Not es,This cl aim was su bmitted wi th medical documenta tion, howe ver the re cords are insufficie nt to dete rmine deci sion of pa yment. If applicabl e, please submit the physician progress note., | |
103 | Denial,Min imum Activ e Duty Ser vice Not M et,Claim D enied - Th e Veteran does not m eet the el igibility requiremen ts and the VA is wit hout legal authority to consid er payment of this c laim. 38 U SC 5303A, | |
104 | Rejection, Modifier E rror,The p rocedure c ode is inc onsistent with the m odifier us ed or a re quired mod ifier is m issing., | |
105 | Line Item, Modifier E rror ,Th e procedur e code is inconsiste nt with th e modifier used or a required modifier i s missing. , | |
106 | Rejection, New Patien t (3-Year Rule) Erro r,"New Pat ient" qual ifications were not met., | |
107 | Line Item, Newborn Se rvices aft er 7 days from birth - 38 USC 1786,Line Denied - N ewborn car e rendered more than 7 calenda r days aft er the bir th of the child. 38 CFR 17.38 (a) (1) (x iv), | |
108 | Denial,New born Servi ces after 7 Days fro m Birth 38 USC 1786, Claim Deni ed - Newbo rn care re ndered mor e than sev en calenda r days aft er the bir th of the child. 38 CFR 17.38 (a) (1) (x iv), | |
109 | Rejection, Newborn Se rvices mus t bill Sep arately,Se rvices for a newborn must be b illed sepa rately., | |
110 | Rejection, No Payable Lines,The re are no payable li nes on thi s claim., | |
111 | Rejection, Non-Covere d Charge(s ),Non-cove red charge (s)., | |
112 | Line Item, Non-Covere d Charge(s ),Non-cove red charge (s)., | |
113 | Rejection, Not a VA C laim/Bille d to VA in Error,Cla im/service not cover ed by this payer. Yo u must sen d the clai m to the c orrect pay er., | |
114 | Line Item, Not Covere d in Benef its Packag e - 38 CFR 17.38,Lin e Denied - This serv ice is not a covered benefit i n the Vete ran's medi cal benefi ts package as descri bed under 38 CFR 17. 38 (c) , | |
115 | Denial,Not Covered i n Benefits Package 3 8 CFR 17.3 8,Claim De nied - Thi s service is not a c overed ben efit in th e Veteran' s medical benefits p ackage as described under 38 C FR 17.38 ( c). , | |
116 | Rejection, NPI Missin g/Invalid - Attendin g,The atte nding Nati onal Provi der Identi fier (NPI) is either missing, contains i nvalid cha racters or is malfor med., | |
117 | Rejection, NPI Missin g/Invalid - Billing, The billin g National Provider Identifier (NPI) is either mis sing, cont ains inval id charact ers or is malformed. , | |
118 | Rejection, NPI Missin g/Invalid - Operatin g,The oper ating Nati onal Provi der Identi fier (NPI) is either missing, contains i nvalid cha racters or is malfor med., | |
119 | Rejection, NPI Missin g/Invalid - Renderin g,The rend ering Nati onal Provi der Identi fier (NPI) is either missing, contains i nvalid cha racters or is malfor med., | |
120 | Rejection, Nursing Ho me - Send to Local V A,Nursing Home Claim - Please submit cla im to the VA Facilit y that aut horized th is care., | |
121 | Denial,OIG Exclusion List 38 U SC 1703/17 25/1728,Cl aim Denied - The non -VA provid er is list ed on the OIG Exclus ionary Lis t and is i n violatio n of the e xclusion w hen provid ing servic es to a fe deral heal th benefic iary. 42 U SC 1320a-7 , | |
122 | Rejection, Overcoding Error,Inf ormation s ubmitted d oes not su pport this level of service., | |
123 | Line Item, Overcoding Error,Inf ormation S ubmitted d oes not su pport this level of service., | |
124 | Line Item, Packaged S ervice,Thi s item or service is packaged with the r eimburseme nt for ano ther servi ce., | |
125 | Rejection, Patient Ca nnot be Id entified,P atient can not be ide ntified. The name, social sec urity numb er and/or date of bi rth does n ot match d ata in our file. Ple ase verify this info rmation., | |
126 | Rejection, Patient St ill Inpati ent Status - 38 USC 1725,Patie nt is stil l in an in patient st atus. Ple ase rebill after pat ient disch arges., | |
127 | Suspend,Pe nding Pati ent Regist ration,Pen ding Patie nt Registr ation, | |
128 | Suspend,Pe nding Rece ipt of UB/ Facility C laim,Pendi ng Receipt of UB/Fac ility Clai m, | |
129 | Rejection, Place of S ervice Err or,Missing /incomplet e/invalid/ inappropri ate Place of Service ., | |
130 | Rejection, POA Indica tor Error Medical Re cords,Miss ing/incomp lete/inval id Present on Admiss ion Indica tor., | |
131 | Line Item, Previously Denied,Li ne Item Pr eviously D enied., | |
132 | Line Item, Profession al Fees,Pr ofessional fees as n oted by us e of reven ue code 94 X, 97X, 98 X are not payable wh en submitt ed on an i nstitution al claim. Please res ubmit prof essional f ees on CMS -1500., | |
133 | Rejection, Profession al Fees N ot Allowed on UB (CA H Okay),Pr ofessional fees as n oted by us e of reven ue code 94 X, 97X, 98 X are not payable wh en submitt ed on an i nstitution al claim. Please res ubmit prof essional f ees on CMS -1500., | |
134 | Rejection, Provider C redentials Error,Mis sing/Incom plete/inva lid creden tialing da ta., | |
135 | Line Item, Provider m ay not Bil l this Ser vice,This provider t ype/provid er special ty may not bill this service., | |
136 | Rejection, Rebill App licable Se rvices on Single Cla im,Rebill all applic able servi ces on a s ingle clai m., | |
137 | Line Item, Rebill Mul tiple Serv ices on Se parate Lin es,Multipl e Service needs to b e billed o n separate lines., | |
138 | Line Item, Rebill Ser vice on Se parate Cla im,Rebill service on separate claim., | |
139 | Rejection, Rendering Facility I nformation Error,Mis sing/incom plete/inva lid inform ation on w here the s ervices we re furnish ed., | |
140 | Line Item, Revenue Co de Error,M issing/inc omplete/in valid reve nue code(s )., | |
141 | Rejection, Revenue Co de Error M edical Rec ords,Missi ng/incompl ete/invali d revenue code(s)., | |
142 | Line Item, Service Da te Error,T he service date is r equired. If date is present o n claim, t hen it app ears to be incorrect ., | |
143 | Line Item, Stable for Transfer - 38 USC 1 725,Line D enied - Ve teran was stable to safely tra nsfer to a VA facili ty for con tinued tre atment. 38 CFR 17.10 05 (c), | |
144 | Line Item, Stable for Transfer - 38 USC 1 728,Line D enied - Th e date(s) of service occurred after the point at w hich the V eteran was stabilize d and coul d have bee n discharg ed or safe ly transpo rted to a VA or othe r Federal facility f or continu ed treatme nt. 38 CFR 17.121 (a ), | |
145 | Suspend,Su pervisory Payment,A supervisor y key is n eeded to c omplete th is payment ., | |
146 | Suspend,Su pervisory Review Com plete,Supe rvisory Re view Compl ete, | |
147 | Suspend,Su pervisory Review Req uest,Super visory Rev iew Reques t, | |
148 | Rejection, Tax Identi fication N umber Erro r,Missing/ incomplete /invalid T ax Identif ication Nu mber (TIN) ., | |
149 | Line Item, Third Part y Reimburs ement Redu ction,Docu mentation provided t o our offi ce indicat e a third party has made parti al reimbur sement for these ser vices whic h results in a reduc tion to th e VA allow able. In accordance with 38 U SC 1725, a cceptance of VA paym ent exting uishes any liability to the Ve teran., | |
150 | Rejection, Treatment Authorizat ion Code E rror Medic al Records ,Missing/i ncomplete/ invalid HI PPS Treatm ent Author ization Co de (TAC)., | |
151 | Rejection, Type of Bi ll Error,M issing/inc omplete/in valid Type of Bill., | |
152 | Suspend,Un able to Cr eate Autho rization,U nable to C reate Auth orization, | |
153 | Line Item, Unbundling ,The benef it for thi s service is include d in the p ayment/all owance for another s ervice/pro cedure tha t has alre ady been a djudicated ., | |
154 | Line Item, Unit/Days Error,Miss ing/incomp lete/inval id days or units of service., | |
155 | Rejection, Units/Days Error Med ical Recor ds,Missing /incomplet e/invalid days or un its of ser vice., | |
156 | Line Item, Unlisted C ode - More Specified Available ,"Not othe rwise clas sified" or "unlisted " procedur e code (CP T/HCPCS) w as billed when there is a spec ific proce dure code for this p rocedure/s ervice., | |
157 | Rejection, Value Code Error Med ical Recor ds,Missing /incomplet e/invalid value code (s) or amo unt(s)., | |
