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1 | CCRS.zip\CCRS\CCRS-BUSRULES-v1.5.3.zip\CCRS-BUSRULES-v1.5.3-436e6fff1115001d614ccd45b469ad60a9bdb27b\docs | CARC-RARC_List_CCRS_BusinessEngineRules.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 | CARC-RARC_List_CCRS_BusinessEngineRules.xlsx | Fri Jun 15 15:05:54 2018 UTC |
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1 | SHEET: Bus iness Edit ing Rules | |
2 | RULE #,RUL E,RULE DES CRIPTION, | |
3 | 001a,Timel y Filing O utpatient, Outpatient claims ar e submitte d within a llowed tim eframe fro m date of service, | |
4 | 001b,Timel y Filing I npatient,I npatient c laims are submitted within the allowed t ime frame from date of dischar ge, | |
5 | 2,Claim Am ount Thres hold,Claim s that exc eed $30,00 0 are flag ged for au dit and he ld for 24 hours, | |
6 | 3,Referral s,Claim li nes have a matching referral, | |
7 | 4,List of Excluded I ndividuals and Entit ies (LEIE) ,Claim lin e CCN prov iders were not in th e LEIE dur ing the da te of serv ice, | |
8 | 5,Dates of Service,C laim line service wa s provided within th e dates of service s pecified b y the refe rral, | |
9 | 6,Duplicat es,Claim l ine is not a duplica te of anot her claim line submi tted withi n the clai m or withi n a previo us claim t hat was no t set to r ejected or denied, | |
10 | 7,Standard ized Episo de of Care (SEOC),Se rvice prov ided withi n the clai m line is included w ithin the SEOC, | |
11 | 8,Payment Authority, CCRS must validate p ayment aut hority for referral to payment authority in the 83 7COB, | |
12 | ||
13 | ||
14 | SHEET: CAR C | |
15 | Claim Adju stment Rea son Codes (CARC),com ment/quest ion, | |
16 | Claim adju stment rea son codes communicat e an adjus tment, mea ning that they must communicat e why a cl aim or ser vice line was paid d ifferently than it w as billed. If there is no adju stment to a claim/li ne, then t here is no adjustmen t reason c ode., | |
17 | Code No.,C ode Descri ption,Appl icable Rul e, | |
18 | 226,Inform ation requ ested from the Billi ng/Renderi ng Provide r was not provided o r not prov ided timel y or was i nsufficien t/incomple te. At lea st one Rem ark Code m ust be pro vided (may be compri sed of eit her the NC PDP Reject Reason Co de, or Rem ittance Ad vice Remar k Code tha t is not a n ALERT.), Timely Fil ing,what r emark code ? The word ing is con fusing, | |
19 | 18,Exact d uplicate c laim/servi ce (Use on ly with Gr oup Code O A except w here state workers' compensati on regulat ions requi res CO),Du plicate, | |
20 | 165,Referr al absent or exceede d.,Referra l,What is the differ ence betwe en this on e and the next, whic h one shou ld we use? , | |
21 | 288,Referr al absent, Referral, | |
22 | 181,Proced ure code w as invalid on the da te of serv ice.,Dates of Servic e,We don't check for valid pro cedure cod es, is it for ETL?, | |
23 | B7,This pr ovider was not certi fied/eligi ble to be paid for t his proced ure/servic e on this date of se rvice. Usa ge: Refer to the 835 Healthcar e Policy I dentificat ion Segmen t (loop 21 10 Service Payment I nformation REF), if present.,D ates of Se rvice,We d on't check for provi der certif ication. B elongs to LIEIE, | |
24 | 243,Servic es not aut horized by network/p rimary car e provider s.,SEOC, | |
25 | 273,Covera ge/program guideline s were exc eeded.,Dol lar Thresh old,No clu e what thi s is about , how it r elates to dollar thr eshold, | |
26 | 287,Referr al exceede d,Dollar T hreshold,D on't check for refer ral amount . Should w e?, | |
27 | 45,Charge exceeds fe e schedule /maximum a llowable o r contract ed/legisla ted fee ar rangement. Usage: Th is adjustm ent amount cannot eq ual the to tal servic e or claim charge am ount; and must not d uplicate p rovider ad justment a mounts (pa yments and contractu al reducti ons) that have resul ted from p rior payer (s) adjudi cation. (U se only wi th Group C odes PR or CO depend ing upon l iability), Dollar Thr eshold, | |
