BILLING NEWS

RARC and CARC Update

Code Current Narrative Medicare Initiated
N430 Procedure code is inconsistent with the units billed. Start: 11/5/2007 Note: (New Code 11/5/07) YES
N431 Service is not covered with this procedure. Start: 11/5/2007 Note: (New Code 11/5/07) YES
N432 Adjustment based on a Recovery Audit. Start: 11/5/2007 Note: (New Code 11/5/07) YES

Modified Codes

Code Current Modified Narrative Implementation Date
M25 The information furnished does not substantiate the need for this level of service. If you believe the service should have been fully covered as billed, or if you did not know and could not reasonably have been expected to know that we would not pay for this level of service, or if you notified the patient in writing in advance that we would not pay for this level of service and he/she agreed in writing to pay, ask us to review your claim within 120 days of the date of this notice. If you do not request a appeal, we will, upon application from the patient, reimburse him/her for the amount you have collected from him/her in excess of any deductible and coinsurance amounts. We will recover the reimbursement from you as an overpayment. 11/5/2007
M26 The information furnished does not substantiate the need for this level of service. If you have collected any amount from the patient for this level of service /any amount that exceeds the limiting charge for the less extensive service, the law requires you to refund that amount to the patient within 30 days of receiving this notice. The requirements for refund are in 1824(I) of the Social Security Act and 42CFR411.408. The section specifies that physicians who knowingly and willfully fail to make appropriate refunds may be subject to civil monetary penalties and/or exclusion from the program. If you have any questions about this notice, please contact this office. 11/5/2007
M75 Multiple automated multichannel tests performed on the same day combined for payment. 11/5/2007
M112 Reimbursement for this item is based on the single payment amount required under the DMEPOS Competitive Bidding Program for the area where the patient resides. 11/5/2007
M113 Our records indicate that this patient began using this item/service prior to the current contract period for the DMEPOS Competitive Bidding Program. 11/5/2007
M114 This service was processed in accordance with rules and guidelines under the DMEPOS Competitive Bidding Program or a Demonstration Project. For more information regarding these projects, contact your local contractor. 11/5/2007
M115 This item is denied when provided to this patient by a non-contract or non-demonstration supplier. 11/5/2007
N70 Consolidated billing and payment applies. 11/5/2007
N367 Alert: The claim information has been forwarded to a Consumer Account Fund processor for review. 11/5/2007
N377 Payment based on a processed replacement claim. 11/5/2007
N385 Notification of admission was not timely according to published plan procedures. 11/5/2007

New Claim Adjustment Reason Codes

Code Modified Narrative Modification Date
212 Administrative surcharges are not covered Start: 11/05/2007 11/05/2007