158 | Rejection, Vendor Doc umentation Incomplet e,The Tax Identifica tion Numbe r (TIN), E FT informa tion, and/ or billing address l isted on t his claim is not reg istered or conflicts with the informatio n on file with the V A Financia l Services Center. P lease cont act our of fice (phon e number p rovided in this lett er) if add itional in formation is needed. , | |
159 | Suspend,Ve ndor Revie w Complete ,Vendor Re view Compl ete, | |
160 | Suspend,Ve ndor Revie w In Proce ss,A diffe rent claim for this vendor was forwarded for vendo r review., | |
161 | Suspend,Ve ndor Revie w Request, Vendor Rev iew Reques t, | |
162 | Denial,Vet eran is an Inmate of Another A gency,Clai m Denied - Services were provi ded to a V eteran who is either a patient or inmate in an ins titution o f another government agency wh ere that a gency has a duty to provide th e services . 38 CFR 1 7.38 (c) ( 5), | |
163 | Line Item, Veteran Re fused Tran sfer - 38 USC 1703 , Claim Deni ed - Veter an could h ave safely transferr ed to a VA facility for contin ued treatm ent, but d eclined to transfer. 38 CFR 17 .53, | |
164 | Line Item, Veteran Re fused Tran sfer - 38 USC 1725 , Line Denie d - Vetera n could ha ve been sa fely trans ferred to a VA facil ity for co ntinued tr eatment, b ut decline d to trans fer. 38 CF R 17.1005 (d), | |
165 | Line Item, Veteran Re fused Tran sfer- 38 U SC 1728,Li ne Denied - Veteran was stabil ized and r efused tra nsfer to a VA facili ty. 38 CF R 17.121 ( c), | |
166 | Rejection, Zip Code - 9 digits required M edical Rec ords,The 9 -digit zip code of t he Renderi ng Facilit y is requi red. Pleas e submit a replaceme nt claim., | |
167 | ||
168 | ||
169 | ||
170 | ||
171 | SHEET: cro sswalk | |
172 | TYPE*,FBCS Descripti on,PFRAR/V eteran Let ter Descri ption,CARC ,RARC,CAGC ,COMMENTS, | |
173 | Denial,38 USC 1703 C laim Past 6-Year Ti mely Filin g,Claim De nied - The claim was filed out side the 6 -year time ly filing limitation . 31 USC 3 702 (b),29 ,CO,CARC 2 9: The tim e limit fo r filing h as expired . | |
174 | CAQH Rule #3 complia nt - do n ot use a R ARC | |
175 | , | |
176 | Denial,38 USC 1703 V eteran Ref used Trans fer,Claim Denied - V eteran cou ld have be en safely transferre d to a VA facility f or continu ed treatme nt, but de clined to transfer. 38 CFR 17. 53,155, PR ,CARC 155: Patient r efused the service/p rocedure. | |
177 | CAQH Rule #3 complia nt - do no t use a RA RC, | |
178 | Denial,38 USC 1725 A mbulance T ransport D isapproved ,Claim De nied - Amb ulance cla im did not meet all required c riteria. The non-VA facility must be ap proved and paid befo re payment can be ma de for the emergency transport ation. 38 CFR 17.100 3,A1,N30,C O,CARC 96: Non-covere d charge(s ). (requir es 1 RARC) RARC N30: Patient i neligible for this s ervice. | |
179 | ||
180 | Not a CAQH CORE Busi ness Scena rio, | |
181 | Denial,38 USC 1725 C laim Past 90-Day Tim ely Filing ,Claim Den ied - The claim was filed outs ide the 90 -day timel y filing l imitation. 38 CFR 1 7.1004 (d) ,29,CO,CAR C 29: The time limit for filin g has expi red. CAQH Rule #3 compli ant - do n ot use a R ARC, | |
182 | Denial,38 USC 1725 N o VA Treat ment in Pa st 24 Mont hs,Claim D enied - At the time the emerge ncy treatm ent was pr ovided, Ve teran had not receiv ed VA trea tment with in the pas t 24 month s prior to the emerg ency treat ment. 38 C FR 17.1002 (d),A1,N3 0,PR,CARC A1:Claim/S ervice Den ied. (requ ires 1 RAR C) RARC N3 0 Patient ineligible for this service. | |
183 | ||
184 | Not a CAQH CORE Busi ness Scena rio, | |
185 | Denial,38 USC 1725 N on-Emergen cy Dept.,C laim Denie d - Servic es were no t provided in an eme rgency dep artment. 3 8 CFR 17.1 002 (a),A1 ,N30,PR,CA RC A1:Clai m/Service Denied. (r equires 1 RARC) RARC N30 Patie nt ineligi ble for th is service . | |
186 | ||
187 | Not a CAQH CORE Busi ness Scena rio, | |
188 | Denial,38 USC 1725 N on-Emergen t Care,Cla im Denied - The trea tment prov ided did n ot meet th e Prudent Layperson definition of an eme rgency. 38 CFR 17.10 02 (b),40, CO,CARC 40 : Charges do not mee t qualific ations for emergent/ urgent car e. | |
189 | CAQH Rule #3 complia nt - does not need a RARC, | |
190 | Denial,38 USC 1725 P atient Not Enrolled, Claim Deni ed - The c laim was s ubmitted f or a patie nt who is not enroll ed in a VA Health Ca re System. 38 CFR 1 7.1002 (d) ,A1,N30,PR ,CARC A1: Claim/Serv ice Denied . (require s 1 RARC) RARC N30 P atient ine ligible fo r this ser vice. | |
191 | ||
192 | Not a CAQH CORE Busi ness Scena rio, | |
193 | Denial,38 USC 1725 S table for Transfer,C laim Denie d - Vetera n was stab le to safe ly transfe r to a VA facility f or continu ed treatme nt. 38 CFR 17.1005 ( c),A1,N30, PR,CARC A1 : Claim/Se rvice Deni ed. (requi res 1 RARC ) RARC N30 Patient i neligible for this s ervice. | |
194 | ||
195 | ||
196 | Not a CAQH CORE Busi ness Scena rio, | |
197 | Denial,38 USC 1725 S upporting Documentat ion Not Re ceived Tim ely,Claim Denied - T he claim i s consider ed abandon ed and pay ment is pr ohibited w hen the su pporting d ocumentati on needed to conside r the clai m was not received w ithin 30 d ays from t he date re quested. 3 8 CFR 17.1 004 (e ),1 64,CO,CARC 164 : Att achment/ot her docume ntation re ferenced o n the clai m was not received i n a timely fashion. | |
198 | ||
199 | CAQH CORE Rule #1, p er CORE ei ther no RA RC , | |
200 | Denial,38 USC 1725 V A Facility Available ,Claim Den ied - VA o r other Fe deral faci lity was a vailable t o provide the servic es. 38 CFR 17.1002 ( c),A1,N30, PR,CARC A1 :Claim/Ser vice Denie d. (requir es 1 RARC) . RARC N30 : Patient ineligible for this service. | |
201 | ||
202 | Not a CAQH CORE Busi ness Scena rio, | |
203 | Denial,38 USC 1725 V eteran has Other Ins urance Ben efit,Claim Denied - Veteran ha s other co verage und er a healt h plan con tract. 38 CFR 17.10 02 (f),A1, N30,PI,CAR C A1:Claim /Service D enied. (re quires 1 R ARC) RARC N30 Patien t ineligib le for thi s service. | |
204 | ||
205 | Not a CAQH CORE Busi ness Scena rio, | |
206 | Denial,38 USC 1725 V eteran has Third Par ty Liabili ty,Claim D enied - Ve teran has a contract ual or leg al recours e against a third pa rty that i n whole ex tinguishes the Veter an's liabi lity. 38 CFR 17.100 2 (g),A1,N 30,CO,CARC A1:Claim/ Service De nied. (req uires 1 RA RC) RARC N 30 Patient ineligibl e for this service. | |
207 | ||
208 | Not a CAQH CORE Busi ness Scena rio, | |
209 | Denial,38 USC 1725 V eteran Ref used Trans fer,Claim Denied - V eteran cou ld have sa fely trans ferred to a VA facil ity for co ntinued tr eatment, b ut decline d to trans fer. 38 CF R 17.1005 (d),155,PR ,CARC 155: Patient r efused the service/p rocedure. | |
210 | CAQH Rule #3 complia nt - does not need a RARC, | |
211 | Denial,38 USC 1728 C laim Past 2-Year Ti mely Filin g,Claim De nied - The claim was filed out side the t wo-year ti mely filin g limitati on. 38 CF R 17.126,2 9,CO,CARC 29: The ti me limit f or filing has expire d. C AQH Rule # 3 complian t - do not use a RAR C, | |
212 | Denial,38 USC 1728 N on-Emergen t Care,Cla im Denied - The trea tment prov ided does not meet t he Prudent Layperson definitio n of an em ergency. 38 CFR 17. 120 (b),40 ,PI,CARC 4 0: Charges do not me et qualifi cations fo r emergent /urgent ca re. | |
213 | CAQH Rule #3 complia nt - does not need a RARC, | |
214 | Denial,38 USC 1728 N ot Eligibl e for Bene ficiary Tr avel,Claim Denied - Veteran do es not mee t eligibil ity criter ia for tra vel benefi ts as esta blished un der Title 38 CFR 70. 10.,A1,N30 ,PR,CARC A 1:Claim/Se rvice Deni ed. (requi res 1 RARC ) RARC pat ient ineli gible for this servi ce. | |
215 | ||
216 | Not a CAQH CORE Busi ness Scena rio, | |
217 | Denial,38 USC 1728 S table for Transfer,C laim Denie d - The da te(s) of s ervice occ urred afte r the poin t at which the Veter an was sta bilized an d could ha ve been di scharged o r safely t ransported to a VA o r other Fe deral faci lity for c ontinued t reatment. 38 CFR 17. 121 (a),A1 ,N30,PR,CA RC A1:Clai m/Service Denied. (r equires 1 RARC) RARC N30 Patie nt ineligi ble for th is service . | |
218 | ||
219 | Not a CAQH CORE Busi ness Scena rio, | |
