Look for standard use of remittance advice codes in 2014

September 6th, 2013 - Scott Kraft   
Categories:   Billing   Denials & Denial Management  
0 Votes - Sign in to vote or comment.

Confusion over how to respond to electronic remittance advice (ERA) will hopefully decline in 2014, thanks to efforts from the Council for Affordable Quality Healthcare (CAQH) to streamline and standardize how payers use ERA codes to convey why your claims are being denied or rejected.

These standardization efforts were driven by the Affordable Care Act (ACA). Remittance codes will be divided into these four categories:
1. Additional Information Required – Missing/Invalid/Incomplete Documentation
2. Additional Information Required – Missing/Invalid/Incomplete Data from Submitted Claim
3. Billed Service Not Covered by Health Plan
4. Benefit for Billed Services Not Payable

The efforts at standardization are designed to head off confusion from how different payers are deciding to use electronic remittance advice on claims. The benefit to physician practices is the ability to better understand how to quickly determine the best response to claims denials and rejections.

Underneath the four core reasons why claims aren’t being paid, the CAQH standardization breaks down the remittance advice codes in a standardized way. The changes will be implemented by CMS by Jan. 6, 2014.

For an example of how it works, let’s look at the first scenario from above, Additional Information Required – Missing/Incomplete/Invalid Documentation.

In the first scenario, you’ll see an initial code, in this case Claim Adjustment Reason Code 16: Claim/service lacks information which is needed for adjudication. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT).

The presence of that code limits the remittance advice remark codes (RARCs) that should accompany the claims denial because you are now focused on only denials or claims rejections caused by missing information.

Two examples of RARCs you might see are M47 (Missing/incomplete/invalid internal or document control number, or M51 (Missing/incomplete/invalid procedure). But you wouldn’t see either of those two codes without seeing an initial denial or rejection claim type to help frame your response.

The denial code infrastructure being established by CAQH is a HIPAA standard code set, which should make it easier to determine how to more quickly and effectively address denials in 2014.

###

Questions, comments?

If you have questions or comments about this article please contact us.  Comments that provide additional related information may be added here by our Editors.


Latest articles:  (any category)

Billing for Telemedicine in Chiropractic
January 14th, 2020 - Evan M. Gwilliam DC MBA BS CPC CCPC QCC CPC-I MCS-P CPMA CMHP
Many large private payers recognize the potential cost savings and improved health outcomes that telemedicine can help achieve, therefore they are often willing to cover it. While there are several considerations, there could be certain circumstances where telemedicine might apply to chiropractic care.
Non-Surgical Periodontal Treatment
January 14th, 2020 - Christine Taxin
AAP treatment guidelines stress that periodontal health should be achieved in the least invasive and most cost-effective manner. This is often accomplished through non-surgical periodontal treatment.Non-surgical periodontal treatment does have its limitations. When it does not achieve periodontal health, surgery may be indicated to restore periodontal health.SCALING AND ROOT PLANINGScaling ...
Q/A: Can Chiropractors Bill 99211?
January 14th, 2020 - Wyn Staheli, Director of Research
Can chiropractic offices bill code 99211? Technically it can be used by chiropractors, but in most instances, it is discouraged. Considering that 99211 is a low complexity examination for an established patient, this code is not really made for the physician to use. In fact, in 2021, changes are coming for this code...
Denials due to MUE Usage - This May be Why!
January 7th, 2020 - Chris Woolstenhulme, QCC, CMCS, CPC, CMRS
CMS assigns Medically Unlikely Edits (MUE's) for HCPCS/CPT codes, although not every code has an MUE. MUE edits are used to limit tests and treatments provided to a Medicare patient for a single date of service or for a single line item on a claim form. It is important to understand MUE's are ...
CMS Report on QPP Shows Increasing Involvement
January 6th, 2020 - Wyn Staheli, Director of Research
MIPS 2018 participation increased according to the final report issued by CMS on January 6, 2020.
CPT 2020 Changes to Psychiatry Services
January 3rd, 2020 - Namas
As of January 1, 2020, CPT made changes to the health and behavior assessment and intervention codes (96150-96155) and therapeutic interventions that focus on cognitive function (97127). If you code and audit services in this category, you must pay close attention to the changes as they include the removal and ...
Medicare Changes Bilateral Reporting Rules for Certain Supplies
December 30th, 2019 - Wyn Staheli, Director of Research
DME suppliers must bill bilateral supplies with modifiers RT and LT on separate claim lines or they are being rejected.



About Codapedia by innoviHealth Contact Us Terms of Use Privacy Policy Advertise with Us

innoviHealth - 62 E 300 North, Spanish Fork, UT 84660 - Phone 801-770-4203 (9-5 Mountain)

Copyright © 2000-2020 innoviHealth Systems, Inc. - CPT® copyright American Medical Association