Providers receive results of reviews on their Electronic Remittance Advice (ERA). Search by selecting categories Claim Adjustment Reason Codes (CARC) or Remittance Advice Remark Codes (RARC) and the corresponding code below.
Reason | Corrective Action |
|---|---|
Diagnosis to modifier comparison; | Claim correction to correct modifier or diagnosis |
Diagnosis to Diagnosis Comparison; | Claim correction to remove unspecified diagnosis |
Excludes1 Diagnosis; Per ICD-10-CM codes cannot be billed together. | Claim correction to remove Excludes1 diagnosis |
Secondary diagnosis is the only diagnosis on the claim; | Claim correction to add appropriate primary diagnosis |
Unacceptable principle diagnosis per ICD-10-CM | Claim correction to add appropriate primary diagnosis |
Principle diagnosis is on the Outpatient Prospective Payment System (OPPS) unacceptable principle diagnosis list | Claim correction to change principle diagnosis |
If a provider disagrees with a payment determination and a claim correction is not the next step, request a Reconsideration using the Appeal form. Reconsideration timelines for request align with the respective appeal timelines for commercial and Medicaid Expansion.
A reconsideration is not an appeal as it’s a payment dispute and not an adverse benefit determination; it does not use the member’s appeal rights. A reconsideration of a payment determination is a provider right only. When completing the appeal form, select Provider on behalf of self.
Providers will receive a reconsideration notification within 45 days of receipt of the request. If a provider disagrees with the determination, they will have the option of requesting a second reconsideration within 45 days. Providers will receive a reconsideration notification of their subsequent request within 45 days of receipt of the request.