220 | Denial,38 USC 1728 S upporting Documentat ion Not Re ceived Tim ely,Claim Denied - T he claim i s consider ed abandon ed and pay ment is pr ohibited w hen the su pporting d ocumentati on needed to conside r the clai m was not received w ithin one year from the date r equested. 38 CFR 17. 131,164,CO ,CARC 164 : Attachme nt/other d ocumentati on referen ced on the claim was not recei ved in a t imely fash ion. | |
221 | ||
222 | CAQH CORE BS# 1 comp liant, | |
223 | Denial,38 USC 1728 V A Facility Available ,Claim Den ied - VA o r other Fe deral faci lity was a vailable t o provide the servic es. 38 CFR 17.120 (c ),A1,N30,C O,CARC A1: Claim/Ser vice Denie d. (requir es 1 RARC) RARC N30 Patient in eligible f or this se rvice. | |
224 | ||
225 | Not a CAQH CORE Busi ness Scena rio, | |
226 | Denial,38 USC 1728 V eteran Ref used Trans fer,Claim Denied - V eteran was stabilize d and refu sed transf er to a VA facility. 38 CFR 1 7.121 (c), A1,N30,PR, CARC A1: C laim/Servi ce Denied. (requires 1 RARC)RA RC N30 Pat ient ineli gible for this servi ce. | |
227 | ||
228 | Not a CAQH CORE Rule , | |
229 | Denial,Exc eeds Month ly Fee ID Limit,Clai m Denied - Fee ID ca rd amount exceeds th e current authorized monetary limit.,198 , PI ,CARC 198: Prec ertificati on/authori zation exc eeded. | |
230 | CAQH CORE BS#3 compl iant , | |
231 | Denial,Fug itive Felo n Prohibit ed Benefit s,Claim De nied - Vet eran is no t entitled to benefi ts for any period in which Vet eran is a Fugitive F elon. 38 U SC 5313B,9 6,N30, PR, CARC A1: C laim/Servi ce Denied. (requires 1 RARC) RA RC N30 Pat ient ineli gible for this servi ce. | |
232 | CAQH CORE BS#3 compl iant , | |
233 | Denial,Min imum Activ e Duty Ser vice Not M et,Claim D enied - Th e Veteran does not m eet the el igibility requiremen ts and the VA is wit hout legal authority to consid er payment of this c laim. 38 U SC 5303A,1 77, PR,CAR C 177: Pat ient has n ot met the required eligibilit y requirem ents. | |
234 | CAQH CORE BS#3 compl iant , | |
235 | Denial,New born Servi ces after 7 Days fro m Birth 38 USC 1786, Claim Deni ed - Newbo rn care re ndered mor e than sev en calenda r days aft er the bir th of the child. 38 CFR 17.38 (a) (1) (x iv),32, PR ,CARC 32 O ur records indicate that this dependent is not an eligible d ependent a s defined. | |
236 | CAQH CORE BS#3 compl iant , | |
237 | Denial,Not Covered i n Benefits Package 3 8 CFR 17.3 8,Claim De nied - Thi s service is not a c overed ben efit in th e Veteran' s medical benefits p ackage as described under 38 C FR 17.38 ( c). ,A1,N 30,PR,CARC A1: Claim /Service D enied. (re quires 1 R ARC)RARC p atient ine ligible fo r this ser vice. N30- Patient in eligible f or this se rvice. | |
238 | Not a COEW Business Scenario, | |
239 | Denial,OIG Exclusion List 38 U SC 1703/17 25/1728,Cl aim Denied - The non -VA provid er is list ed on the OIG Exclus ionary Lis t and is i n violatio n of the e xclusion w hen provid ing servic es to a fe deral heal th benefic iary. 42 U SC 1320a-7 ,B7, PR,CA RC B7 This provider was not ce rtified/el igible to be paid fo r this pro cedure/ser vice on th is date of service. | |
240 | ||
241 | CAQH CORE BS#3 compl iant , | |
242 | Denial,Vet eran is an Inmate of Another A gency,Clai m Denied - Services were provi ded to a V eteran who is either a patient or inmate in an ins titution o f another government agency wh ere that a gency has a duty to provide th e services . 38 CFR 1 7.38 (c) ( 5),A1,N30, PR,CARC A1 :Claim/Ser vice Denie d. (requir es 1 RARC) RARC pati ent inelig ible for t his servic e. | |
243 | ||
244 | Not a CAQH CORE Rule , | |
245 | ||
246 | Claim Reje ct,Admissi on Hour Er ror Medica l Records, Missing/in complete/i nvalid adm ission hou r.,16,N46, CO ,CARC 1 6: Claim/s ervice lac ks informa tion or ha s submissi on/billing error(s) which is n eeded for adjudicati on. (requi res 1 RARC ) RARC N46 : Missing/ incomplete /invalid a dmission h our. | |
247 | CAQH CORE BS#2 Compl iant, | |
248 | Claim Reje ct,Additio nal Charge s Doesn't Change Pay ment,Addit ional char ges does n ot change the reimbu rsement pr eviously p aid.,193,C O,CARC 193 : Original Payment d ecision is being mai ntained. U pon review , it was d etermined that this Claim was processed properly. | |
249 | Not covere d in a CO RE Busines s Rule, | |
250 | Claim Reje ct,Ambulan ce - Forwa rd to Bene ficiary Tr avel,There is no evi dence of a n authoriz ation for the invoic e submitte d. Please contact t he VA faci lity Benef iciary Tra vel Office regarding eligible beneficiar ies.,15,CO ,CARC 15 : The auth orization number is missing, i nvalid, or does not apply to t he billed services o r provider . | |
251 | CAQH CORE BS #2 Comp liant, | |
252 | Claim Reje ct,Ambulan ce - Point -of-Pickup Zip Code Error Medi cal Record s,The poin t-of-pick- up zip cod e is requi red to pro cess this claim. On a CMS-1500 claim the zip code must be pr esent in b lock 19, 2 3, or 32. On CMS-145 0 the zip code must be present in block 39, 40, or 41.,16,N5 3,CO,CARC 16: Claim/ service la cks inform ation or h as submiss ion/billin g error(s) which is needed for adjudicat ion. (requ ires 1 RAR C)RARC N53 : Missing/ incomplete /invalid p oint of pi ck up addr ess. | |
253 | CAQH CORE BS #2 Comp liant, | |
254 | Claim Reje ct,Anesthe sia Time/U nits Error ,Missing/i ncomplete/ invalid an esthesia t ime/units. ,16,N203,C O ,CARC 16 : Claim/se rvice lack s informat ion or has submissio n/billing error(s) w hich is ne eded for a djudicatio n. (requir es 1 RARC) RARC N203 : Missing/ incomplete /invalid a nesthesia time/units . | |
255 | CAQH CORE BS #2 Comp liant, | |
256 | Claim Reje ct,ASC Mus t Bill on HCFA,Reque st for add itional in formation. Ambulator y Surgical Centers E ssential c laim requi rements: 1 ) Submit C MS-1500 or EDI 837 p rofessiona l claim. 2 ) Name of ASC facili ty in box 32 3) Plac e of Servi ce must be 24. 4) Mu st contain the facil ity NPI in block 33a . ,16,N34 ,CO,CARC 1 6: Claim/s ervice lac ks informa tion or ha s submissi on/billing error(s) which is n eeded for adjudicati on. (requi res 1 RARC ) RARC N34 : Incorrec t claim fo rm/format for this s ervice | |
257 | CAQH CORE BS #2 Comp liant, | |
258 | Claim Reje ct,Authori zation Abs ent (Home Health & C ontractors ),Authoriz ation abse nt.,197,CO ,CARC 197: Precertif ication/au thorizatio n/notifica tion absen t. | |
259 | CAQH CORE BS #3 Comp liant, | |
260 | Claim Reje ct,Authori zation Exc eeded (Hom e Health & Contracto rs),Author ization ex ceeded.,19 8, PI ,CAR C 198: Pre certificat ion/author ization ex ceeded. | |
261 | CAQH CORE BS #3 Comp liant, | |
262 | Claim Reje ct,Authori zed as Cho ice Progra m,Our docu mentation indicates this claim was autho rized unde r the Choi ce Program . Please c oordinate payment wi th the Cho ice Progra m contract or referen ced in the authoriza tion.,22, PI ,CARC 2 2: This ca re may be covered by another p ayer per c oordinatio n of benef its. | |
263 | CAQH CORE BS #3 Comp liant, | |
264 | Claim Reje ct,Bill to Contracto r Specifie d in the A uthorizati on,Service s were ref erred to y ou or coor dinated by a VA cont ractor. P lease subm it claim t o the cont ractor spe cified in the author ization or contract. ,22, PI,CA RC 22: Thi s care may be covere d by anoth er payer p er coordin ation of b enefits. | |
265 | CAQH CORE BS #3 Comp liant, | |
266 | Claim Reje ct,Billing Date Pred ates Servi ce Date,Bi lling date predates service da te.,110,CO ,CARC 110 : Billing date preda tes servic e date. | |
267 | CAQH CORE BS #2 Comp liant, | |
268 | Claim Reje ct,Claim L acks Info/ Billing Er ror ,Claim /service l acks infor mation or has submis sion/billi ng error(s ) which is needed fo r adjudica tion.,15,M A130,CO,CA RC 15 :The authoriza tion numbe r is missi ng, invali d, or does not apply to the bi lled servi ces or pro vider. | |
269 | RARC MA130 : Your cla im contain s incomple te and/or invalid in formation, and no ap peal right s are affo rded becau se the cla im is unpr ocessable. Please su bmit a new claim wit h the comp lete/corre ct informa tion. | |
270 | CAQH CORE BS #2 Comp liant, | |
271 | Claim Reje ct,Claim w ill be Pro cessed Man ually in V ista,This claim will be proces sed manual ly in a di fferent sy stem. A Me dical Paym ent Identi fication N otice will be provid ed when th e payment is process ed.,B13,CO ,CARC B13: Previousl y paid. Pa yment for this claim /service m ay have be en provide d in a pre vious paym ent. | |
