Post on 23-Aug-2018
SEPTEMBER 2017 MEETING PITTSBURGH PA | SUNDAY | SEPTEMBER 24 2017
SEPTEMBER 24, 2017 1
September 2017 Meeting Announcement
The September 2017 Code Maintenance Committee meeting will be held in
Pittsburgh, PA on Sunday, September 24 at The Westin Convention Center.
This is the same hotel where the ASC X12 Standing Meeting is held. Please
see http://www.x12.org for meeting information.
The Code Committee meets from 1:00 pm until 3:30 pm - usually in the same
room as the Medicare Caucus. To request a new code, change or deletion, use
the Request Form. Post to the September 2017 Agenda entry to reflect your
topics for discussion, or reply to individual posting when new codes are listed.
The agenda for the meeting will close on Friday, August 25, 2017. A virtual
preliminary screening meeting will be scheduled to review requests. That
meeting will be announced via the "Meeting Announcements" Online
Conference. No voting will be held on that session, but requests will be
screened to determine if additional outreach is needed. This timing permits
groups to conduct conference calls prior to the Code Maintenance Committee
meeting.
Each October the committee will hold elections for the Chair and Vice-Chair
position of the committee. In the even year (e.g. 2016, 2018) the Vice-Chair
position election is held. In the odd year (2017, 2019) the Chair position
election is held.
Old Business
Tabled items from June 2017
8
Claim Status Code Set Updates
Name: Mike Denison
Company: Change Healthcare
Phone: 615-932-3382
Email: MDenison@ChangeHealthcare
Request Type: Revision
List Name Health Care Claim Status
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SEPTEMBER 24, 2017 2
Value: Description Field
Description: There are several (consistent) modifications within the March 2017
Claim Status table update Description field that outline the required
"Usage:" of an entity code when utilizing certain status codes.
For example from the March published Status.csv file update: Current
description (message) as outlined in the published March 2017
Description field (which I believe is in error):
Status code 16
Description Field Claim/encounter has been forwarded to entity.
Note: This code requires use of an Entity Code. This change effective
September 1, 2017: Claim/encounter has been forwarded to entity.
Usage This code requires use of an Entity Code.
I believe the intent of the workgroup was to modify effective Sept. 1,
2017 as simply: Status code 16
Description Field Claim/encounter has been forwarded to entity.
Usage: This code requires use of an Entity Code. With the only
intended change being the modification of the word "Note" to "Usage".
There are 133 modifications similar to the above in the published
March update.
As often the contents of the Description field are
communicated/presented verbatim within provider facing solutions, the
descriptive "message" associated with the code will go from a simple
message to a duplicative, wordy, confusing, and time bound message
losing value and effectiveness.
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SEPTEMBER 24, 2017 3
Explanation: If the desire is to communicate advance notice of an upcoming Claim
Status change (which is great), it would be more appropriate to
communicate in the Note field similar to: March publication:
Code 16
Description Claim/encounter has been forwarded to entity. Note:
This code requires use of an Entity Code.
Effective Date 1/1/1995
Deactivation Date
Last Modified Date 3/1/2017
Note Description change effective September 1, 2017: Claim/encounter
has been forwarded to entity. Usage: This code requires use of an
Entity Code.
September publication:
Code 16
Description Claim/encounter has been forwarded to entity. Usage:
This code requires use of an Entity Code.
Effective Date 1/1/1995
Deactivation Date
Last Modified Date 9/1/2017
Note Description change effective September 1, 2017: Claim/encounter
has been forwarded to entity. Usage: This code requires use of an
Entity Code.
Commenter:
Comment:
Motioner:
Seconder:
SEPTEMBER 2017 MEETING PITTSBURGH PA | SUNDAY | SEPTEMBER 24 2017
SEPTEMBER 24, 2017 4
Discussion Pre-Meeting May 15, 2017
Mike – shouldn’t it be in the note column instead of the description
column.
Merri-Lee – that is the process
Deb – this hasn’t changed in 20 years.
Mike – seems ridiculous how it is published.
Pete – what if we used the effective date and deactive date separately.
Mike thinks that would be a good idea.
Deb – we have to be careful, the entire industry has been doing this for
20 years with no problems.
Mike – he thinks that the industry has been tolerant and adapted to the
bad way it has been done. It seems ridiculous.
Margaret – Deb has a point. Anything we do to change how it is done
today will be impacting the entire industry.
Mike – these descriptions do change but when the change is dramatic
and the description goes to a duplicative description with repetitive
wording
June 4, 2017 Standing Meeting
Deb McCachern – issue arrived out of the March publishing of the
codes. Since the only change was from note to usage putting this in
the description field, it was confusing to providers. They received
questions from providers. The request is to not put this in the
description field, but in the Note field.
Discussion:
Pete – agree that there is a problem with the veracity. It would be good
to have two entries for the code.
Gail – concerned that this is an underlying data base issue and we
can’t discuss that here. She doesn’t think we can take action. It needs
to go to the publisher.
Margaret – the publisher is aware of this request. As mentioned in the
pre-meeting this will be a system change to everyone.
Does it stay as is or do we look for some alternative. Question, do we
want to make a change or not.
Pat W. – she believes it would be good to take a look to see if there is
a different way it could be done. She will be glad to assist in the work.
Volunteers – Pat, Deb McCachern, Pete, Deb S. Tina, Sam
Doreen – if a practice management vendor displays only part, does not
provide entire description. It is really up to the entity that displays the
data. Is this a good use of our time?
Pat W.- need to keep in mind CAQH CORE looks at this code list so
we will need to coordinate with them.
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SEPTEMBER 24, 2017 5
Qu
VOTE RESULTS - NUMBER OF: YES_______ NO ____ ABSTAIN____
Passed:
Failed:
Tabled: X
Assigned Code:
Definition:
10
New code for coinsurance
Name: Meg Kutz
Company: Anthem, Inc
Phone: 518 817 7724
Email: margaret.Kutz@anthem.com
Request Type: New
List Name Health Care Claim Status
Value:
Description: Coinsurance Status Code
Explanation: there are two other similar codes 98 and 753 for cost share. One for
deductible and the other for Co-pay but there is not a status for
Coinsurance. For consistence and to promote clarity on the 277 please
create a new code for coinsurance.
Commenter:
Comment:
Motioner:
Seconder:
SEPTEMBER 2017 MEETING PITTSBURGH PA | SUNDAY | SEPTEMBER 24 2017
SEPTEMBER 24, 2017 6
Discussion Pre-Meeting May 15, 2017
Meg – nothing out there for co-insurance.
Margaret – comments? None
June 4 ,2017 Standing Meeting
Durwin– motion to approve
Karen S. – second
Karen S – WG5 agrees but believes it should be amended to “charges
apply to co-insurance” Betsy – does not believe that makes sense.
Sam – the entire claim would be all charges to apply to the deductible.
Wouldn’t this be the status as paid? Meg – she doesn’t know.
Suggests that this should be tabled until we can obtain the answer.
Durwin makes motion to table request. Karen seconds
Motion made by Durwin to table. Karen Second
NUMBER OF: YES 15 NO 0 ABSTAIN 0
Motion carries.
Pre-Meeting August 31, 2017
Meg – withdraws
September 24, 2017
Margaret – Meg confirmed that it is withdrawn.
Qu
VOTE RESULTS - NUMBER OF: YES____ NO __ ABSTAIN___
Passed:
Failed:
Tabled: WITHDRAWN
Assigned Code:
Definition:
New Business
New items since the last meeting.
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SEPTEMBER 24, 2017 7
Chair Election
Margaret Weiker – was originally elected to finish out Merri-Lee
Stine’s postion. Elections are as follows; odd years Chair and
even years Vice Chair. At this time there has been no changes
to the process. There could be changes once the ECO process
is incorporated.
Laurie Burckhardt – Nominates to re-elect Margaret Weiker.
Sherry Wilson – Seconded.
Merri-Lee Stine– Motion to close nominations.
Gail Kocher– Seconded.
Discussion: MaryKay McDaniel - can you technically run as
representative for NCPDP and chair? Margaret – according to the
MOU between NCPDP and X12, not allowed to hold leadership
positions. Before it was ok since this committee is not part of
X12. MaryKay – and it is still not. Margaret – if it goes forward,
we will address at that time.
Closing nominations – approve 16 opposed 0 abstain 0
Merri-Lee – Makes motion to elect Margaret by unanimous
consent.
Gail – Seconded.
Approve 15 opposed 0 abstain –
Motion carries.
1
would like to see new code for hearing aids
Name: Donna Reynolds
Company: Dr. Stephanie Herrera
Phone: 979-299-1520
Email: officemanager@lakejacksonent.com
Request Type: New
List Name Health Care Service Type
Value:
Description: Hearing Aids
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SEPTEMBER 24, 2017 8
Explanation: These are not included under DME - need new category
Commenter:
Comment:
Motioner:
Seconder:
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SEPTEMBER 24, 2017 9
Discussion Pre-Meeting August 31, 2017
WG1 – Bruce – for hearing aids, what is needed? Are they asking for a
service type?