Modified Claim Adjustment Reason Codes

Code Modified Narrative Implementation Date
121 Indemnification adjustment - compensation for outstanding member responsibility. Start: 01/01/1995 | Last Modified: 09/30/2007 4/1/2008
192 Non standard adjustment code from paper remittance. Note: This code is to be used by providers/payers providing Coordination of Benefits information to another payer in the 837 transaction only. This code is only used when the non-standard code cannot be reasonably mapped to an existing Claims Adjustment Reason Code, specifically Deductible, Coinsurance and Co-payment. Start: 10/31/2005 | Last Modified: 09/30/2007 4/1/2008
206 National Provider Identifier - missing. Start: 07/09/2007 | Last Modified: 09/30/2007 4/1/2008
207 National Provider identifier - Invalid format Start: 07/09/2007 | Stop: 05/23/2008 | Last Modified: 09/30/2007 4/1/2008
208 National Provider Identifier - Not matched. Start: 07/09/2007 | Last Modified: 09/30/2007 4/1/2008
15 The authorization number is missing, invalid, or does not apply to the billed services or provider. Start: 01/01/1995 | Last Modified: 09/30/2007 4/1/2008
17 Requested information was not provided or was insufficient/incomplete. At least one Remark Code must be provided (may be comprised of either the Remittance Advice Remark Code or NCPDP Reject Reason Code.) Start: 01/01/1995 | Last Modified: 09/30/2007 4/1/2008
19 This is a work-related injury/illness and thus the liability of the Worker's Compensation Carrier. Start: 01/01/1995 | Last Modified: 09/30/2007 4/1/2008
20 This injury/illness is covered by the liability carrier. Start: 01/01/1995 | Last Modified: 09/30/2007 4/1/2008
21 This injury/illness is the liability of the no-fault carrier. Start: 01/01/1995 | Last Modified: 09/30/2007 4/1/2008
22 This care may be covered by another payer per coordination of benefits. Start: 01/01/1995 | Last Modified: 09/30/2007 4/1/2008
23 The impact of prior payer(s) adjudication including payments and/or adjustments. Start: 01/01/1995 | Last Modified: 09/30/2007 4/1/2008
24 Charges are covered under a capitation agreement/managed care plan. Start: 01/01/1995 | Last Modified: 09/30/2007 4/1/2008
31 Patient cannot be identified as our insured. Start: 01/01/1995 | Last Modified: 09/30/2007 4/1/2008
33 Insured has no dependent coverage. Start: 01/01/1995 | Last Modified: 09/30/2007 4/1/2008
34 Insured has no coverage for newborns. Start: 01/01/1995 | Last Modified: 09/30/2007 4/1/2008
55 Procedure/treatment is deemed experimental/investigational by the payer. Start: 01/01/1995 | Last Modified: 09/30/2007 4/1/2008
56 Procedure/treatment has not been deemed `proven to be effective' by the payer. Start: 01/01/1995 | Last Modified: 09/30/2007 4/1/2008
58 Treatment was deemed by the payer to have been rendered in an inappropriate or invalid place of service. Start: 01/01/1995 | Last Modified: 09/30/2007 4/1/2008
59 Processed based on multiple or concurrent procedure rules. (For example multiple surgery or diagnostic imaging, concurrent anesthesia.) Start: 01/01/1995 | Last Modified: 09/30/2007 4/1/2008
61 Penalty for failure to obtain second surgical opinion. Start: 01/01/1995 | Last Modified: 09/30/2007 4/1/2008
95 Plan procedures not followed. Start: 01/01/1995 | Last Modified: 09/30/2007 4/1/2008
97 The benefit for this service is included in the payment/allowance for another service/procedure that has already been adjudicated. Start: 01/01/1995 | Last Modified: 09/30/2007 4/1/2008
107 The related or qualifying claim/service was not identified on this claim. Start: 01/01/1995 | Last Modified: 09/30/2007 4/1/2008
108 Rent/purchase guidelines were not met. Start: 01/01/1995 | Last Modified: 09/30/2007 4/1/2008
112 Service not furnished directly to the patient and/or not documented. Start: 01/01/1995 | Last Modified: 09/30/2007 4/1/2008