272 | CAQH CORE BS #3 Comp liant, | |
273 | Claim Reje ct,Contrac t Inclusiv e Charges, Charges ar e inclusiv e of a con tracted/ne gotiated r ate or are separatel y billable charges t hat requir ed pre-aut horization . The pat ient is no t liable f or these c harges.,45 ,CO,CARC 4 5: Charge exceeds fe e schedule /maximum a llowable o r contract ed/legisla ted fee ar rangement. | |
274 | ||
275 | Not a CAQH CORE BS R ule, which is fine, | |
276 | Claim Reje ct,Contrac tor Billed to VA in Error,Serv ices were not author ized under VA contra ct and sho uld be bil led to VA directly b y the prov ider. ,22, CO,CARC 22 : This car e may be c overed by another pa yer per co ordination of benefi ts. | |
277 | CAQH CORE BS #3 Comp liant,?, | |
278 | Claim Reje ct,CPT/HCP CS Error,M issing/inc omplete/in valid CPT or HCPCS c ode(s).,16 ,M51,CO ,C ARC 16: Cl aim/servic e lacks in formation or has sub mission/bi lling erro r(s) which is needed for adjud ication. ( requires 1 RARC) RAR C M51: Mis sing/incom plete/inva lid proced ure code(s ). | |
279 | CAQH CORE BS#2 Compl iant , | |
280 | Claim Reje ct,Date of Service O utside Aut horization Range,Dat e(s) on au thorizatio n does not include d ate(s) on claim. Aut horization date may be extende d, pending verificat ion from f acility. P lease cont act the re ferring VA facility for approv al.,198,CO ,CARC 198: Precertif ication/au thorizatio n exceeded . | |
281 | CAQH CORE BS#3 Compl iant, | |
282 | Claim Reje ct,Device Code Error ,This clai m contains a device code but n o procedur e is bille d. ,16,M51 ,CO ,CARC 16: Claim/ service la cks inform ation or h as submiss ion/billin g error(s) which is needed for adjudicat ion. (requ ires 1 RAR C) RARC M5 1: Missing /incomplet e/invalid procedure code(s). | |
283 | CAQH CORE BS#2 Compl iant , | |
284 | Claim Reje ct,Diagnos is Code Er ror Medica l Records, This claim contains one or mor e invalid diagnosis codes or i s missing a diagnosi s code.,16 ,M76,CO ,C ARC 16: Cl aim/servic e lacks in formation or has sub mission/bi lling erro r(s) which is needed for adjud ication. ( requires 1 RARC) RAR C M76: Mis sing/incom plete/inva lid diagno sis or con dition. | |
285 | CAQH CORE BS#2 Compl iant , | |
286 | Claim Reje ct,Dialysi s Facility Claim Err or Medical Records,R equest for additiona l informat ion. Dialy sis Claims Essential claim req uirements: 1) Submit on CMS-14 50 or EDI 837 Instit utional fo rmat. 2) M ust contai n the faci lity NPI i n block 56 3) ESRD r elated dru gs and lab oratory te sts or sep arately bi llable dru gs or labo ratory tes t must app end modifi ers CD, CE , CF, AY, or 91, to each CPT/H CPCS code. 4) Approp riate valu e and cond ition code s must be on the CMS -1450, inc luding hei ght and we ight. 5) T ype of Bil l (TOB) in block 4 m ust be 72X . ,16,N34 ,CO ,CARC 16: Claim/ service la cks inform ation or h as submiss ion/billin g error(s) which is needed for adjudicat ion. (requ ires 1 RAR C) RARC N3 4: Incorre ct claim f orm/format for this service. | |
287 | CAQH CORE BS#2 Compl iant , | |
288 | Claim Reje ct,Dialysi s Independ ent Labora tory - Mod ifier AY P ayable Onl y,Effectiv e January 1, 2011, a ll ESRD-re lated lab tests must be billed by the re nal dialys is facilit y, whether provided directly o r under ar rangements with an i ndependent laborator y. In the event the lab tests were furn ished for reasons ot her than E SRD treatm ent, the p rovider ma y submit a claim for separate payment us ing modifi er AY.,4,C O ,CARC 4: The proce dure code is inconsi stent with the modif ier used o r a requir ed modifie r is missi ng. | |
289 | ||
290 | CAQH CORE BS#2 Compl iant , | |
291 | Claim Reje ct,Dischar ge Status Error Medi cal Record s,Missing/ incomplete /invalid d ischarge s tatus info rmation.,1 6,N50,CO , CARC 16: C laim/servi ce lacks i nformation or has su bmission/b illing err or(s) whic h is neede d for adju dication. (requires 1 RARC) RA RC N50: Mi ssing/inco mplete/inv alid disch arge infor mation. | |
292 | CAQH CORE BS#2 Compl iant , | |
293 | Claim Reje ct,DoD Arr ears,This claim has been ident ified as p art of the VA/DoD FY 11- 14 Arr ears Recon ciliation and will b e adjudica ted accord ing to tha t agreemen t. This c laim is re jected to facilitate this effo rt.,B13,CO ,CARC B13: Previousl y paid. Pa yment for this claim /service m ay have be en provide d in a pre vious paym ent. | |
294 | ||
295 | CAQH CORE BS#3, | |
296 | Claim Reje ct,DRG Err or Medical Records,M issing/inc omplete/in valid DRG code.,16,N 208,CO ,CA RC 16: Cla im/service lacks inf ormation o r has subm ission/bil ling error (s) which is needed for adjudi cation. (r equires 1 RARC) RARC N208: Mis sing/incom plete/inva lid DRG co de. | |
297 | ||
298 | CAQH CORE BS#2 Compl iant | |
299 | ||
300 | , | |
301 | Claim Reje ct,Duplica te Claim,D uplicate o f a claim processed, or to be processed. ,18,CO ,C ARC 18: Ex act duplic ate claim/ service. | |
302 | CAQH CORE BS#2, | |
303 | Claim Reje ct,ICD-10 Required A fter 9/30/ 15,ICD-10 is require d for date s of servi ce after 9 /30/15.,16 ,M76,CO ,C ARC 16: Cl aim/servic e lacks in formation or has sub mission/bi lling erro r(s) which is needed for adjud ication. ( requires 1 RARC) RAR C M76: Mis sing/incom plete/inva lid diagno sis or con dition. | |
304 | CAQH CORE BS#2 Compl iant , | |
305 | Claim Reje ct,IHS-Ins paid abov e All-Incl usive Rate / V20,Ins urance pai d more tha n all-incl usive rate .,45,CO,CA RC 45: Cha rge exceed s fee sche dule/maxim um allowab le or cont racted/leg islated fe e arrangem ent. | |
306 | Not a CAQH CORE BS R ule, which is fine, | |
307 | Claim Reje ct,Incorre ct VA faci lity (Do N OT use for EDI),This invoice w as submitt ed to the incorrect VA facilit y. Another VA Facili ty has jur isdiction over this claim. We have forwa rded the c laim to th e responsi ble VA Fac ility.,B11 ,OA,CARC B 11: The cl aim/servic e has been transferr ed to the proper pay er/process or for pro cessing. C laim/servi ce not cov ered by th is payer/p rocessor. | |
308 | CAQH CORE BS#3 | |
309 | , | |
310 | Claim Reje ct,Medical Records - Mill Bil l - All Re cords,Medi cal record s have not been rece ived or ar e insuffic ient to de termine de cision of payment. I f applicab le, please submit th e ambulanc e trip not es, ER Rep ort, H&P n otes, phys ician orde rs, progre ss notes, surgery op erative no tes, and d ischarge s ummary wit hin 30 day s. If reco rds are no t received your clai m will be considered abandoned . You may request ad ditional t ime, which may exten d this tim e limit as reasonabl y necessar y.,252,N70 6,CO ,CARC 252: An a ttachment/ other docu mentation is require d to adjud icate this claim/ser vice. (req uires 1 RA RC) RARC N 706: Missi ng Documen tation. | |
311 | CAQH CORE BS#1, | |
312 | Claim Reje ct,Medical Records - Mill Bil l - Discha rge Summar y,Medical records ha ve not bee n received or are in sufficient to determ ine decisi on of paym ent. If ap plicable, please sub mit the di scharge su mmary with in 30 days . If recor ds are not received your claim will be c onsidered abandoned. You may r equest add itional ti me, which may extend this time limit as reasonably necessary .,252,N706 ,CO ,CARC 252: An at tachment/o ther docum entation i s required to adjudi cate this claim/serv ice. (requ ires 1 RAR C) RARC N7 06: Missin g Document ation. | |
313 | CAQH CORE BS#1, | |
314 | Claim Reje ct,Medical Records - Mill Bil l - ER Rep ort,Medica l records have not b een receiv ed or are insufficie nt to dete rmine deci sion of pa yment. If applicable , please s ubmit the emergency room repor t within 3 0 days. If records a re not rec eived you r claim wi ll be cons idered aba ndoned. Yo u may requ est additi onal time, which may extend th is time li mit as rea sonably ne cessary.,2 52,N714,CO ,CARC 252 : An attac hment/othe r document ation is r equired to adjudicat e this cla im/service . (require s 1 RARC) RARC N714: Missing R eport | |
315 | CAQH CORE BS#1, | |