Gail – hearing aid would not be a service type, it is a supply.
Merri-Lee – could request a service type code for
Traditionally broken out for carriers. They could ask specifically for
hearing aid and they could return that benefit.
Bruce – as a pre-cert or a referral. Could use as a service type for the
278 as well. He was looking for some more description.
Gail – why are we getting this now? If there is a gap today, why hasn’t
this come forward before now and by many others.
Merri-Lee – there is a gap now.
Gail – would expect there to be more context around this from a payer.
She is not having plans come to her and saying they can’t do this. The
description as it stands is not for a service type.
Gail – can you describe this better?
Merri-Lee – in an eligibility transaction makes sense to her.
Bruce – the request is not clear on what they are looking for.
Margaret – will send email to submitter and ask for further description
and what type of inquiry is it?
Email Response from Submitter:
We are an otolaryngologist office and we have 2 audiologists who sell
and service hearing aids. We are getting the audiologists credentialed
and on our insurance contracts so that we can file insurance for
hearing aids. I've discovered, as I verify benefits or request pre-
determination for them, there is not ANSI code for hearing aids. There
is no way to verify benefits for them through any insurance company
online portal due to this. I also cannot go through the automated benefit
verification process since hearing aids are not classified separately.
Therefore, I must wait to speak to a representative to verify benefits
properly. This is quite time consuming.
Thank you for your consideration.
September 24, 2017
Margaret emailed the submitter to get additional information. The
agenda has been posted and the email is in the agenda.
Discussion:
Gail – still doesn’t make sense. The request talks about credentialing
and then eligibility.
Margaret – they are credentialed. They get them in the plan but when
she does eligibility benefits for hearing aids, there is not a code to
convey.
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Qu
VOTE RESULTS - NUMBER OF: YES__12__ NO _1_ ABSTAIN__1_
Passed: X – request is denied
Failed:
Tabled:
Assigned Code:
Definition:
2
New Status Code
Name: Cindy Bigenwalt
Company: Blue Cross and Blue Shield of Kansas
Phone: 785-291-8757
Email: Cindy.Bigenwalt@bcbsks.com
Request Type: New
List Name Health Care Claim Status
Value:
Description: Procedure code and diagnosis code are not compatible
Explanation: When the procedure code and diagnosis are not compatible, we are unable to
complete the processing of the claim.
Commenter:
Comment:
Motioner:
Seconder:
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SEPTEMBER 24, 2017 11
Discussion Pre-Meeting August 31, 2017
Cindy – she is not sure she meant to send this request. It looks like it
was answered on the 26th and recommendations were given of what
could be used. She doesn’t recall sending a follow-up.
Margaret – there are two requests
Gail – what does she mean by someone responded? Cindy – noticed
that there was a comment from the RARC committee.
Merri-Lee – that is a different request. That was the RARC committee,
not this committee.
Margaret – what you read sounds like a response from the RARC
committee
Cindy – she guesses that they did submit a request for this committee.
Karen – looking at codes and if you are talking about 277
acknowledgements and front-end editing, you can use 254 with 454. If
talking 276/277 use 488 status code - pointing to the procedure code
you sent is not compatible with the diagnosis. They don’t have the
words “compatible” but those codes will work.
Karen – you can use multiple status codes so you could use a
combination that will convey the message. If you as a company are
only giving one, that could be causing issues. Maybe you should look
at your company’s process and see if codes need to be added for the
complete message.
Karen – it depends on which transaction you are talking about. You
are letting the claim come in and process, wouldn’t it go out on the
835? If that is the case, it wouldn’t be a status code.
Cindy – her company will give it a try.
Karen – if you are rejecting from the 835 that is one set of codes, if it is
before adjudication it would be status codes.
September 24, 2017
Withdrawn per email from Cindy Bigenwalt dated Sept. 21, 2017.
VOTE RESULTS - NUMBER OF: YES_______ NO ____ ABSTAIN____
Passed:
Failed:
Tabled: WITHDRAWN
Assigned Code:
Definition:
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SEPTEMBER 24, 2017 12
3
add entity required to status code
Name: Kena H. Gwinn
Company: Anthem
Phone: 804.339.9317
Email: kena.gwinn@anthem.com
Request Type: Revision
List Name Health Care Claim Status
Value: 403
Description: Entity referral notes/orders/prescription
Explanation: note needs added that entity code is required when sending this
status code
Commenter:
Comment:
Motioner:
Seconder:
Discussion Pre-Meeting August 31, 2017
Karen – she hasn’t gone over this with the wg yet, but she is thinking it
will be approved. This code is needed.
Sept 2017
Margaret – did group meet and what did they decide?
Karen – wg agreed that they should have and makes motion to approve
Laurie – seconded
Approved – 14 opposed 0 abstain 1
Effective date: Laurie –
Merri-Lee – new codes were effective upon publication. Modified codes was 6
months.
Pat – 6 months after publication
VOTE RESULTS - NUMBER OF: YES_______ NO ____ ABSTAIN____
Passed: X – approved – effective 6 months after publication
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SEPTEMBER 24, 2017 13
Failed:
Tabled:
Assigned Code: 403
Definition: Entity referral notes/orders/prescription. Usage: This code requires use
of an entity.
4
Code List Change Request Form
Name: Harvey Mintz
Company: CSRA
Phone: (518)257-4844
Email: harvey.mintz@csra.com
Request Type: Revision
List Name Claim Adjustment Reason Code
Value: 16
Description: Change Definition to:
Claim/service has submission/billing error(s) or lacks information which is
needed for adjudication. 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.
Or:
Claim/service lacks information has which is needed for adjudication 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.
Explanation: The problem with the current definition of CARC 16 is the clause "errors which
is needed", for two reasons; because it is "information", not "errors" that
adjudication requires, and because of > the plural-singular conflict.
Commenter:
Comment:
Motioner:
Seconder:
SEPTEMBER 2017 MEETING PITTSBURGH PA | SUNDAY | SEPTEMBER 24 2017
SEPTEMBER 24, 2017 14
Discussion Pre-Meeting August 31, 2017
Pat W. – WG3 reviewed and they are in agreement with it. They will
suggest a small wording change, but they will move this forward.
Gail – can we have the proposed wording?
Pat – “Claim/service lacks information or has submission/billing
error(s)”
Karen – Can we say – “Claim/Service lacks information which is
needed for adjudication”
Pat W. – will take that back to the WG and have a response in Sept.
September 24, 2017
Pat – makes motion to approve with a variation in description on first
16 Claim/Service has submission(s)/ or lacks information.
Seconded – Sherry Wilson
Discussion – none
Approve 16 opposed 0 abstain 0
Pat – makes motion to make effective immediately
Seconded – Sherry Wilson
Discussion:
Pat – it isn’t substantive it is just clean up.
Merri-Lee – disagrees because databases have to update.
Gail – making it effective immediately is so we can have it now
otherwise we are pushing something off that needs to be done.
Laurie – is a little concerned with making it immediate because they
have to have the language on the EOB in WI and it makes it a tight
line.
Gail – lets do 3 months, just seems ridiculous to hold off for 6 months
when it should be just a change in a table.
Gail – requests that motion be modified to make effective 3 months
after publication.
Pat – her thought was making it effective in 3 months.
Effective Feb. 1, 2018.
Donna – can we put together a table that shows the publication dates
and possible effective dates? Margaret has taken as an action item.
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SEPTEMBER 24, 2017 15
VOTE RESULTS - NUMBER OF: YES_12_ NO _1_ ABSTAIN_1_
Passed: X – effective 3 months after publication (February 1, 2018)
Failed:
Tabled:
Assigned Code: Revise 16
Definition: Claim/service has submission/billing error(s) or lacks information. 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.
5
Code List Change Request Form
Name: Harvey Mintz
Company: CSRA
Phone: (518)257-4844
Email: harvey.mintz@csra.com
Request Type: Revision
List Name Claim Adjustment Reason Code
Value: B12
Description: Change definition from "Services not documented in patients' medical
records." to "Services not documented in patient's medical records."
Explanation: Correct plural to singular.
Commenter:
Comment:
Motioner:
Seconder:
SEPTEMBER 2017 MEETING PITTSBURGH PA | SUNDAY | SEPTEMBER 24 2017
SEPTEMBER 24, 2017 16
Discussion Pre-Meeting August 31, 2017
Pat W. – this is just changing to “patient’s”. 835 WG agrees.
September 24, 2017
Margaret – read description of the request.
Pat – makes motion to approve revised wording as submitted
LuAnn – seconded
Discussion: None
Approve 16 opposed 0 abstain 0
Pat – motion to make effective immediately
Sherry – seconded
Discussion:
Gail – isn’t it the same discussion we just had. If we are doing non-
substantive on this one too, we should just say these are effective 3
months after publication date.