28 | 184,The pr escribing/ ordering p rovider is not eligi ble to pre scribe/ord er the ser vice bille d. Usage: 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.,LEIE, | |
29 | 185,The re ndering pr ovider is not eligib le to perf orm the se rvice bill ed. Usage: Refer to the 835 He althcare P olicy Iden tification Segment ( loop 2110 Service Pa yment Info rmation RE F), if pre sent.,LEIE , | |
30 | 283,Attend ing provid er is not eligible t o provide direction of care.,L EIE, | |
31 | B7,This pr ovider was not certi fied/eligi ble to be paid for t his proced ure/servic e on this date of se rvice. Usa ge: Refer to the 835 Healthcar e Policy I dentificat ion Segmen t (loop 21 10 Service Payment I nformation REF), if present.,L EIE, | |
32 | ||
33 | ||
34 | SHEET: RAR C | |
35 | Remittance Advice Re mark Codes (RARC), | |
36 | Remittance Advice Re mark Codes (RARCs) a re used to provide a dditional explanatio n for an a djustment already de scribed by a Claim A djustment Reason Cod e (CARC) o r to conve y informat ion about remittance processin g. Each RA RC identif ies a spec ific messa ge as show n in the R emittance Advice Rem ark Code L ist. There are two t ypes of RA RCs, suppl emental an d informat ional. The majority of the RAR Cs are sup plemental; these are generally referred to as RARC s without further di stinction. Supplemen tal RARCs provide ad ditional e xplanation for an ad justment a lready des cribed by a CARC. Th e second t ype of RAR C is infor mational; these RARC s are all prefaced w ith Alert: and are o ften refer red to as Alerts. Al erts are u sed to con vey inform ation abou t remittan ce process ing and ar e never re lated to a specific adjustment or CARC., | |
37 | Code No.,C ode Descri ption,Appl icable Rul e, | |
38 | N111,No ap peal right except du plicate cl aim/servic e issue. T his servic e was incl uded in a claim that has been previously billed an d adjudica ted.,Dupli cate,Sound s like it' s related to appeals of some s ort, is it correct m apping?, | |
39 | N111,No ap peal right except du plicate cl aim/servic e issue. T his servic e was incl uded in a claim that has been previously billed an d adjudica ted.,Dupli cate, | |
40 | N385,Notif ication of admission was not t imely acco rding to p ublished p lan proced ures.,Time ly Filing, We don't c heck for n otificatio n of admis sion, how is it rela ted to an invoice?, | |
41 | N630,Refer ral not au thorized b y attendin g physicia n,Referral ,How do we know that it was no t authoriz ed by the attending physician? Also, I'm only awar e of billi ng or reff ering prov iders in t he system, | |
42 | N475,Missi ng complet ed referra l form.,Re ferral, | |
43 | N476,Incom plete/inva lid comple ted referr al form,Re ferral,How do we kno w it's inc omplete?, | |
44 | MA40,Missi ng/incompl ete/invali d admissio n date.,Da tes of Ser vice,ETL?, | |
45 | MA31,Missi ng/incompl ete/invali d beginnin g and endi ng dates o f the peri od billed. ,Dates of Service,ET L?, | |
46 | N299,Missi ng/incompl ete/invali d occurren ce date(s) .,Dates of Service,E TL?, | |
47 | N300,Missi ng/incompl ete/invali d occurren ce span da te(s).,Dat es of Serv ice,ETL?, | |
48 | N301,Missi ng/incompl ete/invali d procedur e date(s). ,Dates of Service,ET L?, | |
49 | N335,Missi ng/incompl ete/invali d referral date.,Dat es of Serv ice,ETL?, | |
50 | N351,Servi ce date ou tside of t he approve d treatmen t plan ser vice dates .,Dates of Service,W here do I find treat ment plan service da tes? What treatment plan?, | |
51 | N592,Adjus ted becaus e this is not the in itial pres cription o r exceeds the amount allowed f or the ini tial presc ription.,D ollar thre shold,What is the in itial pres cription, where do I find it?, | |
52 | N132,Alert : Payments will ceas e for serv ices rende red by thi s US Gover nment deba rred or ex cluded pro vider afte r the 30 d ay grace p eriod as p reviously notified., LEIE, |
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