316 | Claim Reje ct,Medical Records - Mill Bil l - H&P,Me dical reco rds have n ot been re ceived or are insuff icient to determine decision o f payment. If applic able, plea se submit the Histor y & Physic al notes w ithin 30 d ays. If re cords are not receiv ed your c laim will be conside red abando ned. You m ay request additiona l time, wh ich may ex tend this time limit as reason ably neces sary.,252, N221,CO or PI ,CARC 252 An att achment/ot her docume ntation is required to adjudic ate this c laim/servi ce. (requi res 1 RARC ) RARC N22 1 Missing Admitting History an d Physical report. | |
317 | CAQH CORE BS#1, | |
318 | Claim Reje ct,Medical Records - Mill Bil l - Progre ss Notes,M edical rec ords have not been r eceived or are insuf ficient to determine decision of payment . If appli cable, ple ase submit the progr ess notes within 30 days. If r ecords are not recei ved your claim will be consid ered aband oned. You may reques t addition al time, w hich may e xtend this time limi t as reaso nably nece ssary.,252 ,N393,CO o r PI ,CARC 252: An a ttachment/ other docu mentation is require d to adjud icate this claim/ser vice. (req uires 1 RA RC) RARC N 221: Missi ng Progres s notes/re port. | |
319 | ||
320 | CAQH CORE BS#1, | |
321 | Claim Reje ct,Medical Records - Mill Bil l - Ambula nce Trip N otes,Reque st for add itional in formation. Medical r ecords hav e not been received or are ins ufficient to determi ne decisio n of payme nt. If app licable, p lease subm it the amb ulance tri p notes wi thin 30 da ys. If rec ords are n ot receive d your cl aim will b e consider ed abandon ed. You ma y request additional time, whi ch may ext end this t ime limit as reasona bly necess ary.,252,N 714,CO or PI ,CARC 2 52: An att achment/ot her docume ntation is required to adjudic ate this c laim/servi ce. (requi res 1 RARC ) RARC N71 4: Missing Report. | |
322 | ||
323 | CAQH CORE BS#1, | |
324 | Claim Reje ct,Medical Records - All Recor ds,Medical records h ave not be en receive d or are i nsufficien t to deter mine decis ion of pay ment. If a pplicable, please su bmit the a mbulance t rip notes, ER Report , H&P note s, physici an orders, progress notes, sur gery opera tive notes , and disc harge summ ary.,252,N 706,CO,CAR C 252: An attachment /other doc umentation is requir ed to adju dicate thi s claim/se rvice. (re quires 1 R ARC) RARC N706: Miss ing Docume ntation. | |
325 | ||
326 | CAQH CORE BS#1, | |
327 | Claim Reje ct,Medical Records - Discharge Summary,M edical rec ords have not been r eceived or are insuf ficient to determine decision of payment . Please s ubmit the discharge summary. , 252,N706,C O ,CARC 2 52: An att achment/ot her docume ntation is required to adjudic ate this c laim/servi ce. (requi res 1 RARC ) RARC N70 6: Missing Documenta tion. | |
328 | ||
329 | CAQH CORE BS#1, | |
330 | Claim Reje ct,Medical Records - ER report ,Medical r ecords hav e not been received or are ins ufficient to determi ne decisio n of payme nt. If app licable, p lease subm it the eme rgency roo m report. ,252,N714, CO,CARC 25 2: An atta chment/oth er documen tation is required t o adjudica te this cl aim/servic e. (requir es 1 RARC) RARC N714 : Missing Report. | |
331 | ||
332 | CAQH CORE BS#1, | |
333 | Claim Reje ct,Medical Records - H&P Notes ,Medical r ecords hav e not been received or are ins ufficient to determi ne decisio n of payme nt. If app licable, p lease subm it the His tory & Phy sical Note s.,252,N22 1,CO ,CAR C 252: An attachment /other doc umentation is requir ed to adju dicate thi s claim/se rvice. (re quires 1 R ARC) RARC N221: Miss ing Admitt ing Histor y and Phys ical repor t. | |
334 | ||
335 | CAQH CORE BS#1, | |
336 | Claim Reje ct,Medical Records - Progress Notes,This claim was submitted with medi cal docume ntation, h owever the records a re insuffi cient to d etermine d ecision of payment. If applic able, plea se submit the physic ian progre ss note.,2 52,N393,CO ,CARC 252 : An attac hment/othe r document ation is r equired to adjudicat e this cla im/service . (require s 1 RARC) RARC N221: Missing P rogress no tes/report . | |
337 | ||
338 | CAQH CORE BS#1, | |
339 | Claim Reje ct,Medical Records - Ambulance Trip Note s,Medical records ha ve not bee n received or are in sufficient to determ ine decisi on of paym ent. If ap plicable, please sub mit the am bulance tr ip notes., 252,N714,C O ,CARC 25 2: An atta chment/oth er documen tation is required t o adjudica te this cl aim/servic e. (requir es 1 RARC) RARC N714 : Missing Report. | |
340 | ||
341 | CAQH CORE BS#1, | |
342 | Claim Reje ct,Modifie r Error,Th e procedur e code is inconsiste nt with th e modifier used or a required modifier i s missing. ,4,CO,CARC 4: The pr ocedure co de is inco nsistent w ith the mo difier use d or a req uired modi fier is mi ssing. | |
343 | ||
344 | ||
345 | CAQH CORE BS#2 Compl iant , | |
346 | Claim Reje ct,New Pat ient (3-Ye ar Rule) E rror,"New Patient" q ualificati ons were n ot met.,B1 6,CO,CARC B16: "New Patient" q ualificati ons were n ot met. | |
347 | ||
348 | ||
349 | CAQH CORE BS#3 Compl iant , | |
350 | Claim Reje ct,Newborn Services must bill Separately ,Services for a newb orn must b e billed s eparately. ,32,N15,CO ,CARC 16: Our record s indicate that this dependent is not an eligible dependent as defined . RARC N1 5: Service s for a ne wborn must be billed separatel y. | |
351 | ||
352 | CAQH CORE BS#3 Compl iant , | |
353 | Claim Reje ct,No Paya ble Lines, There are no payable lines on this claim .,16,MA130 ,PI,CARC 1 6 Claim/se rvice lack s informat ion or has submissio n/billing error(s) w hich is ne eded for a djudicatio n. (requi res 1 RARC ) RARC MA1 30: Your c laim conta ins incomp lete and/o r invalid informatio n, and no appeal rig hts are af forded bec ause the c laim is un processabl e. Please submit a n ew claim w ith the co mplete/cor rect infor mation. | |
354 | ||
355 | Requesting that CAQH add this combinatio n to BS #2 (note: if they don' t this wil l be out o f complian ce),I will request t his RARC b e added to the next Codes revi ew - this way we can still use it. , | |
356 | Claim Reje ct,Non-Cov ered Charg e(s),Non-c overed cha rge(s).,16 ,M79,CO,CA RC 96: Non -covered c harge(s). (requires 1 RARC) RA RC M79: Mi ssing/inco mplete/inv alid charg e.,CAQH CO RE Complia nt BS#2, | |
357 | Claim Reje ct,Not a V A Claim/Bi lled to VA in Error, Claim/serv ice not co vered by t his payer. You must send the c laim to th e correct payer.,22, PI,CARC 22 : This car e may be c overed by another pa yer per co ordination of benefi ts. | |
358 | CAQH CORE BS#3 Compl iant , | |
359 | Claim Reje ct,NPI Mis sing/Inval id - Atten ding,The a ttending N ational Pr ovider Ide ntifier (N PI) is eit her missin g, contain s invalid characters or is mal formed.,20 6,N253,CO ,CARC 206: National Provider I dentifier - missing. RARC N253 : Missing/ incomplete /invalid a ttending p rovider pr imary iden tifier. | |
360 | CAQH CORE BS#2 Compl iant , | |
361 | Claim Reje ct,NPI Mis sing/Inval id - Billi ng,The bil ling Natio nal Provid er Identif ier (NPI) is either missing, c ontains in valid char acters or is malform ed.,206,CO ,CARC 206 : National Provider Identifier - missing . | |
362 | CAQH CORE BS#2 Compl iant , | |
363 | Claim Reje ct,NPI Mis sing/Inval id - Opera ting,The o perating N ational Pr ovider Ide ntifier (N PI) is eit her missin g, contain s invalid characters or is mal formed.,20 6,CO ,CARC 206: Nati onal Provi der Identi fier - mis sing. | |
364 | CAQH CORE BS#2 Compl iant , | |
365 | Claim Reje ct,NPI Mis sing/Inval id - Rende ring,The r endering N ational Pr ovider Ide ntifier (N PI) is eit her missin g, contain s invalid characters or is mal formed.,20 6,CO ,CARC 206: Nati onal Provi der Identi fier - mis sing. | |
366 | CAQH CORE BS#2 Compl iant , | |
367 | Claim Reje ct,Nursing Home - Se nd to Loca l VA,Nursi ng Home Cl aim - Plea se submit claim to t he VA Faci lity that authorized this care .,22,CO,CA RC 22: Thi s care may be covere d by anoth er payer p er coordin ation of b enefits. | |
368 | ||
369 | CAQH CORE BS#3 Compl iant , | |
370 | Claim Reje ct,Overcod ing Error, Informatio n submitte d does not support t his level of service .,150,CO,C ARC 150: I nformation submitted does not support th is level o f service. | |
371 | CAQH CORE BS#3 Compl iant , | |
