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Back  RFI # 2318: CARC 45 Questions

Formal vs. Informal Help Informal Formal

Submitter

Joshua Mier

Description

CARC 45 states it must be used with either Group Code PR or CO. Can CARC 45 be used for pay or deny Explanation Codes or both? If CARC 45 can be used for pay Explanation Codes, why can’t CARC 45 have a group code of PI? For example, a payer pays a Non Par Medicare Dialysis service based on a Non Par Medicare Fee Schedule, but the service billed by the provider was paid under a more appropriate code. In this case, CARC 45 could fit the claim adjustment reason because we paid the Non Par Dialysis based on a Non Par Medicare Fee Schedule, and Group Code PI (Payer Initiated) could also fit because in the opinion of the payer, the adjustment is not the responsibility of the patient, and there is no supporting contract between the provider and the payer. CARC 45 however, states that only Group Codes PR or CO can be used. Should the CARC determine the Group Code or should the Group Code determine the CARC?

Response

Could you please send this back to the submitter and let them know RFIs are not used for interpretting the TR2s. Please ask them to send their questions about CARCs to codes-help@x12.org.

Thanks
Submission 9/13/2018
Status Date 10/5/2018
Status F - Final
Primary References
Document CARC
SectionCAGC