UCare to Deny Claims When Comprehensive Procedure Code Is Not Applied

Providers are required to bill the most comprehensive code for procedures versus individual (component) codes. Effective for claims received on or after June 28, 2022, UCare will apply edits to deny claims when the most comprehensive code is not billed.

Recently, UCare has noticed an increase in Individual and Family Plan professional claims with individual (component) codes billed instead of the most comprehensive procedure code(s). An example would be billing lab codes 84443, 85025, 80053 instead of the lab panel code 80050 (80050 includes all 3 codes).

Claims identified with these billing errors will be denied with the following CARC/RARC:

CARC: 16 – Claim/service lacks information or has submission/billing error(s). Usage: Do not use this code for claims attachment(s)/other documentation. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code or Remittance Advice Remark Code that is not an ALERT). Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

RARC: N784 – Missing comprehensive procedure code.

Source: https://media.ucare.org/-/media/documents/provider/provider-news/bulletin_2022_june7_componentcodes.pdf