372 | Claim Reje ct,Patient Cannot be Identifie d,Patient cannot be identified . The nam e, social security n umber and/ or date of birth doe s not matc h data in our file. Please ver ify this i nformation .,31, PI , CARC 31: P atient can nont be id entified. | |
373 | CAQH CORE BS#3 Compl iant , | |
374 | Claim Reje ct,Patient Still Inp atient Sta tus - 38 U SC 1725,Pa tient is s till in an inpatient status. Please reb ill after patient di scharges., 135,N662,C O,CARC 135 : Interim bills cann ot be proc essed. RAR C N662: Co nsideratio n of payme nt will be made upon receipt o f a final bill. | |
375 | Not a CAQH Business Scenario, which is f ine, | |
376 | Claim Reje ct,Place o f Service Error,Miss ing/incomp lete/inval id/inappro priate Pla ce of Serv ice.,16,M7 7,CO,CARC 16 Claim/s ervice lac ks informa tion or ha s submissi on/billing error(s) which is n eeded for adjudicati on. (requi res 1 RARC ). RARC M7 7: Missing /incomplet e/invalid place of s ervice. | |
377 | ||
378 | ||
379 | CAQH CORE BS#2 Compl iant , | |
380 | Claim Reje ct,POA Ind icator Err or Medical Records,M issing/inc omplete/in valid Pres ent on Adm ission Ind icator.,16 ,N434,CO , CARC 16: C laim/servi ce lacks i nformation or has su bmission/b illing err or(s) whic h is neede d for adju dication. (requires 1 RARC) RA RC N434: M issing/Inc omplete/in valid Pres ent on Adm ission Ind icator. | |
381 | CAQH CORE BS#2 Compl iant , | |
382 | Claim Reje ct,Profess ional Fees Not Allo wed on UB (CAH Okay) ,Professio nal fees a s noted by use of re venue code 94X, 97X, 98X are n ot payable when subm itted on a n institut ional clai m. Please resubmit p rofessiona l fees on CMS-1500., 89,CO,CARC 89: Profe ssional fe es removed from char ges. | |
383 | ||
384 | CAQH CORE BS#3 Comp liant, | |
385 | Claim Reje ct,Provide r Credenti als Error, Missing/In complete/i nvalid cre dentialing data.,B7, N570,CO,CA RC B7: Thi s provider was not c ertified/e ligible to be paid f or this pr ocedure/se rvice on t his date o f service. (requires 1 RARC) R ARC N570: Missing/In complete/i nvalid cre dentialing data., | |
386 | Claim Reje ct,Rebill Applicable Services on Single Claim,Rebi ll all app licable se rvices on a single c laim.,16,N 149,CO,CAR C 16: Clai m/service lacks info rmation or has submi ssion/bill ing error( s) which i s needed f or adjudic ation. RAR C N149: Re bill all a pplicable services o n a single claim. | |
387 | Not a CORE set combi nation - I will be r equesting that this RARC combi nation is added, how ever if th ey deny th e request VA will be non-compl iant , | |
388 | Claim Reje ct,Renderi ng Facilit y Informat ion Error, Missing/in complete/i nvalid inf ormation o n where th e services were furn ished.,16, MA114,CO , CARC 16: C laim/servi ce lacks i nformation or has su bmission/b illing err or(s) whic h is neede d for adju dication. (requires 1 RARC). R ARC MA114 Missing/in complete/i nvalid inf ormation o n where th e services were furn ished. | |
389 | CAQH CORE BS#2 Compl iant , | |
390 | Claim Reje ct,Revenue Code Erro r Medical Records,Mi ssing/inco mplete/inv alid reven ue code(s) .,16,M50,C O ,CARC 16 : Claim/se rvice lack s informat ion or has submissio n/billing error(s) w hich is ne eded for a djudicatio n. (requir es 1 RARC) RARC M50: Missing/i ncomplete/ invalid re venue code (s). | |
391 | CAQH CORE BS#2 Compl iant , | |
392 | Claim Reje ct,Tax Ide ntificatio n Number E rror,Missi ng/incompl ete/invali d Tax Iden tification Number (T IN).,16,N2 09,CO ,CAR C 16: Clai m/service lacks info rmation or has submi ssion/bill ing error( s) which i s needed f or adjudic ation. (re quires 1 R ARC) RARC 209: Missi ng/incompl ete/invali d taxpayer identific ation numb er (TIN). | |
393 | CAQH CORE BS#2 Compl iant , | |
394 | Claim Reje ct,Treatme nt Authori zation Cod e Error Me dical Reco rds,Missin g/incomple te/invalid HIPPS Tre atment Aut horization Code (TAC ).,16,MA30 ,CO ,CARC 16: Claim/ service la cks inform ation or h as submiss ion/billin g error(s) which is needed for adjudicat ion. (requ ires 1 RAR C) RARC N7 52: Missin g/incomple te/invalid HIPPS Tre atment Aut horization Code (TAC ). | |
395 | CAQH CORE BS#2 Compl iant , | |
396 | Claim Reje ct,Type of Bill Erro r,Missing/ incomplete /invalid T ype of Bil l.,16,MA30 ,CO ,CARC 16: Claim/ service la cks inform ation or h as submiss ion/billin g error(s) which is needed for adjudicat ion. (requ ires 1 RAR C) RARC MA 30: Missin g/incomple te/invalid Type of B ill. | |
397 | ||
398 | CAQH CORE BS#2 Compl iant , | |
399 | Claim Reje ct,Units/D ays Error Medical Re cords,Miss ing/incomp lete/inval id days or units of service.,1 6,M53,CO ,CARC 16 C laim/servi ce lacks i nformation or has su bmission/b illing err or(s) whic h is neede d for adju dication. (requires 1 RARC) RA RC M53 Mis sing/incom plete/inva lid days o r units of service. | |
400 | ||
401 | CAQH CORE BS#2 Compl iant , | |
402 | Claim Reje ct,Value C ode Error Medical Re cords,Miss ing/incomp lete/inval id value c ode(s) or amount(s). ,16,M49,CO ,CARC 16 Claim/ser vice lacks informati on or has submission /billing e rror(s) wh ich is nee ded for ad judication . (require s 1 RARC) RARC M49 M issing/inc omplete/in valid valu e code(s) or amount( s)service. | |
403 | CAQH CORE BS#2 Compl iant , | |
404 | Claim Reje ct,Vendor Documentat ion Incomp lete,The T ax Identif ication Nu mber (TIN) , EFT info rmation, a nd/or bill ing addres s listed o n this cla im is not registered or confli cts with t he informa tion on fi le with th e VA Finan cial Servi ces Center . Please c ontact our office (p hone numbe r provided in this l etter) if additional informati on is need ed.,16,MA1 14,CO or P I ,CARC 16 : Claim/se rvice lack s informat ion or has submissio n/billing error(s) w hich is ne eded for a djudicatio n. (requir es 1 RARC) RARC MA11 4 Missing/ incomplete /invalid i nformation on where the servic es were fu rnished. | |
405 | CAQH CORE BS#2 Compl iant , | |
406 | Claim Reje ct,Zip Cod e - 9 digi ts require d Medical Records,Th e 9-digit zip code o f the Rend ering Faci lity is re quired. Pl ease submi t a replac ement clai m.,16,N294 ,CO or PI ,CARC 16: Claim/serv ice lacks informatio n or has s ubmission/ billing er ror(s) whi ch is need ed for adj udication. (requires 1 RARC) R ARC N294: Missing/in complete/i nvalid ser vice facil ity primar y address. | |
407 | CAQH CORE BS#2 Compl iant , | |
408 | ||
409 | Line Item, Add On Cod e Error,Ad d-on code cannot be billed alo ne.,234,N1 22,CO,234 - This pro cedure is not paid s eparately. At least one Remark Code must be provid ed (may be comprised of either the NCPDP Reject Re ason Code, or Remitt ance Advic e Remark C ode that i s not an A LERT.) | |
410 | N122 -Add- on code ca nnot be bi lled by it self. | |
411 | CAQH CORE BS#4 Compi ant,Specia l note RAR C N122 is listed as "not appl icable' in VistA Fee , to chan ge this it will take a Patch ? , | |
412 | Line Item, Billed Cha rge Error, Missing/in complete/i nvalid cha rge.,16,M7 9,CO ,16 - Claim/ser vice lacks informati on or has submission /billing e rror(s) wh ich is nee ded for ad judication . Do not u se this co de for cla ims attach ment(s)/ot her docume ntation. A t least on e Remark C ode must b e provided (may be c omprised o f either t he NCPDP R eject Reas on Code, o r Remittan ce Advice Remark Cod e that is not an ALE RT.) Note: Refer to the 835 He althcare P olicy Iden tification Segment ( loop 2110 Service Pa yment Info rmation RE F), if pre sent. | |
413 | M79 - Miss ing/incomp lete/inval id charge. | |
414 | ||
415 | CAQH CORE BS#2 Compl iant , | |
416 | Line Item, Contract I nclusive C harges,Cha rges on th is line ar e inclusiv e of a con tracted/ne gotiated r ate or are separatel y billable charges t hat requir ed pre-aut horization . The pat ient is no t liable f or these c harges.,45 ,CO,CARC 4 5: Charge exceeds fe e schedule /maximum a llowable o r contract ed/legisla ted fee ar rangement. | |
417 | ||
418 | Not a CAQH CORE BS R ule, which is fine, | |
419 | Line Item, CPT Code N eeds Recor ds,This CP T/HCPCS co de needs s upporting documentat ion in ord er to be c onsidered for paymen t.,252,N70 6,CO,CARC 252 -An at tachment/o ther docum entation i s required to adjudi cate this claim/serv ice. At le ast one Re mark Code must be pr ovided (ma y be compr ised of ei ther the N CPDP Rejec t Reason C ode, or Re mittance A dvice Rema rk Code th at is not an ALERT). | |