No objections to amending motion
VOTE RESULTS - NUMBER OF: YES__16__ NO _0__ ABSTAIN_1__
Passed: X – effective 3 months from publication (February 1, 2018)
Failed:
Tabled:
Assigned Code: Revise B12
Definition: Services not documented in patient's medical records.
6
Code to show a PR of Spenddown
Name: Vicky Pierce
Company: Utah State Medicaid
Phone: 801-884-3902
Email: vickypierce@utah.gov
Request Type: New
List Name Claim Adjustment Reason Code
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SEPTEMBER 24, 2017 17
Value:
Description: Spenddown Amount
Explanation: New CARC for Spenddown Amount. Medicaid makes the patient responsible
for a portion of a claim when a claim is used to meet their Spenddown. This is
different than a Copay, Coinsurance or Deductible. Need new value to report
PR of Spenddown.
Commenter:
Comment:
Motioner:
Seconder:
Discussion Pre-Meeting August 31, 2017
Pat W. – there was a lot of conversation about this in the 835 WG call.
There was not enough Medicaid experience on the call. There were a
number of people that were going to reach out and see if they can get
more information on it. Hoping that Vickie could help out with how UT
handles it. They know there is a CARC 178, but they feel this could be
a little different.
Gail – spenddown is a little different for Medicaid
September 24, 2017
Pat – discussed in WG3 would like to table to next meeting – motion
made
Gail – seconded
Discussion:
Sue – the code committee of the NMEH is inactive.
VOTE RESULTS - NUMBER OF: YES__15__ NO _0_ ABSTAIN_1_
Passed:
Failed:
Tabled: X
Assigned Code:
Definition:
7
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SEPTEMBER 24, 2017 18
New Code for PR or Cost or Care
Name: Vicky Pierce
Company: Utah State Medicaid
Phone: 801-884-3902
Email: vickypierce@utah.gov
Request Type: New
List Name Claim Adjustment Reason Code
Value:
Description: Cost of Care Amount
Explanation: New CARC for Cost of Care Amount. Medicaid makes the patient responsible
for a portion of Nursing Home Charges in order for a member to be eligible for
Medicaid. This is also known as Patient Liability. This is different than a
Copay, Coinsurance or Deductible. Need new value to report PR of Cost of
Care. Currently it is being reported in Copay but is causing confusion for
providers as this amount is not a copay.
Commenter:
Comment:
Motioner:
Seconder:
Discussion Pre-Meeting August 31, 2017
Pat W. – same kind of issue. There is a CARC that could work. Still
need further information to adjudicate.
Margaret – she doesn’t think this is just for UT.
Gail – we need to loop in our committee Medicaid representative to
make sure we don’t do something for one state and it causes a
problem for others.
Laurie B. – agrees we really need someone with a strong Medicaid
background.
September 24, 2017
Pat – motion to deny. Discussed with Vicky and she agreed to use
code 162
Sherry – seconded
VOTE RESULTS - NUMBER OF: YES_15_ NO _0_ ABSTAIN_0_
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SEPTEMBER 24, 2017 19
Passed: X – Motion passed. Request denied.
Failed:
Tabled:
Assigned Code:
Definition:
8
New Status Code
Name: Cindy Bigenwalt
Company: Blue Cross and Blue Shield of Kansas
Phone: 785-291-8757
Email: Cindy.Bigenwalt@bcbsks.com
Request Type: New
List Name Health Care Claim Status
Value:
Description: Qualifier/date combination missing/incomplete/invalid for box 14/15
Explanation: Box 14 & 15 require a qualifier if a date is submitted and vice versa.
Commenter:
Comment:
Motioner:
Seconder:
SEPTEMBER 2017 MEETING PITTSBURGH PA | SUNDAY | SEPTEMBER 24 2017
SEPTEMBER 24, 2017 20
Discussion Pre-Meeting August 31, 2017
Cindy – it may not need to be this specific. Box 14 and 15 has the new
qualifier codes. They are seeing providers sending qualifiers and no
date or date and no codes.
Gail – this sounds like you are rejecting a claim because of this and if
that is the case a CARC would be the appropriate code to use.
Pat – they will circle back. Off the top of her head, she doesn’t know
what the 14 and 15 are.
Karen – from a status perspective there is a date for all status codes.
From this perspective you could reject because something is wrong
with this information.
Laurie – when she did the research on this she didn’t find a CARC.
She also wasn’t too clear about the business workflow so she couldn’t
go any further.
Gail – would like to talk with the State of Kansas to see if she, in
representing BCBS plans, can help Cindy. She would like to connect
with her offline and make sure we have all the information. There is 20
minutes left to get through the rest of the agenda.
September 24, 2017
Withdrawn per email from Cindy Bigenwalt dated Sept. 21, 2017.
VOTE RESULTS - NUMBER OF: YES_______ NO ____ ABSTAIN____
Passed:
Failed:
Tabled: WITHDRAWN
Assigned Code:
Definition:
9
Add CLIA reference to status code
Name: Karen Shutt
Company: Highmark
Phone: 717-302-4905
Email: karen.shutt@highmark.com
Request Type: Revision
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SEPTEMBER 24, 2017 21
List Name Health Care Claim Status
Value: 544
Description: Add the acronym CLIA and also Number to Status Code 544 for
synchronization with the 837 data element.
Clinical Laboratory Improvement Amendment (CLIA) Number
Explanation: For consistency with the 837 data element/REF name and also easier
identification within the status code list, code 544 should be updated to include
CLIA and Number in the description.
Commenter:
Comment:
Motioner:
Seconder:
Discussion Pre-Meeting August 31, 2017
Karen – wants to add “(CLIA)” and Number because that is what is in
the guide. If they don’t search for CLIA, they won’t find it.
September 24, 2017
Karen – makes motion to approve this request adding CLIA to the
description for easier searching.
Sue – seconded
Effective date: 3 months after publication date. None opposing
VOTE RESULTS - NUMBER OF: YES__14_ NO _0_ ABSTAIN_1_
Passed: X - effective 3 months after publication (February 1, 2018)
Failed:
Tabled:
Assigned Code: 544
Definition: Clinical Laboratory Improvement Amendment (CLIA) Number
10
New CARC for Attending physician
Name: Meg Kutz
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SEPTEMBER 24, 2017 22
Company: Anthem, Inc
Phone: 518 817 7724
Email: margaret.Kutz@anthem.com
Request Type: New
List Name Claim Adjustment Reason Code
Value:
Description: New CARC similar to Existing CARC's 183 and 184 but for Attending
Physician
Explanation: "Attending provider is not eligible to provide direction of care"
Commenter:
Comment:
Motioner:
Seconder:
Discussion Pre-Meeting August 31, 2017
Pat – WG3 thought it made sense to add. Appeared to be a gap.
Gail – is it the same verbiage format as the other?
Pat – we will make sure that it is.
September 24, 2017
Pat – makes motion to approve for new code as submitted
Seconded – Crystal
Discussion: None
Effective Date: immediately upon publication
VOTE RESULTS - NUMBER OF: YES_13_ NO _0_ ABSTAIN_0_
Passed: X
Failed:
Tabled:
Assigned Code: 283
Definition: Attending provider is not eligible to provide direction of care
11
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SEPTEMBER 24, 2017 23
Add a code to indicte a Pended Precert Request is in process of being
reviewed. Primarily to be utilized by the Precert Inquiry Transaction
response (X215)
Name: Janice Bakos
Company: WEDI Prior Auth WorkGroup
Phone: 570 775-0229
Email: bakosja@aetna.com
Request Type: New
List Name Health Care Services Review Decision Reason
Value:
Description: Utilization Review currently in progress
Explanation: Providers wish to know their Pended request is actively being reviewed.
Commenter:
Comment:
Motioner:
Seconder:
Discussion Pre-Meeting August 31, 2017
Janice – would like to withdraw this one. They have submitted two
other specific codes.
Margaret – we will pull
Request withdrawn.
VOTE RESULTS - NUMBER OF: YES_______ NO ____ ABSTAIN____
Passed:
Failed:
Tabled: WITHDRAWN
Assigned Code:
Definition:
12
New status code for same/similar procedure
SEPTEMBER 2017 MEETING PITTSBURGH PA | SUNDAY | SEPTEMBER 24 2017
SEPTEMBER 24, 2017 24
Name: Meg Kutz
Company: Anthem, Inc
Phone: 518 817 7724
Email: margaret.Kutz@anthem.com
Request Type: New
List Name Health Care Claim Status
Value:
Description: New status code "Same/similar service previously submitted for time
frame/session"
Explanation: There are no other status codes today that are applicable for this condition
where same or similar svs is billed within a set time frame not necessarily on
same date. (this status is similar to what would eventually go out on the 835
ERA as a denial under RARC M80 and M86. This is also NOT a duplicate
situation.
Commenter:
Comment:
Motioner:
Seconder:
SEPTEMBER 2017 MEETING PITTSBURGH PA | SUNDAY | SEPTEMBER 24 2017
SEPTEMBER 24, 2017 25
Discussion Pre-Meeting August 31, 2017
Karen – she has not run it by the WG, but she didn’t see a problem.