115 Procedure postponed, canceled, or delayed. Start: 01/01/1995 | Last Modified: 09/30/2007 4/1/2008
116 The advance indemnification notice signed by the patient did not comply with requirements. Start: 01/01/1995 | Last Modified: 09/30/2007 4/1/2008
117 Transportation is only covered to the closest facility that can provide the necessary care. Start: 01/01/1995 | Last Modified: 09/30/2007 4/1/2008
118 ESRD network support adjustment. Start: 01/01/1995 | Last Modified: 09/30/2007 4/1/2008
125 Submission/billing error(s). At least one Remark Code must be provided (may be comprised of either the Remittance Advice Remark Code or NCPDP Reject Reason Code.) Start: 01/01/1995 | Last Modified: 09/30/2007 4/1/2008
129 Prior processing information appears incorrect. Start: 02/28/1997 | Last Modified: 09/30/2007 4/1/2008
135 Interim bills cannot be processed. Start: 10/31/1998 | Last Modified: 09/30/2007 4/1/2008
136 Failure to follow prior payerÕs coverage rules. (Use Group Code OA). Start: 10/31/1998 | Last Modified: 09/30/2007 4/1/2008
137 Regulatory Surcharges, Assessments, Allowances or Health Related Taxes. Start: 02/28/1999 | Last Modified: 09/30/2007 4/1/2008
138 Appeal procedures not followed or time limits not met. Start: 06/30/1999 | Last Modified: 09/30/2007 4/1/2008
141 Claim spans eligible and ineligible periods of coverage. Start: 06/30/1999 | Last Modified: 09/30/2007 4/1/2008
142 Monthly Medicaid patient liability amount. Start: 06/30/2000 | Last Modified: 09/30/2007 4/1/2008
146 Diagnosis was invalid for the date(s) of service reported. Start: 06/30/2002 | Last Modified: 09/30/2007 4/1/2008
148 Information from another provider was not provided or was insufficient/incomplete. Start: 06/30/2002 | Last Modified: 09/30/2007 4/1/2008
150 Payer deems the information submitted does not support this level of service. Start: 10/31/2002 | Last Modified: 09/30/2007 4/1/2008
151 Payer deems the information submitted does not support this many services. Start: 10/31/2002 | Last Modified: 09/30/2007 4/1/2008
152 Payer deems the information submitted does not support this length of service. Start: 10/31/2002 | Last Modified: 09/30/2007 4/1/2008
153 Payer deems the information submitted does not support this dosage. Start: 10/31/2002 | Last Modified: 09/30/2007 4/1/2008
154 Payer deems the information submitted does not support this day's supply. Start: 10/31/2002 | Last Modified: 09/30/2007 4/1/2008
155 Patient refused the service/procedure. Start: 06/30/2003 | Last Modified: 09/30/2007 4/1/2008
157 Service/procedure was provided as a result of an act of war. Start: 09/30/2003 | Last Modified: 09/30/2007 4/1/2008
158 Service/procedure was provided outside of the United States. Start: 09/30/2003 | Last Modified: 09/30/2007 4/1/2008
159 Service/procedure was provided as a result of terrorism. Start: 09/30/2003 | Last Modified: 09/30/2007 4/1/2008
160 Injury/illness was the result of an activity that is a benefit exclusion. Start: 09/30/2003 | Last Modified: 09/30/2007 4/1/2008
163 Attachment referenced on the claim was not received. Start: 06/30/2004 | Last Modified: 09/30/2007 4/1/2008
164 Attachment referenced on the claim was not received in a timely fashion. Start: 06/30/2004 | Last Modified: 09/30/2007 4/1/2008
165 Referral absent or exceeded. Start: 10/31/2004 | Last Modified: 09/30/2007 4/1/2008
168 Service(s) have been considered under the patient's medical plan. Benefits are not available under this dental plan. Start: 06/30/2005 | Last Modified: 09/30/2007 4/1/2008
169 Alternate benefit has been provided. Start: 06/30/2005 | Last Modified: 09/30/2007 4/1/2008
173 Service was not prescribed by a physician. Start: 06/30/2005 | Last Modified: 09/30/2007 4/1/2008
174 Service was not prescribed prior to delivery. Start: 06/30/2005 | Last Modified: 09/30/2007 4/1/2008
175 Prescription is incomplete. Start: 06/30/2005 | Last Modified: 09/30/2007 4/1/2008
