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Back  RFI # 2052: CAS*CO*45 being used as denial

Formal vs. Informal Help Informal Formal

Submitter

Sharon Sieve

Description

State Medicaid payor sending CO*45 w Rarc codes missing info and other denial rarc info. Is it compliant to send CO*45 when more specific denial should be used?. This is causing our automation to write off 100% of charges rather than deny and allow us to provide more info to payor. Payor states this is how they have done and have not had any complaints. exa: CLP*5400000000000*2*1010*0*0*MC*201500000000*13*1~
NM1*QC*1*INTERPRETATION*X12****MR*000000000~
REF*EA*X00000~
DTM*232*20150319~
DTM*233*20150319~
SVC*NU>0270*30*0**2~
DTM*472*20150319~
CAS*CO*45*30~
REF*6R*0000000~
LQ*HE*N115~
SVC*NU>0272*17*0**3~
DTM*472*20150319~
CAS*CO*45*17~
REF*6R*0000000~
LQ*HE*M20~
LQ*HE*N115~
SVC*HC>11042*726*0*0360*1~
DTM*472*20150319~
CAS*CO*45*726~
REF*6R*0000000~
LQ*HE*N479~
LQ*HE*N115~
SVC*HC>99213*237*0*0761*1~
DTM*472*20150319~
CAS*CO*45*237~
REF*6R*0000000~
LQ*HE*N479~
LQ*HE*N115~

Submitter Assigned Keywords

CAS*CO*45 used as a denial

Response

While the guide is silent on this explicit issue, the intent is that the Claim Adjustment Reason Codes (CARCs) be used to accurately report the adjustments.

CARC 45 currently reads “Charge exceeds fee schedule/maximum allowable or contracted/legislated fee arrangement. (Use only with Group Codes PR or CO depending upon liability)”. This is predicated upon there being an applicable allowed amount, which is non-zero, and that the reduction is to that allowed amount. The reported usage is inconsistent with that intent. All examples documented in the TR3 (Sections 1.10.2.6, 1.10.2.7, 1.10.2.8, 1.10.2.14.1, 1.10.2.15, and Section 3) reflect CARC 45 as a reduction to the submitted charge and NOT a rejection of the full submitted charge.

The RARCs reported are inconsistent with CARC 45.

N115 is reporting that the payment was based on a Local Coverage Determination (LCD) while M20 and N479 are reporting missing data on the claims or other documentation.These RARCs are used with CARC 16.
Submission 5/14/2015
Status Date 9/21/2015
Status F - Final
Primary References
Document 005010X221
SectionDetail
Set ID2100
Table2