She will present to the WG.
September 24, 2017
Karen – WG5 generally agreed on it but was not sure on the verbiage.
Karen – makes motion to approve request with modified language.
Laurie – Seconded
Discussion:
Karen – preferred language – take out the word “same” in the original
request.
Meg – the only thing she is concerned about with the word same, you
could have the same service within the same set timeframe. This is
not for duplicates. She looked at RARCs and there are
Gail – the way Meg just explained the situation is the verbiage we
should use. Can we just say you cannot do this twice in one
timeframe? Only one same/similar service can be submitted for the
same timeframe/session
Pete – “submitted service is similar to a service previously submitted
for this timeframe.”
Gigi – shouldn’t the word “same” be in there?
Donna – the key is that this is in the same timeframe.
Gail – issue is that similar does not mean exact. Can be same service
and submitted on day 2 and 3 but it is only allowed to be submitted
within 5 day period. It is more about a specified timeframe.
Verbiage now; “submitted service is similar/same to a service
previously submitted for this timeframe.”
Meg - recommends “Service submitted for the same/similar service
within a set timeframe.”
Nancy – is good with Meg’s recommendation
Effective immediately.
VOTE RESULTS - NUMBER OF: YES_15__ NO _0_ ABSTAIN_0_
Passed: X
Failed:
SEPTEMBER 2017 MEETING PITTSBURGH PA | SUNDAY | SEPTEMBER 24 2017
SEPTEMBER 24, 2017 26
Tabled:
Assigned Code: 779
Definition: Service submitted for the same/similar service within a set
timeframe.
13
new code for lifetime max
Name: Meg Kutz
Company: Anthem, Inc
Phone: 518 817 7724
Email: margaret.Kutz@anthem.com
Request Type: New
List Name Health Care Claim Status
Value:
Description: New status for lifetime max benefit has been met. "Lifetime benefit maximum"
Explanation: Currently only one code for benefit max (483) and no code for lifetime max.
They are two different denials. Sending 483 for lifetime max would not be
compliant or accurate. please approve new code for lifetime.
Commenter:
Comment:
Motioner:
Seconder:
SEPTEMBER 2017 MEETING PITTSBURGH PA | SUNDAY | SEPTEMBER 24 2017
SEPTEMBER 24, 2017 27
Discussion Pre-Meeting August 31, 2017
Meg – there is one for benefit but not lifetime max.
Karen – will need to work it with the WG. She thinks this is going down
the path of creating a status code for the same thing that is in a CARC.
Meg – they have struggled with this for years. Trying to reduce their
calls.
September 24, 2017
Karen – motion to approve request
Sherry – seconded
Discussion:
Gail – is the motion to approve exactly the way the request was
submitted?
Margaret – the request is to add “Lifetime Benefit Maximum”
Motion carries.
Effective immediately.
VOTE RESULTS - NUMBER OF: YES_15_ NO _0_ ABSTAIN_0_
Passed: X
Failed:
Tabled:
Assigned Code: 780
Definition: Lifetime Benefit Maximum
14
New status for readmission denial
Name: Meg Kutz
Company: Anthem, Inc
Phone: 518 817 7724
Email: margaret.Kutz@anthem.com
Request Type: New
List Name Health Care Claim Status
Value:
Description: new status code for denial "Claim has been identified as a readmission"
SEPTEMBER 2017 MEETING PITTSBURGH PA | SUNDAY | SEPTEMBER 24 2017
SEPTEMBER 24, 2017 28
Explanation: When claim received that is within 24 hours of discharge the claim must be
denied and provider must send an adjustment to the original admission. there
is not good status code to state denied for readmission. We are currently
using Status 735 right now but that is not an accurate code.
Commenter:
Comment:
Motioner:
Seconder:
Discussion Pre-Meeting August 31, 2017
Karen – WG has not talked about it yet.
September 24, 2017
Karen – makes motion to approve request.
Sherry – seconded
Discussion: None
Effective immediately.
VOTE RESULTS - NUMBER OF: YES_14_ NO _0_ ABSTAIN_1_
Passed: X
Failed:
Tabled:
Assigned Code: 781
Definition: Claim has been identified as a readmission
15
Revise CARC 5 description
Name: Patricia Wijtyk
Company: TMG Health
Phone: 6102029565
Email: pwijtyk@tmghealth.com
Request Type: Revision
List Name Claim Adjustment Reason Code
Value: 5
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SEPTEMBER 24, 2017 29
Description: The procedure code/type of bill is inconsistent with the place of service.
Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110
Service Payment Information REF), if present.
Explanation: Revise term: type of bill to be consistent
Commenter: Patricia Wijtyk
Comment: There are multiple ways to report a missing or exceeded authorization. Add a
note: To report missing authorization, use CARC 197 or CARC 16 and RARC
M62.
Motioner:
Seconder:
Discussion Pre-Meeting August 31, 2017
Pat – the comment belongs with the next entry. Because they are
deactivating the next one. Syncing up the wording of “bill type” across
the industry.
September 24 2017
Pat – makes motion to approve change to CARC 5 as submitted. “The
procedure code/type of bill is inconsistent with the place of service”
Gail – seconded
Motion carries – effective 3 months after publication
VOTE RESULTS - NUMBER OF: YES_14_ NO _0_ ABSTAIN_0_
Passed: X – effective 3 months after publication (February 1, 2018)
Failed:
Tabled:
Assigned Code: 5
Definition: The procedure code/type of bill is inconsistent with the place of
service. Usage: Refer to the 835 Healthcare Policy Identification
Segment (loop 2110 Service Payment Information REF), if present.
16
CARC 15 deactivate and add new
Name: Patricia Wijtyk
Company: TMG Health
SEPTEMBER 2017 MEETING PITTSBURGH PA | SUNDAY | SEPTEMBER 24 2017
SEPTEMBER 24, 2017 30
Phone: 6102029565
Email: pwijtyk@tmghealth.com
Request Type: Revision
List Name Claim Adjustment Reason Code
Value: 15 and new
Description: Deactivate CARC 15
Add 1 new codes:
Authorization number may be valid but does not apply to the billed services
Explanation: Update to older code
Commenter:
Comment:
Motioner:
Seconder:
Discussion Pre-Meeting August 31, 2017
Pat – this is part of the cleanup that WG3 has taken up. There are
many codes that overlap. Deactivate 15 and add the above to 5 so
that there is one code.
September 24, 2017
Pat – makes motion to approve
Sue – seconded
Discussion: None
Immediate effective date for the new and 6 months after publication for
the deactivated code.
Meg – thought that deactivated codes were 1 year after publication. It
allows you to update databases, etc.
Gail – it would be more complicated because there is an operating rule
impacted. It has to allow the new one to be effective and she believes
that 6 months gives it enough time for the operating rule also.
Pat – read the rules again and it says 6 months for deactivated codes.
“Authorization number may be valid but does not apply to the billed
services.”
SEPTEMBER 2017 MEETING PITTSBURGH PA | SUNDAY | SEPTEMBER 24 2017
SEPTEMBER 24, 2017 31
VOTE RESULTS - NUMBER OF: YES_16__ NO _0_ ABSTAIN_0_
Passed: X – code 284 effective immediately; deactivated code15 effective 6 months
after publication (May, 1, 2018)
Failed:
Tabled:
Assigned Code: 284
Definition: Authorization number may be valid but does not apply to the
billed services
17
Revise description for CARC32
Name: Patricia Wijtyk
Company: TMG Health
Phone: 6102029565
Email: pwijtyk@tmghealth.com
Request Type: Revision
List Name Claim Adjustment Reason Code
Value: 32
Description: Revise to: This dependent is not an eligible dependent.
Explanation: Update wording for older code
Commenter:
Comment:
Motioner:
Seconder:
SEPTEMBER 2017 MEETING PITTSBURGH PA | SUNDAY | SEPTEMBER 24 2017
SEPTEMBER 24, 2017 32
Discussion Pre-Meeting August 31, 2017
Pat – cleaning up wording
September 24, 2017
Pat – makes motion to approve as revised. This is very old.
Sue – seconded
Discussion:
Karen – why does it have to be changed?
Pat – just reviewing and trying to clean up codes, it caught their eye.
Doreen – talking about a patient, would it be better to say the patient is
not the dependent?
Karen – agrees.
New proposed language – the “The patient is not an eligible
dependent”
Gail – it could cause more issues when it is a record issue. Feels
should read “Our records indicate the patient is not an eligible
dependent”
Laurie – thinks maybe WG3 should take it back looking at the
definitions.
Motion carries to “Our records indicate the patient is not an eligible
dependent”
Effective 3 months after publication.
