clm104c22.pdf

60.3  Remittance Advice Remark Codes  (Rev. 3288, Issued: 07- 02-15, Effective: 08- 03-15, Implementation: 08- 03-15)  Remittance Advice Remark Codes (RARCs) are used in  a remittance advice to further explain an adjustment or relay informational messages that cannot be expressed with a claim adjustment reason code.  Remark codes are maintained by CMS, but may be used by any health plan when they apply.  MACs must report a ppropriate remark code(s) that apply.  There is another type of remark codes that does not add supplemental explanation for a specific adjustment but provides general adjudication information. These Informational remark codes start with the word Alert and can be reported without Group and Claim Adjustment Reason Code.  An example of an Informational RARC would be:   MA01: Alert: If you do not agree with what we approved for these services, you may appeal our decision.  To make sure that we are fair to you, we require another individual that did not process your initial claim to conduct the appeal.  However, in order to be eligible for an appeal, you must write to us within 120 days of the date you received this notice, unless you have a good reason for being late.   Remark codes at the service line level must be reported in the ASC X12 835 LQ segment.  Remark codes that apply to an entire claim must be reported in either an ASC X12 835 MIA (inpatient) or MOA (non- inpatient) segment, as applicable.  Althou gh the IG allows up to 5 remark codes to be reported in the MOA/MIA segment and up to 99 remark codes in the LQ segment, system limitation may restrict how many codes MACs can actually report.   The remark code list is updated three times a year, and the li st is posted at the WPC website and gets updated at the same time when the reason code list is updated.  Both code lists are updated on or around March 1, July 1, and November 1.  MACs must use the latest approved remark codes as included in the Recurring Code Update CR or any other CMS instruction or downloading the list from the WPC Website after each update.  MAC and shared system changes must be made, as necessary, as part of a routine release to reflect changes such as retirement of previously used cod es or newly created codes that may impact Medicare.   60.4 - Requests for Additional Codes  (Rev. 3288, Issued: 07- 02-15, Effective: 08- 03-15, Implementation: 08- 03-15)  The CMS has a national responsibility for maintenance of the remittance advice remark codes and the Claim Adjustment Status Code Maintenance Committee maintains the claim adjustment reason codes.  Requests for new or modification or deactivation of RARCs and CARCs should be sent to a mail box set up by CMS:   Remittance_Advice.CMS.HHS.GOV.   The MACs should send their requests to this mail box for any change in CARC, RARC or any code combination.  Requests for codes must include the suggested wording for the new or revised message, and an explanation of how the message will be used and why it is needed or a justification for the request.   To provide a summary of changes introduced in the previous 4 months, a code update instruction in the form of a CR is issued.  These CRs will establish the deadline for Medicare shared system and MAC changes t o complete the reason and/or remark code updates that had not already been implemented as part of a previous Medicare policy change instruction.   80  The Council for Affordable Quality Healthcare (CAQH) Committee on Operating Rules for Information Exchange (CORE) Mandated Operating Rules  (Rev. 3288, Issued: 07- 02-15, Effective: 08- 03-15, Implementation: 08- 03-15)  Section 1104 of the Patient Protection and Affordable Care Act (ACA) establishes the development and implementations of requirements for  administrative transactions that will improve the utility of the existing HIPAA transactions and reduce administrative costs. A/B MACs/ CEDI/ and DME MACs are required to conform to the following CAQH Core Operating Rules impacting the transmittals of X1 2 835 transactions.  A complete list of ACA mandated operating rules are available at http://www.caqh.org/ORMandate_index.php.  80.1 - Health Care Claim Payment/Advice (835) Infrastructure Rule  (Rev. 3288, Issued: 07- 02-15, Effective: 08- 03-15, Implementation: 08- 03-15)  Section 1104 of the Patient Protection and Affordable Care Act (ACA) establishes the development and implementations of requirements for administrative transactions that will improve the utility of the existing HIPAA transactions and reduce administrative costs. A/B MACs/ CEDI/ and DME MACs are required to conform to the following CAQH Core Operating Rules impacting the transmittals of X12 835 transactions.   A complete list of ACA man dated operating rules are available at http://www.caqh.org/ORMandate_index.php.  80.1.1 - Version X12/5010X221 Companion Guide  (Rev. 2843, Issued: 12- 27-13, Effective: 01- 28-14, Implementation: 01 -28-14)  CAQH CORE mandated operating rules require the usage of a companion guide for the ASC X12 835 standard transaction.  This companion guide is to correspond with the already existing V5010 ASC X12 Implementation Guide.  A companion guide template is available at: http://www.caqh.org/pdf/CLEAN5010/MasterCompGuidTemp- v5010.pdf   80.2 - Uniform Use of CARCs and RARCs Rule  (Rev. 3288, Issued: 07- 02-15, Effective: 08 -03-15, Implementation: 08- 03-15)  The CAQH CORE mandated operating rules require the usage of a standardized CARC and RARC combinations when used on the ASC X12 835 transactions.  These combinations are maintained in a list updated three time s a year by CAQH CORE.   The complete CARC/RARC code combination list is available at:  http://www.caqh.org/CORECodeCombinations.php  The MACs may submit to CMS a request for modification to an ex isting code combination or a request to create a new code combination to the CAQH CORE Code Combination List.  MACs may also request modifications, additions, or deletions of individual CARC and RARC codes to CMS.  Requests are to be submitted to: Remittance_Advice@CMS.HHS.GOV .  All requests must include business justifications and contain, when available, reference to CMS instruction for the requested action.  80.3 - EFT Enrollment Data Rule  (Rev. 3288, Issued: 07 -02-15, Effective: 08- 03-15, Implementation: 08- 03-15)  The CAQH CORE mandated operating rules establish standards for the enrollment of providers to electronic funds transfer (EFT) programs.  The rule mandates the required data elements and the order in which they appear on the EFT enrollment forms.  The rule also mandates acceptable EFT enrollment submission formats.   A complete list of required data elements and submission formats are available at http://www.caqh.org/Host/CORE/EFT -ERA/EFT_Enrollment_Data_Rule.pdf   80.4 - ERA Enrollment Form  (Rev. 3288, Issued: 07- 02-15, Effective: 08- 03-15, Implementation: 08- 03-15)  The CAQH CORE mandated operating rules establish standards for the enrollment of providers to ERA programs.  The rule mandates the required data elements and the order in which they appear on the ERA enrollment forms.  The rule also mandates acceptable EFT enrollment submission formats.   A comp lete list of required data elements and submission formats are available at http://www.caqh.org/Host/CORE/EFT -ERA/ERA_Enrollment_Data_Rule.pdf   Transmittals Issued for this Chapter  Rev #  Issue Date  Subject  Impl Date  CR#  R11427CP  05/20/2022  Claims Processing Manual Update -  Pub. 100.04 for Elimi nation of Certificates of Medical Necessity (CMNs) and Durable Medical Equipment Forms (DIFs)  01/03/2023  12734  R11414CP  05/12/2022  Claims Processing Manual Update -  Pub. 100.04 for  Elimination of Certificates of Medical Necessity (CMNs) and Durable Medical Equipment Forms (DIFs)  - Rescinded and replaced by Transmittal 11427 06/13/2022  12734  R10236CP