420 | ||
421 | N706- Mis sing docum entation. | |
422 | ||
423 | ||
424 | CAQH CORE BS#1 Compl iant , | |
425 | Line Item, CPT/HCPCS Error,Miss ing/incomp lete/inval id procedu re code(s) .,16,M51,C O ,CARC 16 : Claim/se rvice lack s informat ion or has submissio n/billing error(s) w hich is ne eded for a djudicatio n. (requir es 1 RARC) RARC M51: Missing/i ncomplete/ invalid pr ocedure co de(s). | |
426 | CAQH CORE BS#2 Compl iant , | |
427 | Line Item, Date of Se rvice Outs ide Author ization Ra nge,Date(s ) on autho rization d oes not in clude date (s) on cla im. Author ization da te may be extended, pending ve rification from faci lity. Plea se contact the refer ring VA fa cility for approvals .,198,CO,C ARC 198: P recertific ation/auth orization exceeded. | |
428 | CAQH CORE BS#3 Compl iant, | |
429 | Line Item, Device Cod e Error,Th is line co ntains a d evice code but no pr ocedure is billed. , 16,M51,CO ,CARC 16: Claim/serv ice lacks informatio n or has s ubmission/ billing er ror(s) whi ch is need ed for adj udication. (requires 1 RARC) R ARC M51: M issing/inc omplete/in valid proc edure code (s). | |
430 | CAQH CORE BS#2 Compl iant , | |
431 | Line Item, Duplicate Line,The s ame servic e is repor ted on two or more l ine items without a modifier; line item appears to be duplic ate of a s econd proc edure.,18, CO,CARC 18 : Exact du plicate cl aim/servic e. | |
432 | CAQH CORE BS#2 Compl iant , | |
433 | Line Item, Exceeds Mo nthly Fee ID Limit,L ine Denied - Fee ID card amoun t exceeds the curren t authoriz ed monetar y limit.,1 98, PI ,CA RC 198: Pr ecertifica tion/autho rization e xceeded. | |
434 | CAQH CORE BS#3 compl iant , | |
435 | Line Item, Exceeds Nu mber/Frequ ency Appro ved,Exceed s number/f requency a pproved/al lowed with in time pe riod.,273, N435,CO,CA RC 273 - C overage/pr ogram guid elines wer e exceeded . | |
436 | ||
437 | RARC N435 - Exceeds number/fre quency app roved /all owed withi n time per iod withou t support documentat ion., | |
438 | Line Item, Global Per iod Inclus ive,Servic e appears to be with in a globa l period. ,234,N525, PI ,96 - Non-covere d charge(s ). At leas t one Rema rk Code mu st be prov ided (may be compris ed of eith er the NCP DP Reject Reason [si c] Code, o r Remittan ce Advice Remark Cod e that is not an ALE RT.) Note: Refer to the 835 He althcare P olicy Iden tification Segment ( loop 2110 Service Pa yment Info rmation RE F), if pre sent. | |
439 | ||
440 | N525 - The se service s are not covered wh en perform ed within the global period of another s ervice. | |
441 | CAQH CORE BS#4 compl iant , | |
442 | Line Item, IHS-Ins pa id above A ll Inclusi ve Rate / V20,Line D enied - In surance pa id more th en all-inc lusive rat e.,45,CO,C ARC 45: Ch arge excee ds fee sch edule/maxi mum allowa ble or con tracted/le gislated f ee arrange ment. | |
443 | Not a CAQH CORE BS R ule, which is fine, | |
444 | Line Item, Incidental Services, Procedure code incid ental to p rimary pro cedure.,97 ,N19, PI , CARC 97 - The benefi t for this service i s included in the pa yment/allo wance for another se rvice/proc edure that has alrea dy been ad judicated. Note: Ref er to the 835 Health care Polic y Identifi cation Seg ment (loop 2110 Serv ice Paymen t Informat ion REF), if present . | |
445 | RARC - Pro cedure cod e incident al to prim ary proced ure. | |
446 | CAQH CORE BS#4 compl iant , | |
447 | Line Item, Lab Panel Required,A lab panel code shou ld be code d in lieu of the ind ividual la b codes fo r this dat e of servi ce.,234,N3 90,CO,234 - This pro cedure is not paid s eparately. | |
448 | N390 - Thi s service/ report can not be bil led separa tely. | |
449 | CAQH CORE BS#4 compl iant , | |
450 | Line Item, Lack of Me dical Nece ssity,Line item non- covered be cause this is not de emed a "me dical nece ssity.",25 0,N170,CO ,250-he at tachment/o ther docum entation t hat was re ceived was the incor rect attac hment/docu ment. The expected a ttachment/ document i s still mi ssing. | |
451 | N170 - A n ew/revised /renewed c ertificate of medica l necessit y is neede d. | |
452 | CAQH CORE BS#1 compl iant | |
453 | , | |
454 | Line Item, Line Item Not Author ized,This line item is not aut horized. , 243,CO,243 - Services not autho rized by n etwork/pri mary care providers. | |
455 | ||
456 | CAQH CORE BS#3, | |
457 | Line Item, Line Item Previously Paid,This line was previously paid and the origin al payment decision is being m aintained. ,B13,CO,CA RC B13: Pr eviously p aid. Payme nt for thi s claim/se rvice may have been provided i n a previo us payment . | |
458 | ||
459 | CAQH CORE BS#3, | |
460 | Line Item, Modifier E rror ,Th e procedur e code is inconsiste nt with th e modifier used or a required modifier i s missing. ,4,CO,CARC 4: The pr ocedure co de is inco nsistent w ith the mo difier use d or a req uired modi fier is mi ssing. | |
461 | ||
462 | ||
463 | CAQH CORE BS#2 Compl iant , | |
464 | Line Item, Newborn Se rvices aft er 7 days from birth - 38 USC 1786,Line Denied - N ewborn car e rendered more than 7 calenda r days aft er the bir th of the child. 38 CFR 17.38 (a) (1) (x iv),32, PR ,CARC 32 O ur records indicate that this dependent is not an eligible d ependent a s defined. | |
465 | CAQH CORE BS#3 compl iant , | |
466 | Line Item, Non-Covere d Charge(s ),Non-cove red charge (s).,B1,CO ,B1 - Non- Covered Vi sits, no R ARC requir ed | |
467 | CAQH CORE BS#3, | |
468 | Line Item, Not Covere d in Benef its Packag e - 38 CFR 17.38,Lin e Denied - This serv ice is not a covered benefit i n the Vete ran's medi cal benefi ts package as descri bed under 38 CFR 17. 38 (c) ,9 5,N584, PR ,95-Plan p rocedures not follow ed. | |
469 | N584 -Not covered ba sed on the insured's noncompli ance with policy or statutory conditions . | |
470 | CAQH compl iant - BS #3, | |
471 | Line Item, Overcoding Error,Inf ormation S ubmitted d oes not su pport this level of service.,1 50,CO,CARC 150: Info rmation su bmitted do es not sup port this level of s ervice. | |
472 | CAQH CORE BS#3 Compl iant , | |
473 | Line Item, Packaged S ervice,Thi s item or service is packaged with the r eimburseme nt for ano ther servi ce.,97,CO, 97-The ben efit for t his servic e is inclu ded in the payment/a llowance f or another service/p rocedure t hat has al ready been adjudicat ed. Note: Refer to t he 835 Hea lthcare Po licy Ident ification Segment (l oop 2110 S ervice Pay ment Infor mation REF ), if pres ent. | |
474 | CAQH CORE BS#4 compl iant , | |
475 | Line Item, Previously Denied,Li ne Item Pr eviously D enied.,97, M86,CO,97- The benefi t for this service i s included in the pa yment/allo wance for another se rvice/proc edure that has alrea dy been ad judicated. Note: Ref er to the 835 Health care Polic y Identifi cation Seg ment (loop 2110 Serv ice Paymen t Informat ion REF), if present . | |
476 | M86-Servic e denied b ecause pay ment alrea dy made fo r same/sim ilar proce dure withi n set time frame. | |
477 | CAQH CORE BS#4 Comp liant, | |
478 | Line Item, Profession al Fees,Pr ofessional fees as n oted by us e of reven ue code 94 X, 97X, 98 X are not payable wh en submitt ed on an i nstitution al claim. Please res ubmit prof essional f ees on CMS -1500.,89, CO,CARC 89 : Professi onal fees removed fr om charges . | |
479 | ||
480 | CAQH CORE BS#3 Comp liant, | |
481 | Line Item, Provider m ay not Bil l this Ser vice,This provider t ype/provid er special ty may not bill this service., 170,N95,CO ,170-Payme nt is deni ed when pe rformed/bi lled by th is type of provider. Note: Ref er to the 835 Health care Polic y Identifi cation Seg ment (loop 2110 Serv ice Paymen t Informat ion REF), if present | |
482 | N95 -This provider t ype/provid er special ty may not bill this service. | |
483 | CAQH CORE BS#3 Comp liant, | |
484 | Line Item, Rebill Mul tiple Serv ices on Se parate Lin es,Multipl e Service needs to b e billed o n separate lines.,16 ,N63,CO ,C ARC 16: Cl aim/servic e lacks in formation or has sub mission/bi lling erro r(s) which is needed for adjud ication. ( requires 1 RARC) | |
485 | N63-Rebill services on separat e claim li nes. | |
486 | CAQH CORE BS#2 Compl iant, | |