VOTE RESULTS - NUMBER OF: YES__10__ NO _3_ ABSTAIN_2_
Passed: X – effective 3 months after publication (February 1, 2018)
Failed:
Tabled:
Assigned Code: 32
Definition: Our records indicate the patient is not an eligible dependent
18
CARC 138
Name: Patricia Wijtyk
SEPTEMBER 2017 MEETING PITTSBURGH PA | SUNDAY | SEPTEMBER 24 2017
SEPTEMBER 24, 2017 33
Company: TMG Health
Phone: 6102029565
Email: pwijtyk@tmghealth.com
Request Type: Revision
List Name Claim Adjustment Reason Code
Value: 138 and new code
Description: Deactivate CARC 138
Add 2 new codes for:
Appeal procedures not followed - 285
and
Appeal time limits not met - 286
Explanation: Update to older code to help clarify the reason for the adjustment
Commenter:
Comment:
Motioner:
Seconder:
Discussion Pre-Meeting August 31, 2017
Pat – getting rid of 138 but split the description into 2 codes.
September 24, 2017
Pat – makes motion to approve deactivating 138 and replace with 2
new codes.
Sue – seconded
Discussion: None
Effective date of deactivated code 138 is 6 months (May 1, 2018).
New codes 285 & 286 effective immediately.
VOTE RESULTS - NUMBER OF: YES_14_ NO _0_ ABSTAIN_0_
Passed: X – deactivate 138 effective 6 months after publication (May 1, 2018)
Failed:
Tabled:
SEPTEMBER 2017 MEETING PITTSBURGH PA | SUNDAY | SEPTEMBER 24 2017
SEPTEMBER 24, 2017 34
Assigned Code: 285 and 286
Definition: 285 Appeal procedures not followed
286 Appeal time limits not met
19
CARC 139 description revision
Name: Patricia Wijtyk
Company: TMG Health
Phone: 6102029565
Email: pwijtyk@tmghealth.com
Request Type: Revision
List Name Claim Adjustment Reason Code
Value: 139
Description: Revise description to: Contracted funding agreement - Subscriber is employed
by the provider of services. Use only with Group Code CO.
Explanation: Adding the group code restriction will allow for better use of the code
Commenter:
Comment:
Motioner:
Seconder:
SEPTEMBER 2017 MEETING PITTSBURGH PA | SUNDAY | SEPTEMBER 24 2017
SEPTEMBER 24, 2017 35
Discussion Pre-Meeting August 31, 2017
Pat – adding “Use Group Code OA only”
September 24, 2017
Pat – makes motion to revise CARC 139
Sherry – seconded
Discussion:
Gail – does that mean the notes from the pre-meeting is incorrect?
“Use only with Group Code CO” Pre-meeting notes were incorrect with
OA
Effective 6 months from publication because it is substantive.
Discussion:
Meg – this actually changes the usage and should be 6 months
because adding a group code.
Gail – agrees with 6 months
Margaret – is anyone opposed with 6 months?
Mike – can the committee consider being effective June 1 for coding?
Effective date: 6 months from publication
VOTE RESULTS - NUMBER OF: YES_15_ NO _0_ ABSTAIN_0_
Passed: X – revision effective 6 months after publication (May 1, 2018)
Failed:
Tabled:
Assigned Code: Revise 139
Definition: Contracted funding agreement - Subscriber is employed by the provider
of services. Use only with Group Code CO
20
CARC 165
Name: Patricia Wijtyk
Company: TMG Health
Phone: 6102029565
SEPTEMBER 2017 MEETING PITTSBURGH PA | SUNDAY | SEPTEMBER 24 2017
SEPTEMBER 24, 2017 36
Email: pwijtyk@tmghealth.com
Request Type: Revision
List Name Claim Adjustment Reason Code
Value: 165
Description: Deactivate 165
Add 1 new:
Referral exceeded
Explanation: Update to older code
Commenter: Patricia Wijtyk
Comment: Add a note to CAR 165: To report a missing referral, use CARC 16 and
RARCs N475, N476, N489 or N490 as appropriate.
Motioner:
Seconder:
SEPTEMBER 2017 MEETING PITTSBURGH PA | SUNDAY | SEPTEMBER 24 2017
SEPTEMBER 24, 2017 37
Discussion Pre-Meeting August 31, 2017
Pat – same cleanup project.
Pat – when we say “add a note” we need to be careful because we
have a new attribute for notes. It is called Note, but not within the
description.
Karen – she thinks saying “in the notes section, add the following” is a
lot clearer. She feels we need to start making that distinction.
September 24, 2017
Pat – makes motion to deactivate 165. Add a note (other field) “To
report a missing referral, use CARC 16 and RARCs N475, N476, N489
or N490 as appropriate””
Sue – seconded
Discussion:
Donna – if it is deleted in a system, then there wouldn’t be a need for
the note.
Gail – if we are going to activate 165 why wouldn’t we create two new
codes instead of one and not to use 16 and add a bunch of RARCs.
Feels it will make it harder for the provider like it is.
Pat – there was a reason, it is all about missing information and how to
report it.
Gail – would like to know what the provider community says.
Pat – if we create a new CARC that says missing, direct them to 16
and the RARCs
Betsy – as a provider – looking at 16, it may not be that the claim is not
missing information but may be missing the referral.
Karen – recommends the note say CARC 16 or 250 to use.
Gail – that is the point it might not be an attachment. It may not be
something that was sent in with it.
Colleen from Aetna – the RARCs that are mentioned to use with 16 are
not in the CORE combinations.
Rachel – comment on the CORE code combinations. Just because
they are not in the combination now it does not mean that it won’t be
added when the work is published out of this meeting.
Gail – she understands what Rachel is saying but she does not feel
that X12 should post in our database until they are included.
Pete – starting to favor two new codes as well.
Doreen – the note about the RARCs is just instructional. Why can’t
that be used?
Margaret – the motion on the floor is to deactivate 165 and add notes
SEPTEMBER 2017 MEETING PITTSBURGH PA | SUNDAY | SEPTEMBER 24 2017
SEPTEMBER 24, 2017 38
VOTE RESULTS - NUMBER OF: YES__14__ NO _0_ ABSTAIN_0_
Passed: X – 165 deactivation effective 6 months after publication (May 1, 2018)
Failed:
Tabled:
Assigned Code: 287 and 288
Definition: 287
Referral Exceeded
288
Referral Absent
21
CARC 168
Name: Patricia Wijtyk
Company: TMG Health
Phone: 6102029565
Email: pwijtyk@tmghealth.com
Request Type: Revision
List Name Claim Adjustment Reason Code
Value: 168
Description: Deactivate 168,
Add new code:
Services considered under the dental and medical plans, benefits not
available.
Add to note section, not note in description: Also see See CARCs 254 and
270, 280
Explanation: This will fill the gap for the other codes
Commenter:
Comment:
Motioner:
Seconder:
SEPTEMBER 2017 MEETING PITTSBURGH PA | SUNDAY | SEPTEMBER 24 2017
SEPTEMBER 24, 2017 39
Discussion Pre-Meeting August 31, 2017
Pat – same cleanup project. In the way it is worded there were gaps
between the messages and this is trying to fill in some of those gaps.
September 24, 2017
Pat – makes motion to deactivate 168 and add a new code as
submitted with a note referring to the other codes.
Sue – seconded
Discussion: None
New code 289 effective immediately and deactivated 168 will be in 6
months after publication.
VOTE RESULTS - NUMBER OF: YES_12_ NO _0_ ABSTAIN_2_
Passed: X – 168 deactivation effective 6 months after publication (May 1, 2018)
Failed:
Tabled:
Assigned Code: 289
Definition: Services considered under the dental and medical plans, benefits
not available.
22
CARC 197, 198, new code
Name: Patricia Wijtyk
Company: TMG Health
Phone: 6102029565
Email: pwijtyk@tmghealth.com
Request Type: Revision
List Name Claim Adjustment Reason Code
Value: 197, 198
Description: Deactivate 97
Add new code for: Precertification/Notification/Authorization number may be
valid but does not apply to the billed services.
Change CARC 198 to: Precertification/authorization/notification exceeded
Explanation: To have consisten descritpon across precerts, autha and notifications
SEPTEMBER 2017 MEETING PITTSBURGH PA | SUNDAY | SEPTEMBER 24 2017
SEPTEMBER 24, 2017 40
Commenter:
Comment:
Motioner:
Seconder:
SEPTEMBER 2017 MEETING PITTSBURGH PA | SUNDAY | SEPTEMBER 24 2017
SEPTEMBER 24, 2017 41
Discussion Pre-Meeting August 31, 2017
Pat – same cleanup project.
September 24, 2017
Deactivate 197 (description above is incorrect) and modify 198
Pat – makes motion to deactivate 197, create a new code and modify
198 with new verbiage.
Sue – seconded
Discussion:
Laurie – on the description for 198
precertification/notification/authorization to be consistent with new code
request.
Pete – if 197 is deactivated it says that it is absent and we are not
replacing with anything that says absent, how are we accommodating
that? Gail same question.
Pat – have 15 says authorization 165 says referral. They found other
codes that had absent.
Gail – we just approved deactivating 15 so that is off the table. We
need to keep 197 and ok with changing 198.
