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Back  RFI # 1776: Payer Payment Error 835 carc

Formal vs. Informal Help Informal Formal

Submitter

Barber Meg

Description

When a payment has been made to the wrong provider or processed under the incorrect Subscriber id. Our system adjust the claim with a denial stating payer error, paid to wrong provdier or payer error processed under wrong subscriber /dependent This is not a provider billing error but a payer processing error.
I can't seem to find an appropriate CARC/RARC combination for these. We need to send out the take back and then the reprocess (denial)
We do reprocess the claim but under a new claim id and with the correct information. - this would create an entirely diff 835

Any suggestions?

CARC 129 seems to fit but Core does not really have any good RARC's to use and i dont feel this fits also under the 4 op rules. Based on your suggestion i can inquire with Core in the market survey.
I also do not see any in the full list that would say payer error?

Submitter Assigned Keywords

CARC RARC

Response

This scenario is specifically addressed in the ASC X12 005010X221A1 in section 1.10.2.8 Reversals and Corrections.
Reverse the original payment to the incorrect provider using CLP02 code 22, “reversal of previous payment”. Send original Claim Adjustment group codes in CAS01 and the appropriate adjustments. All original charge, payment, and adjustment amounts are negated.

Then, send the corrected claim payment to the correct provider.

There is no correction information sent to the original (incorrect) provider, since that provider never sent the claim to the health plan.

Recommendation

If a reason for the reversal is important to your company, suggest requesting a new RARC code that would be an Alert and sent with the reversal claim.
Submission 4/11/2013
Status Date 6/3/2013
Status F - Final
Primary References
Document 005010X221
Sectioncas
External Code Listcode source 139