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Back  RFI # 422: Claim Level Remark Codes

Formal vs. Informal Help Informal Formal

Submitter

Gale Scott

Description

As of early June 2006, FL Medicaid stopped using proprietory rejection codes and have now adopted the X12 CARC codes which are not as specific as the proprietory codes. Specifically they are using CARC 16 without a Remark Code. Thier interpretation of the IG is that the X12 835 transaction is not provisioned for remark codes at the claim level. I believe the MIA/MOA segment of the 2100 loop is designed to carry the claim level remark codes and FL Medicaid apparently disagrees. This results in a claim level rejection without any detailed explanation being provided. They have also applied this logic to the Claim Status codes so there is no way to find out without calling them. Please tell me if the note on MIA05 or MOA04 would be considered a required entry when a very generic CARC such as 16 is used.

Submitter Assigned Keywords

Remarks

Response

It is the intent of Claim Adjustment Reason Code (CARC) 16 to require the usage of remark codes in the MIA or MOA segments if the remark applies to the entire claim or the LQ segment if the remark applies to a specific line of service.
During the June 2006 Trimester Meeting the language of CARC 16, 17, 96, and 125 was strengthened so that these codes now explicitly state. "...At least one Remark Code must be provided (may be comprised of either the Remittance Advice Remark Code or NCPDP Reject Reason Code.)"
This change is effective 4/1/2007

Recommendation

DISCLAIMER: X12N's interpretations are intended only to clarify the implementation
guides.
It is not within X12N's scope to comment on the actions of specific entities
such as regulatory bodies, carriers, and providers, nor to render an opinion
on an individual entity's compliance with HIPAA or other federal or state
regulations. Requests concerning interpretations of the HIPAA regulations as
issued by the Department of Health and Human Services should be submitted
via email to askhipaa@cms.hhs.gov.
Submission 6/28/2006
Status Date 8/18/2006
Status F - Final
Primary References
Document 004010X091A1
Sectionn/a
Page118
Set ID835
Table2
Loop2100
Segment IDMIA
Element Position05
Industry NameRemark Code
External Code List411
Secondary References
RFI ID 380
Document 004010X091A1
Sectionn/a
Page123
Set ID835
Table2
Loop2100
Segment IDmoa