Peggy – in dental they don’t use precertification or notification they use
prior authorization and pretreatment. Margaret – will be the equivalent
of a prior auth, right? Peggy – yes.
Kellene Parthemore – request #16 to create 284 says the same thing
as these requests.
Pat – as part of this motion can we go back to 284 and add
precertification/notification/authorization? Adding the new and putting it
in 284. Not deactivate 197,
Pat – would like to withdraw her motion.
Pat – makes new motion to revise 284 to read
“precertification/notification/authorization” change 198 and not
deactivate 197.
Gail – seconded
Discussion:
Kathy – had the comment on dental.
Margaret – do you oppose adding “pretreatment” and “prior
authorization”. Laurie recommends the prior authorization. Pre-
treatment she doesn’t know.
Gail – agrees with Laurie. Suggests to go ahead and add
“pretreatment” we just want to make sure we are using the same
sequence. Recommends “precertification/notification/authorization
/pretreatment” does not care the order just as long as they are
SEPTEMBER 2017 MEETING PITTSBURGH PA | SUNDAY | SEPTEMBER 24 2017
SEPTEMBER 24, 2017 42
VOTE RESULTS - NUMBER OF: YES_14_ NO _0_ ABSTAIN_1_
Passed: X – 197 and 198 effective 6 months from publication (May 1, 2017)
Failed:
Tabled:
Assigned Code: Revise 197; Revise 198; Revise New 284
Definition: 197 Precertification/authorization/notification/pre-treatment absent. 198 Precertification/notification/authorization/pre-treatment exceeded 284 Precertification/authorization/notification/pre-treatment number may be valid but does not apply to the billed services.
23
New Code
Name: Patricia Wijtyk
Company: TMG Health
Phone: 6102029565
Email: pwijtyk@tmghealth.com
Request Type: New
List Name Claim Adjustment Reason Code
Value:
Description: Claim received by the dental plan, but benefits not available under this plan.
Claim has been forwarded to the patient's medical plan for further
consideration.
NOTE column: Refer to CARC 254. Report 19, 20, or 21 in CLP02.
Explanation: This supplements CARC 254
Commenter:
Comment:
Motioner:
Seconder:
SEPTEMBER 2017 MEETING PITTSBURGH PA | SUNDAY | SEPTEMBER 24 2017
SEPTEMBER 24, 2017 43
Discussion Pre-Meeting August 31, 2017
Pat – filling in a gap received by dental. This is slightly different. Want
to make sure that CLP02 is still used.
September 24, 2017
Pat – makes motion to approve new code as submitted along with a
note that refers to CARC 254. Report Claim Status Codes 19, 20 or 21
in CLP02
Sue – seconded
Discussion:
Laurie – doesn’t understand what the column note means. She feels
the note is confusing.
Margaret – how would you modify the note?
Laurie – doesn’t think that 254 should be referred to.
Pat – because the reference is
Karen – what about adding “if not forwarded”
Margaret: should read CARC 254 if the claim was not forwarded.
Report Claim Status Codes 10, 20, 21 in CLP02.
Pete – should we modify 254 and add a note that says if forwarded, do
this…?
Margaret – suggestion is now to modify 254 with the new note Pete
mentioned.
Merri-Lee – understands what we are trying to do but is concerned that
we are trying to put information in codes that are currently in the TR3s.
Feels that we are getting too far in the details.
Laurie – question – is this process really different when the claim is
forwarded to a different payer. Wouldn’t it be similar to the RARCs that
are used when you are forwarding to an outside payer? The CARC
should say what is done and then refer to the other codes for details?
Pat – approached it as saying “we the payer” and thinking outside of
the box. Thought as making two codes it was a clearer picture.
Margaret – does anyone oppose moving the claim status code to the
note?
Betsy – has looked at codes and doesn’t see anything that is just a
simple forward.
Gail – would like to stick with the new code with a note to use CARC
254 if the claim is not forwarded.
New CARC 290 – effective immediately
Pat – Makes motion to make a note column to 254 to use 290 if the
claim was forwarded.
Gail – seconded
SEPTEMBER 2017 MEETING PITTSBURGH PA | SUNDAY | SEPTEMBER 24 2017
SEPTEMBER 24, 2017 44
VOTE RESULTS - NUMBER OF: YES_14_ NO _0_ ABSTAIN_0_
Passed: X – effective 3 months after publication (February 1, 2018)
Failed:
Tabled:
Assigned Code: New code 290; Revise 254
Definition: 290
Claim received by the dental plan, but benefits not available under this
plan. Claim has been forwarded to the patient’s medical plan for further
consideration.
254
Add note column: Use CARC 290 if the claim was forwarded.
24
New Code
Name: Patricia Wijtyk
Company: TMG Health
Phone: 6102029565
Email: pwijtyk@tmghealth.com
Request Type: New
List Name Claim Adjustment Reason Code
Value:
Description: Claim received by the medical plan, but benefits not available under this plan.
Claim has been forwarded to the patient's dental plan for further consideration.
NOTE attribute: Refer to CARC 270. Report 19, 20, or 21 in CLP02.
Explanation: This supplements CARC 270
Commenter:
Comment:
Motioner:
Seconder:
SEPTEMBER 2017 MEETING PITTSBURGH PA | SUNDAY | SEPTEMBER 24 2017
SEPTEMBER 24, 2017 45
Discussion
Pre-Meeting August 31, 2017
Pat – same as item #23
September 24, 2017
Pat – makes motion to add new code as use code 270 if the claim was
not forwarded and on 270 add note to use new code if the claim was
forwarded.
Gail – seconded
Discussion:
None
Approved 14 opposed 0 abstain 1
Motion passes
New code 291 effective immediately
Revised code will be effective 3 months after publication. (also item
above)
VOTE RESULTS - NUMBER OF: YES 14 NO 0 ABSTAIN 1
Passed: X – revision effective 3 months from publication (February 1, 2018)
Failed:
Tabled:
Assigned Code: New code 291; Revise Code 280
Definition: 291
Claim received by the medical plan, but benefits not available
under this plan. Claim has been forwarded to the patient's dental
plan for further consideration.
NOTE attribute: Use CARC 280 if the claim was not forwarded
Revise 280
NOTE attribute: Use CARC 292 if the claim was forwarded.
25
New Code
Name: Patricia Wijtyk
SEPTEMBER 2017 MEETING PITTSBURGH PA | SUNDAY | SEPTEMBER 24 2017
SEPTEMBER 24, 2017 46
Company: TMG Health
Phone: 6102029565
Email: pwijtyk@tmghealth.com
Request Type: New
List Name Claim Adjustment Reason Code
Value:
Description: Claim received by the medical plan, but benefits not available under this plan.
Claim has been forwarded to the patient's Pharmacy plan for further
consideration.
NOTE attribute: Refer to CARC 280. Report 19, 20, or 21 in CLP02.
Explanation: Supplements CARC 280
Commenter:
Comment:
Motioner:
Seconder:
Discussion Pre-Meeting August 31, 2017
Pat – same thing as above #23
September 24, 2017
Gail – makes a motion to approve the new code with the note on the
new code and the revised code to be created the same as the item
before (#24).
Pat – seconded
Discussion: none
Approved 14 opposed 0 abstentions 1
Motion carries
New code 292 effective immediately
Revised effective 3 months from publication.
VOTE RESULTS - NUMBER OF: YES 14 NO 0 ABSTAIN 1
Passed: X – revised code effective 3 months from publication (February 1, 2018)
Failed:
SEPTEMBER 2017 MEETING PITTSBURGH PA | SUNDAY | SEPTEMBER 24 2017
SEPTEMBER 24, 2017 47
Tabled:
Assigned Code: New code 292; Revised code 270
Definition: 292
Claim received by the medical plan, but benefits not available
under this plan. Claim has been forwarded to the patient's
pharmacy plan for further consideration.
NOTE attribute: Use CARC 270 if the claim was not forwarded
270
NOTE attribute: Use CARC 292 if the claim was forwarded
26
New code to indicate a prior auth request is in Initial review.
Name: Janice Bakos
Company: WEDI Prior Auth WorkGroup
Phone: 570 775-0229
Email: bakosja@aetna.com
Request Type: New
List Name Health Care Services Review Decision Reason
Value:
Description: Initial Utilization Review In Progress
Explanation: For use in the Precert Inquiry transaction. A value to indicate a Prior Auth
request is actively being worked by the initial reviewer. Kindly ignore prior
request of "Utilization Review in progress". This will offer additional details by
the inclusion of the word 'Initial'.
Commenter:
Comment:
Motioner:
Seconder:
SEPTEMBER 2017 MEETING PITTSBURGH PA | SUNDAY | SEPTEMBER 24 2017
SEPTEMBER 24, 2017 48
Discussion Pre-Meeting August 31, 2017
Janice – submitting this on behalf of the WEDI prior auth wg. Request
is to add information where a precert may belong in the review
process. They have requested two new codes.