176 Prescription is not current. Start: 06/30/2005 | Last Modified: 09/30/2007 4/1/2008
177 Patient has not met the required eligibility requirements. Start: 06/30/2005 | Last Modified: 09/30/2007 4/1/2008
178 Patient has not met the required spend down requirements. Start: 06/30/2005 | Last Modified: 09/30/2007 4/1/2008
179 Patient has not met the required waiting requirements. Start: 06/30/2005 | Last Modified: 09/30/2007 4/1/2008
180 Patient has not met the required residency requirements. Start: 06/30/2005 | Last Modified: 09/30/2007 4/1/2008
181 Procedure code was invalid on the date of service. Start: 06/30/2005 | Last Modified: 09/30/2007 4/1/2008
182 Procedure modifier was invalid on the date of service. Start: 06/30/2005 | Last Modified: 09/30/2007 4/1/2008
186 Level of care change adjustment. Start: 06/30/2005 | Last Modified: 09/30/2007 4/1/2008
191 Not a work related injury/illness and thus not the liability of the workersÕ compensation carrier. Start: 10/31/2005 | Last Modified: 09/30/2007 4/1/2008
194 Anesthesia performed by the operating physician, the assistant surgeon or the attending physician. Start: 02/28/2006 | Last Modified: 09/30/2007 4/1/2008
195 Refund issued to an erroneous priority payer for this claim/service. Start: 02/28/2006 | Last Modified: 09/30/2007 4/1/2008
197 Precertification/authorization/notification absent. Start: 10/31/2006 | Last Modified: 09/30/2007 4/1/2008
198 Precertification/authorization exceeded. Start: 10/31/2006 | Last Modified: 09/30/2007 4/1/2008
202 Precertification/authorization exceeded. Start: 10/31/2006 | Last Modified: 09/30/2007 4/1/2008
203 Discontinued or reduced service. Start: 02/28/2007 | Last Modified: 09/30/2007 4/1/2008
A8 Ungroupable DRG. Start: 01/01/1995 | Last Modified: 09/30/2007 4/1/2008
B5 Coverage/program guidelines were not met or were exceeded. Start: 01/01/1995 | Last Modified: 09/30/2007 4/1/2008
B8 Alternative services were available, and should have been utilized. Start: 01/01/1995 | Last Modified: 09/30/2007 4/1/2008
B9 Patient is enrolled in a Hospice. Start: 01/01/1995 | Last Modified: 09/30/2007 4/1/2008
B14 Only one visit or consultation per physician per day is covered. Start: 01/01/1995 | Last Modified: 09/30/2007 4/1/2008
B15 This service/procedure requires that a qualifying service/procedure be received and covered. The qualifying other service/procedure has not been received/adjudicated. Start: 01/01/1995 | Last Modified: 09/30/2007 4/1/2008
B16 `New Patient' qualifications were not met. Start: 01/01/1995 | Last Modified: 09/30/2007 4/1/2008
B18 This procedure code and modifier were invalid on the date of service. Start: 01/01/1995 | Last Modified: 09/30/2007 4/1/2008
B20 Procedure/service was partially or fully furnished by another provider. Start: 01/01/1995 | Last Modified: 09/30/2007 4/1/2008
B23 Procedure billed is not authorized per your Clinical Laboratory Improvement Amendment (CLIA) proficiency test. Start: 01/01/1995 | Last Modified: 09/30/2007 4/1/2008

Deactivated Claim Adjustment Reason Codes

Code Modified Narrative Implementation Date
25 Payment denied. Your Stop loss deductible has not been met. Start: 01/01/1995 | Stop: 04/01/2008 4/1/2008
126 Deductible -- Major Medical Start: 02/28/1997 | Stop: 04/01/2008 | Last Modified: 09/30/2007 Notes: Use Group Code PR and code 1. 4/1/2008
127 Coinsurance -- Major Medical Start: 02/28/1997 | Stop: 04/01/2008 | Last Modified: 09/30/2007 Notes: Use Group Code PR and code 2. 4/1/2008
145 Premium payment withholding Start: 06/30/2002 | Stop: 04/01/2008 | Last Modified: 09/30/2007 Notes: Use Group Code CO and code 45. 4/1/2008
A4 Medicare Claim PPS Capital Day Outlier Amount. Start: 01/01/1995 | Stop: 04/01/2008 | Last Modified: 09/30/2007 4/1/2008

SOURCE: Source
INDUSTRY NEWS TAGS: California Medi-Cal


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