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Phase III Operating Rules - Streamlining Claims Payment Reconciliation

According to the CAQH Index Report, over 227 million electronic remittance advices (ERAs) were sent from health plans to providers in 2017. Providers rely on the ERA to understand why a claim was denied or adjusted and how, if possible, to recoup those dollars. However, if the codes used to convey a claim denial or adjustment on the ERA are unclear, both health plans and providers are subject to unnecessary administrative burdens through extraneous phone calls and redundant or ineffective claim resubmissions and appeals. The Phase III CAQH CORE Operating Rules help eliminate this confusion by standardizing the use of the 1000+ Claims Adjustment Reason Codes (CARCs) and Remittance Advice Remark Codes (RARCs) used in the ERA. Join us on August 8th for a discussion on how the Phase III CAQH CORE 360: Uniform Use of CARCs and RARCs Rule allows providers to automate their claims payment reconciliation processes.


• Learn how the Phase III CAQH CORE Operating Rules help the industry efficiently manage payment decisions, automate posting to patient accounts, and optimize denial management processes.

• Receive an orientation on the CAQH CORE Code Combination Maintenance Process along with real-world results of their industry impact.

• Ensure you are getting the most benefit from your claims denial process by participating in the Market-based Review, an industry-wide mechanism for providing feedback on the CAQH CORE Code Combinations process.