Bruce – they talked about it in WG10 and they support both this
request and #27.
September 24, 2017
Bruce – makes motion to approve two new codes - items #26 and #27
LuAnn – seconded
Discussion: none
Approved 16 opposed 0 abstain 0
New codes: 30 and 31 were adjudicated together
VOTE RESULTS - NUMBER OF: YES__16___ NO _0__ ABSTAIN_0_
Passed: X
Failed:
Tabled:
Assigned Code: 30
Definition: Initial Utilization Review In Progress
27
Decision Reason code to be used in the Precert Inquiry (X215)
tranasaction to indicate that a precert request is currently in review and
has been escalated to a higher level to complete that review.
Name: Janice Bakos
Company: WEDI Prior Auth WorkGroup
Phone: 570 775-0229
Email: bakosja@aetna.com
Request Type: New
List Name Health Care Services Review Decision Reason
Value:
Description: Escalated Utilization Review in Progress.
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SEPTEMBER 24, 2017 49
Explanation: A new code to be used in the X215 inquiry transaction to indicate that not only
is a Pended precert request in active review, but that it has been escalated to
a higher level for review. This request is to be considered instead of the
previously submitted request of "Utilization Review in progress". Request is for
two codes, one for Initial and another for Escalated Utilization Review in
Progress.
Commenter:
Comment:
Motioner:
Seconder:
Discussion Pre-Meeting August 31, 2017
Janice – submitting this on behalf of the WEDI prior auth wg. To add
information where a precert may belong in the review process. They
have requested two new codes.
Bruce – they talked about it in WG10 and they support both this
request and #26.
September 24, 2017
This item was adjudicated with Item #26.
This is new code 31.
VOTE RESULTS - NUMBER OF: YES__16__ NO _0__ ABSTAIN__0__
Passed: X
Failed:
Tabled:
Assigned Code: 31
Definition: Escalated Utilization Review in Progress.
Meeting adjorned at 3:30 There is a need to have the remainder of the agenda adjudicated before the next standing meeting. Margaret will schedule an interim call to complete.
Follow up call October 25, 2017 Quorum was met with 15 voting members.
SEPTEMBER 2017 MEETING PITTSBURGH PA | SUNDAY | SEPTEMBER 24 2017
SEPTEMBER 24, 2017 50
28
CARC P21 - Modify description to insert "and/".
Name: Tina Greene
Company: Mitchell
Phone: 858 368 7104
Email: tina.greene@mitchell.com
Request Type: Revision
List Name Claim Adjustment Reason Code
Value: P21
Description: Deactivate:
Modify P21 description to:
Payment denied based on the Medical Payments Coverage (MPC) or
Personal Injury Protection (PIP) Benefits jurisdictional regulations and/or
payment policies.
Explanation: Modify P21 description to insert "and/".
Commenter:
Comment:
Motioner:
Seconder:
Discussion Pre-Meeting August 31, 2017
Tina – we will take offline and discuss
October 25, 2017
Insert comma after regulations
Motion to approve – LuAnn
Gail seconded
Approved opposed 0 abstain 0
Effective date – 3 months from publication
VOTE RESULTS - NUMBER OF: YES__15_____ NO _00___ ABSTAIN__0__
Passed: X – modify P21 description
SEPTEMBER 2017 MEETING PITTSBURGH PA | SUNDAY | SEPTEMBER 24 2017
SEPTEMBER 24, 2017 51
Failed:
Tabled:
Assigned Code: Revise P21
Definition: Payment denied based on the Medical Payments Coverage (MPC) and/or
Personal Injury Protection (PIP) Benefits jurisdictional regulations, or payment
policies. Usage: If adjustment is at the Claim Level, the payer must send and
the provider should refer to the 835 Insurance Policy Number Segment (Loop
2100 Other Claim Related Information REF qualifier 'IG') if the jurisdictional
regulation applies. If adjustment is at the Line Level, the payer must send and
the provider should refer to the 835 Healthcare Policy Identification Segment
(loop 2110 Service Payment information REF) if the regulations apply. To be
used for Property and Casualty Auto only.
29
CARC P22 - Modify description to insert "and/".
Name: Tina Greene
Company: Mitchell
Phone: 858 368 7104
Email: tina.greene@mitchell.com
Request Type: Revision
List Name Claim Adjustment Reason Code
Value: P22
Description: Deactivate:
Modify P22 description to:
Payment adjusted based on the Medical Payments Coverage (MPC) and/or
Personal Injury Protection (PIP) Benefits jurisdictional regulations or payment
policies.
Explanation: Modify P22 description to insert "and/".
Commenter:
Comment:
Motioner:
Seconder:
SEPTEMBER 2017 MEETING PITTSBURGH PA | SUNDAY | SEPTEMBER 24 2017
SEPTEMBER 24, 2017 52
Discussion Pre-Meeting August 31, 2017
Tina – will discuss offline and bring to Sept.
Discussed with auto and P22 should be modified the same as P21.
October 25, 2017
Insert comma after regulations
Motion to approve – Lu
Gail seconded
Approved opposed 0 abstain 0
Effective date – 3 months from publication
VOTE RESULTS - NUMBER OF: YES__15_____ NO _00___ ABSTAIN____
Passed: X – modify P22 description
Failed:
Tabled:
Assigned Code: Revise P22
Definition: Payment adjusted based on the Medical Payments Coverage (MPC)
and/or Personal Injury Protection (PIP) Benefits jurisdictional
regulations, or payment policies. Usage: If adjustment is at the Claim
Level, the payer must send and the provider should refer to the 835
Insurance Policy Number Segment (Loop 2100 Other Claim Related
Information REF qualifier 'IG') if the jurisdictional regulation applies. If
adjustment is at the Line Level, the payer must send and the provider
should refer to the 835 Healthcare Policy Identification Segment (loop
2110 Service Payment information REF) if the regulations apply. To be
used for Property and Casualty Auto only.
30
CARC 100 - Modify description to insert "/attorney".
Name: Tina Greene
Company: Mitchell
Phone: 858 368 7104
Email: tina.greene@mitchell.com
Request Type: Revision
List Name Claim Adjustment Reason Code
Value: 100
SEPTEMBER 2017 MEETING PITTSBURGH PA | SUNDAY | SEPTEMBER 24 2017
SEPTEMBER 24, 2017 53
Description: Revise to: Payment made to patient/insured/responsible
party/employer/attorney.
Explanation: Modify CARC 100 description to insert "/attorney".
Commenter:
Comment:
Motioner:
Seconder:
Discussion October 25, 2017
Motion to approve – LuAnn
Gail - seconded
Deb –thinks that this code should be split out. So that when the provider has
to go chase, they will know which entity.
Payment made to patient/insured/responsible party.
Payment made to employer.
Payment made to attorney.
LuAnn – withdraws motion
Gail – ok with withdraw
LuAnn – new motion to remove employer from 100 and create two new codes
for employer and attorney
Deb – should these be P codes? Gail suggests that they are not since there
could be use outside of P&C.
Approved 15 opposed 0 abstain 0
New codes will be 293 and revised code 100 – effective in 6 months.
New code 294 (attorney) effective immediately.
Payment made to patient/insured/responsible party. New 100 Effective 6
months from publication
Payment made to employer. Will be CARC 293. Effective 6 months from
publication.
Payment made to attorney. Will be CARC 294. Effective immediately.
VOTE RESULTS - NUMBER OF: YES___15____ NO __0__ ABSTAIN_0___
Passed: X
Failed:
Tabled:
SEPTEMBER 2017 MEETING PITTSBURGH PA | SUNDAY | SEPTEMBER 24 2017
SEPTEMBER 24, 2017 54
Assigned Code: Revised 100, New 293, New 294
Definition: 100: Payment made to patient/insured/responsible party.
293: Payment made to employer.
294: Payment made to attorney.
31
New Code
Name: Tina Greene
Company: Mitchell
Phone: 858 368 7104
Email: tina.greene@mitchell.com
Request Type: New
List Name Claim Adjustment Reason Code
Value:
Description: Payment adjusted based on PPO/MPN/VPN.
Group Code CO
Explanation: CARC P12 is specific to fee schedule adjustment only. There needs to be
more specificity regarding any PPO used. Fee schedule and PPO adjustments
are different. There is a need in the P&C industry to specify the difference. All
stakeholders (Providers, Payers and States) are in agreement.
Commenter: Tina Greene
Comment: We would like to spell out PPO, MPN and VPN.
Preferred Provider Organization (PPO)/Medical Provider Network
(MPN)/Virtual Private Network (VPN).
Commenter: Tina Greene
Comment: VPN - Voluntary Provider Network
Motioner:
Seconder:
SEPTEMBER 2017 MEETING PITTSBURGH PA | SUNDAY | SEPTEMBER 24 2017
SEPTEMBER 24, 2017 55
Discussion Pre-Meeting August 31, 2017
Karen – class of contract code should refer to the network.
Pat – “to be used for Property & Casualty only”
Karen – suggests breaking them out.