487 | Line Item, Rebill Ser vice on Se parate Cla im,Rebill service on separate claim.,16, N61,CO ,16 -CARC 16: Claim/serv ice lacks informatio n or has s ubmission/ billing er ror(s) whi ch is need ed for adj udication. (requires 1 RARC) | |
488 | N61-Rebill services on separat e claims. | |
489 | CAQH CORE BS#2 Compl iant, | |
490 | Line Item, Revenue Co de Error,M issing/inc omplete/in valid reve nue code(s ).,16,M50, CO ,CARC 1 6: Claim/s ervice lac ks informa tion or ha s submissi on/billing error(s) which is n eeded for adjudicati on. (requi res 1 RARC ) | |
491 | RARC M50: Missing/in complete/i nvalid rev enue code( s). | |
492 | CAQH CORE BS#2 Compl iant , | |
493 | Line Item, Service Da te Error,T he service date is r equired. If date is present o n claim, t hen it app ears to be incorrect .,198,N351 ,CO,198-Pr ecertifica tion/autho rization e xceeded. | |
494 | N351-Servi ce date ou tside of t he approve d treatmen t plan ser vice dates . | |
495 | ||
496 | CAQH CORE BS#3 Compl iant, | |
497 | Line Item, Stable for Transfer - 38 USC 1 725,Line D enied - Ve teran was stable to safely tra nsfer to a VA facili ty for con tinued tre atment. 38 CFR 17.10 05 (c),A1, N30,PR,CAR C A1: Clai m/Service Denied. (r equires 1 RARC) RARC N30 Patie nt ineligi ble for th is service . | |
498 | ||
499 | Not a CAQH CORE Rule , | |
500 | Line Item, Stable for Transfer - 38 USC 1 728,Line D enied - Th e date(s) of service occurred after the point at w hich the V eteran was stabilize d and coul d have bee n discharg ed or safe ly transpo rted to a VA or othe r Federal facility f or continu ed treatme nt. 38 CFR 17.121 (a ),A1,N30,P R,CARC A1: Claim/Serv ice Denied . (require s 1 RARC) RARC N30 P atient ine ligible fo r this ser vice. | |
501 | ||
502 | Not a CAQH CORE Rule , | |
503 | Line Item, Third Part y Reimburs ement Redu ction,Docu mentation provided t o our offi ce indicat e a third party has made parti al reimbur sement for these ser vices whic h results in a reduc tion to th e VA allow able. In accordance with 38 U SC 1725, a cceptance of VA paym ent exting uishes any liability to the Ve teran.,215 ,N82,CO,21 5- Based o n subrogat ion of a t hird party settlemen t | |
504 | N82-Provid er must ac cept insur ance payme nt as paym ent in ful l when a t hird party payer con tract spec ifies full reimburse ment | |
505 | Not a CAQH CORE Busi ness Scena rio | |
506 | , | |
507 | Line Item, Unbundling ,The benef it for thi s service is include d in the p ayment/all owance for another s ervice/pro cedure tha t has alre ady been a djudicated .,97,M15,C O,97-The b enefit for this serv ice is inc luded in t he payment /allowance for anoth er service /procedure that has already be en adjudic ated. Note : Refer to the 835 H ealthcare Policy Ide ntificatio n Segment (loop 2110 Service P ayment Inf ormation R EF), if pr esent. | |
508 | M15-Separa tely bille d services /tests hav e been bun dled as th ey are con sidered co mponents o f the same procedure . Separate payment i s not allo wed | |
509 | CAQH Core BS#4 Compl aint, | |
510 | Line Item, Unit/Days Error,Miss ing/incomp lete/inval id days or units of service.,1 6,M53,CO,1 6--Claim/s ervice lac ks informa tion or ha s submissi on/billing error(s) which is n eeded for adjudicati on. Do not use this code for c laims atta chment(s)/ other docu mentation. At least one Remark Code must be provid ed (may be comprised of either the NCPDP Reject Re ason Code, or Remitt ance Advic e Remark C ode that i s not an A LERT.) Not e: Refer t o the 835 Healthcare Policy Id entificati on Segment (loop 211 0 Service Payment In formation REF), if p resent. | |
511 | M53-Missin g/incomple te/invalid days or u nits of se rvice. | |
512 | CAQH Core BS#2 Compl aint, | |
513 | Line Item, Unlisted C ode - More Specified Available ,"Not othe rwise clas sified" or "unlisted " procedur e code (CP T/HCPCS) w as billed when there is a spec ific proce dure code for this p rocedure/s ervice.,16 ,M81,CO,16 -Claim/ser vice lacks informati on or has submission /billing e rror(s) wh ich is nee ded for ad judication . Do not u se this co de for cla ims attach ment(s)/ot her docume ntation. A t least on e Remark C ode must b e provided (may be c omprised o f either t he NCPDP R eject Reas on Code, o r Remittan ce Advice Remark Cod e that is not an ALE RT.) Note: Refer to the 835 He althcare P olicy Iden tification Segment ( loop 2110 Service Pa yment Info rmation RE F), if pre sent. | |
514 | ||
515 | M81-You ar e required to code t o the high est level of specifi city. | |
516 | CAQH Core BS#2 Compl aint, | |
517 | Line Item, Veteran Re fused Tran sfer - 38 USC 1703 , Claim Deni ed - Veter an could h ave safely transferr ed to a VA facility for contin ued treatm ent, but d eclined to transfer. 38 CFR 17 .53,155, P R,CARC 155 : Patient refused th e service/ procedure. | |
518 | ||
519 | CAQH Core BS#3 Compl aint, | |
520 | Line Item, Veteran Re fused Tran sfer - 38 USC 1725 , Line Denie d - Vetera n could ha ve been sa fely trans ferred to a VA facil ity for co ntinued tr eatment, b ut decline d to trans fer. 38 CF R 17.1005 (d),155,PR ,CARC 155: Patient r efused the service/p rocedure. | |
521 | ||
522 | CAQH Core BS#3 Compl aint, | |
523 | Line Item, Veteran Re fused Tran sfer- 38 U SC 1728,Li ne Denied - Veteran was stabil ized and r efused tra nsfer to a VA facili ty. 38 CF R 17.121 ( c),A1,N30, PR,CARC A1 :Claim/Ser vice Denie d. (requir es 1 RARC) RARC N30 Patient in eligible f or this se rvice. | |
524 | ||
525 | Not a CAQH CORE Rule , | |
526 | ||
527 | Suspend,13 58 Funding Needed,13 58 Funding Needed, | |
528 | Suspend,Au thorizatio n Adjustme nt Request ,Authoriza tion Adjus tment Requ est, | |
529 | Suspend,Au thorizatio n Entry Re quest - 17 03,1703 Au thorizatio n Entry Re quest, | |
530 | Suspend,Au thorizatio n Entry Re quest - 17 25,1725 Au thorizatio n Entry Re quest, | |
531 | Suspend,Au thorizatio n Entry Re quest - 17 28,1728 Au thorizatio n Entry Re quest, | |
532 | Suspend,Au thorizatio n Entry Re quest - In patient,In patient Au thorizatio n Entry Re quest, | |
533 | Suspend,Au thorizatio n Entry/Ad justment C omplete,Au thorizatio n Entry/Ad justment C omplete, | |
534 | Suspend,Au thorizatio n In Proce ss,A diffe rent claim for this episode wa s forwarde d for auth orization. , | |
535 | Suspend,Ce ntral Fee Duplicate, A duplicat e claim or improper payment wa s identifi ed on Cent ral Fee re port.,9.6, | |
536 | Suspend,Ce ntral Fee Reject,The claim was rejected by Central Fee, | |
537 | Suspend,Cl inical Rev iew Comple te,Clinica l Review C omplete, | |
538 | Suspend,Cl inical Rev iew Comple te - Denie d,Clinical Review Co mplete - D enied, | |
539 | Suspend,Cl inical Rev iew Comple te - Inpat ient,Clini cal Review Complete - Inpatien t, | |
540 | Suspend,Cl inical Rev iew In Pro cess,A dif ferent cla im for thi s episode was forwar ded for cl inical rev iew., | |
541 | Suspend,Cl inical Rev iew Reques t,Clinical Review Re quest, | |
542 | Suspend,Co ding Revie w Complete ,Coding Re view Compl ete, | |
543 | Suspend,Co ding Revie w Request, Coding Rev iew Reques t, | |
544 | Suspend,Co ntracting Rep Review Needed,Co ntracting Rep Review Needed, | |
545 | Suspend,Er ror - Foll ow-Up Need ed,Error - Follow-Up Needed, | |
546 | Suspend,Me dical Docu mentation Needed,Med ical Docum entation N eeded, | |
547 | Suspend,Pe nding Pati ent Regist ration,Pen ding Patie nt Registr ation, | |
548 | Suspend,Pe nding Rece ipt of UB/ Facility C laim,Pendi ng Receipt of UB/Fac ility Clai m, | |
549 | Suspend,Su pervisory Payment,A supervisor y key is n eeded to c omplete th is payment ., | |
550 | Suspend,Su pervisory Review Com plete,Supe rvisory Re view Compl ete, | |
551 | Suspend,Su pervisory Review Req uest,Super visory Rev iew Reques t, | |
552 | Suspend,Un able to Cr eate Autho rization,U nable to C reate Auth orization, | |
553 | Suspend,Ve ndor Revie w Complete ,Vendor Re view Compl ete, | |
554 | Suspend,Ve ndor Revie w In Proce ss,A diffe rent claim for this vendor was forwarded for vendo r review., | |
555 | Suspend,Ve ndor Revie w Request, Vendor Rev iew Reques t, | |
556 | ||
557 | ||
558 | SHEET: She et2 | |
559 | ||
560 | ||
561 | SHEET: She et3 | |
562 | ||
563 | ||
564 | SHEET: She et1 |
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