Pat – and as long as they all say “to be used for Property & Casualty only” it
would be fine.
October 25, 2017
Payment adjusted based on PPO. Add usage and group code CO.
Payment adjusted based on MPN. Add usage and group code CO..
Payment adjusted based on Voluntary Provider Network (VPN). Add
usage and group code CO
Motion to approve with updates – Pat
Seconded – Deb
Approved 13 opposed 0 abstain 2
To be effective immediately
VOTE RESULTS - NUMBER OF: YES__13_____ NO _0___ ABSTAIN__2__
Passed: X
Failed:
Tabled:
Assigned Code: P24, P25, P26 (effective immediately)
SEPTEMBER 2017 MEETING PITTSBURGH PA | SUNDAY | SEPTEMBER 24 2017
SEPTEMBER 24, 2017 56
Definition: P24 Payment adjusted based on PPO. Usage: If adjustment is at the
Claim Level, the payer must send and the provider should refer to the
835 Class of Contract Code Identification Segment (Loop 2100 Other
Claim Related Information REF). If adjustment is at the Line Level, the
payer must send and the provider should refer to the 835 Healthcare
Policy Identification Segment (loop 2110 Service Payment information
REF) if the regulations apply. To be used for Property and Casualty
only. (Use only with Group Code CO).
P25 Payment adjusted based on MPN. Usage: If adjustment is at the
Claim Level, the payer must send and the provider should refer to the
835 Class of Contract Code Identification Segment (Loop 2100 Other
Claim Related Information REF). If adjustment is at the Line Level, the
payer must send and the provider should refer to the 835 Healthcare
Policy Identification Segment (loop 2110 Service Payment information
REF) if the regulations apply. To be used for Property and Casualty
only. (Use only with Group Code CO).
P26 Payment adjusted based on Voluntary Provider Network (VPN).
Usage: If adjustment is at the Claim Level, the payer must send and
the provider should refer to the 835 Class of Contract Code
Identification Segment (Loop 2100 Other Claim Related Information
REF). If adjustment is at the Line Level, the payer must send and the
provider should refer to the 835 Healthcare Policy Identification
Segment (loop 2110 Service Payment information REF) if the
regulations apply. To be used for Property and Casualty only. (Use
only with Group Code CO).
32
New Code
Name: Tina Greene
Company: Mitchell
Phone: 858 368 7104
Email: tina.greene@mitchell.com
Request Type: New
List Name Claim Adjustment Reason Code
Value:
Description: Payment denied based on the Liability Coverage Benefits jurisdictional
regulations and/or payment policies.
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SEPTEMBER 24, 2017 57
Explanation: Auto industry is in need of a code to specify Third Party (Liability Coverage
Benefits). This different than the MPC and PIP coverage/benefits identified in
existing P codes.
Commenter:
Comment:
Motioner:
Seconder:
Discussion Pre-Meeting August 31, 2017
Call ended.
October 25, 2017
Add usage to new code.
Motion to approve as amended with usage – Pat
Seconded – Deb
Approved Opposed Abstain 1
Effective immediately.
VOTE RESULTS - NUMBER OF: YES__14_ NO _0__ ABSTAIN_1__
Passed: X
Failed:
Tabled:
Assigned Code: P27
Definition: Payment denied based on the Liability Coverage Benefits jurisdictional
regulations and/or payment policies. Usage: If adjustment is at the Claim
Level, the payer must send and the provider should refer to the 835
Insurance Policy Number Segment (Loop 2100 Other Claim Related
Information REF qualifier 'IG') if the jurisdictional regulation applies. If
adjustment is at the Line Level, the payer must send and the provider should
refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service
Payment information REF) if the regulations apply. To be used for Property
and Casualty Auto only.
33
New Code
Name: Tina Greene
SEPTEMBER 2017 MEETING PITTSBURGH PA | SUNDAY | SEPTEMBER 24 2017
SEPTEMBER 24, 2017 58
Company: Mitchell
Phone: 858 368 7104
Email: tina.greene@mitchell.com
Request Type: New
List Name Claim Adjustment Reason Code
Value:
Description: Payment adjusted based on the Liability Coverage Benefits jurisdictional
regulations and/or payment policies.
Explanation: Auto industry is in need of a code to specify Third Party (Liability Coverage
Benefits). This is different than the MPC and PIP coverage/benefits identified
in existing P codes.
Commenter:
Comment:
Motioner:
Seconder:
Discussion October 25, 2017
Pat - Motion to approve new code as written on Go To Meeting.
(includes Usage and To be used for Property and Casualty Auto only)
Deb - seconded
New code P28 effective immediately.
VOTE RESULTS - NUMBER OF: YES_13___ NO _0__ ABSTAIN_2__
Passed: X
Failed:
Tabled:
Assigned Code: P28
SEPTEMBER 2017 MEETING PITTSBURGH PA | SUNDAY | SEPTEMBER 24 2017
SEPTEMBER 24, 2017 59
Definition: Payment adjusted based on the Liability Coverage Benefits jurisdictional
regulations and/or payment policies. Usage: If adjustment is at the Claim
Level, the payer must send and the provider should refer to the 835
Insurance Policy Number Segment (Loop 2100 Other Claim Related
Information REF qualifier 'IG') if the jurisdictional regulation applies. If
adjustment is at the Line Level, the payer must send and the provider should
refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service
Payment information REF) if the regulations apply. To be used for Property
and Casualty Auto only.
34
Tina Greene
Name: Mitchell
Company: 858 368 7104
Phone: tina.greene@mitchell.com
Email: New
Request Type: Claim Adjustment Reason Code
List Name Tina Greene
Value:
Description: Liability Benefits jurisdictional fee schedule adjustment.
Explanation: Auto industry is in need of a code to specify Third Party (Liability Coverage
Benefits). This is different than the MPC and PIP coverage/benefits identified
in existing P codes.
Commenter:
Comment:
Motioner:
Seconder:
SEPTEMBER 2017 MEETING PITTSBURGH PA | SUNDAY | SEPTEMBER 24 2017
SEPTEMBER 24, 2017 60
Discussion October 25, 2017
Usage: If adjustment is at the Claim Level, the payer must send and the
provider should refer to the 835 Class of Contract Code Identification Segment
(Loop 2100 Other Claim Related Information REF). If adjustment is at the
Line Level, the payer must send and the provider should refer to the 835
Healthcare Policy Identification Segment (Loop 2110 Service Payment
information REF) if the regulations apply, To be used for Property and
Casualty Auto only.
Pat - Motion to approve with the addition of Usage.
Deb - Seconded
Approved 13 opposed 0 abstain 2
Effective immediately.
VOTE RESULTS - NUMBER OF: YES_13__ NO _0__ ABSTAIN_2__
Passed: X
Failed:
Tabled:
Assigned Code: P29
Definition: Liability Benefits jurisdictional fee schedule adjustment. Usage: If adjustment
is at the Claim Level, the payer must send and the provider should refer to
the 835 Class of Contract Code Identification Segment (Loop 2100 Other
Claim Related Information REF). If adjustment is at the Line Level, the payer
must send and the provider should refer to the 835 Healthcare Policy
Identification Segment (loop 2110 Service Payment information REF) if the
regulations apply. To be used for Property and Casualty Auto only.
January 2018 Request
01
Delete Duplicate Code
Name: Margaret Weiker
Company: NCPDP
Phone: 480-477-1000
Email: mweiker@ncpdp.org
Request Type: Revision
List Name Health Care Service Type
SEPTEMBER 2017 MEETING PITTSBURGH PA | SUNDAY | SEPTEMBER 24 2017
SEPTEMBER 24, 2017 61
Value:
Description: Delete Duplicate Code
Explanation: Code E24 and 88 are duplicates. E24 needs to be deleted from
the list.
Commenter:
Comment:
Motioner:
Seconder:
Discussion October 25, 2017
Margaret – with this request it will require a deletion of a duplicate code. If we
should wait until the January meeting, that is fine.
Gail – which one should stay and which one deleted? Margaret – 88 is the
code that should be deleted because it is the one that is being used currently.
Gail – doesn’t think E24 is in the standard. Not until 7030.
Bruce – everyone agreed that E24 would be deleted.
Margaret – they went over these codes extensively with 270/271 wg.
Bruce - they had a separate meeting for reviewing the spreadsheet.
Pete – he sees “retail pharmacy prescription drug” Margaret – and that does
not exist.
Gail – why do we still have others that have “drug” in i?. Some other
inconsistencies that we may need to look at.
Gail is comfortable with taking it out, but is 270/271 ok with it?
WG 1’s representatives are ok with deleting E24.
Motion to approve – Kath Jonzzon
Seconded – LuAnn
Approved 15 opposed 0 abstain 0
Effective immediately.
VOTE RESULTS - NUMBER OF: YES_15_ NO 0_ ABSTAIN_0_
Passed: X – delete E24 effective immediately
Failed:
Tabled:
Assigned Code:
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SEPTEMBER 24, 2017 62
Definition: