Phase III CAQH CORE EFT & ERA Operating Rules

IV. CAQH CORE 360: Uniform Use of CARCs and RARCs (835) Rule

  1. Does my health plan organization have to support CORE-required Code Combinations that are not applicable to our business needs?
  2. Do all of the CARCs in the CORE-required Code Combinations tables have to be used with a corresponding RARC?
  3. To what types of entities do the requirements in Section 4.2, Basic Requirements for Receivers of the X12 v5010 835, of the CAQH CORE 360 Rule apply?
  4. Why does the CAQH CORE 360 Rule require a minimum set of CORE-defined Business Scenarios with a maximum set of CORE-required Code Combinations to be supported by all health plans and their PBM agents?
  5. How were the minimum CORE-defined Claim Adjustment/Denial Business Scenarios and applicable maximum set of CORE-required Code Combinations identified?
  6. CAQH CORE 360 Rule, Section 4.2, Basic Requirements for Receivers of the X12 v5010 835, requires that provider facing products display text describing the CORE-defined Claim Adjustment/Denial Business Scenarios and CORE-required Code Combinations to the end user. Is there specific text that such products must display?
  7. Does my provider-facing product satisfy the requirements under Section 4.2, Basic Requirements for Receivers of the X12 v5010 835, of the CAQH CORE 360 Rule if it displays only the descriptions of the CARC/RARC/CAGC and CARC/NCPDP Reject Codes/CAGC include in the X12 v5010 835?
  8. How does the CAQH CORE 360 Rule address the need for the CORE-required Code Combinations for CORE-defined Business Scenarios to align with changes to the published CARC and RARC lists made by the respective Code Maintenance Committees as well as ongoing and evolving industry business needs?
  9. How are the CORE-required Code Combinations for CORE-defined Business Scenarios maintained via the CAQH CORE Code Combinations Maintenance Process?
  10. What is a CAQH CORE Code Combinations Compliance-based Review? When do these reviews occur?
  11. What is a CAQH CORE Code Combinations Market-based Review? When do these reviews occur?
  12. How can my organization submit new Business Scenarios for consideration during the CAQH CORE Code Combinations Market-based Review?
  13. Our health plan uses a code combination that meets the definition of a CORE-defined Business Scenario but is not currently included in the scenario’s maximum set of CORE-required Code Combinations in the CORE-required Code Combinations for CORE-defined Business Scenarios. How can we request addition of this code combination to the CORE-required maximum set?
  14. Does the CAQH CORE 360 Rule apply to batch, real time, or both batch and real time processing of the X12 v5010 835?
  15. How can my organization submit codes for consideration during the CAQH CORE Code Combinations Market-based Review?
  16. My organization is a health plan. What adjustments do we need to make to our internal system to conform to the CAQH CORE 360 Rule requirements for health plan use of the CORE-defined Claim Adjustment/Denial Business Scenarios and CORE-required Code Combinations?
  17. As a health plan, are we allowed by the CAQH CORE 360 Rule to use code combinations that are not included in the CORE-required Code Combinations for CORE-defined Business Scenarios for other business scenarios beyond the minimum set of CORE-defined Business Scenarios?
  18. Within the CORE-required Code Combinations for CORE-defined Business Scenarios, there are code combinations that include the same RARC in multiple CORE-defined Business Scenarios. As a health plan, to which CORE-defined Business Scenario should we map this RARC within our internal system?
  19. Within the CORE-required Code Combinations for CORE-defined Business Scenarios, the same RARC is included in multiple code combinations for a single CORE-defined Business Scenario. As a health plan, to which code combination should we map this RARC within our internal system?
  20. My organization is a health plan. All of the CORE-required Code Combinations for a specific CORE-defined Business Scenario are not applicable to our business needs. Does the CAQH CORE 360 Rule require a health plan to use CORE-defined Business Scenarios for which none of the maximum set of CORE-required Code Combinations is applicable to its business needs?
  21. My organization is a health plan. We currently use some of the CARCs and RARCs in the CORE-required Code Combinations for additional business scenarios (and associated code combinations) that we maintain in conjunction with the four CORE-defined Business Scenarios. Does the CAQH CORE 360 Rule permit us to continue to use these codes in our additional (non-CORE) business scenarios and code combinations?
  22. Some of the CORE-required Code Combinations in the CORE-required Code Combinations for CORE-defined Business Scenarios include only a CARC and CAGC (i.e., these is no RARC listed for use). As a health plan, does the CAQH CORE 360 Rule allow us to include a RARC in this CORE-required Code Combination for use with the CORE-defined Business Scenario?
  23. Does the CAQH CORE 360 Rule specify a maximum length for the description of the CARCs and RARCs that provider facing products extracting data from the X12 v5010 835 must display to the end user, per Rule Section 4.2?
  24. Does the CAQH CORE 360 Rule require health plans to develop and use additional business scenarios beyond those included in the minimum set of CORE-defined Business Scenarios?
  25. My organization is a health plan. We currently use CARCs, RARCs, and/or CAGCs that are not included in the maximum set of CORE-required Code Combinations and do not apply to any of the CORE-defined Business Scenarios. Does the CAQH CORE 360 Rule require us to make any changes to our internal system mappings specific to these CARCs, RARCs, or CAGCs?
  26. Section 4.2 of the CAQH CORE Rule specifies requirements for text that a product extracting the data from the X12 v5010 835 for manual processing must make available to the end user. How is “manual processing” defined for this requirement?
  27. Per Section 3.3, the CAQH CORE 360 Rule applies when entities process the X12 v5010 835 in either real time or batch. Does this requirement mean that the CAQH CORE 360 Rule requires entities to support both batch and real time processing of the X12 v5010 835?
  28. How will organizations be notified about and access new versions of the CORE-required Code Combinations for CORE-defined Business Scenarios?
  29. What is the schedule for adjustments to be made to the CORE-required Code Combinations for CORE-defined Business Scenarios?
  30. What is an Entry Confirmation Email?
  31. What is the purpose of the Unique Entry ID?
  32. How can an entry be deleted?
  33. What type of adjustments to the CORE-required Code Combinations for CORE-defined Business Scenarios will be considered during the 2016 Market-based Review?
  34. Can adjustments for potential new CORE-defined Business Scenarios can be submitted via the online CAQH CORE 2016 Market-based Adjustments Form?
  35. Does the Market-based Review (MBR) Form validate the CARCs and RARCs to ensure that they are valid codes?
  36. When will the approved Market-based Adjustments be published?
  37. If I submit an adjustment via the Market-based Review (MBR), will it automatically be added to the CORE-required Code Combinations?
  38. Why do I have to submit supporting information (i.e., an assessment of the CORE-required Code Combination Evaluation Criteria, a Business Case, and discretionary Real World Usage Data) for each Market-based Review (MBR) entry in my submission?
  39. Does CAQH CORE offer additional methods that organizations can use to submit Market-based Review (MBR) submissions beyond the online CAQH CORE 2016 Market-based Adjustments Form?
  40. If I hit “Finish Survey” on Part II of my organization’s online CAQH CORE 2016 Market-based Adjustments Form and realize, prior to the 01/31/17 submission deadline that I need to add additional entries to my submission, is a process available for my organization to add these entries?
  41. My organization is a subsidiary of a much larger company. The online Market-based Review (MBR) Form requires one submission per organization. However, I do not know who will be submitting from my organization. Can I submit a separate online MBR Form?
  42. What resources are available to assist entities in submitting potential Market-based Adjustments for consideration during the CAQH CORE 2016 Market-based Review of the CORE-required Code Combinations for CORE-defined Business Scenarios?
  43. How should entities implement code combinations in the CORE-required Code Combinations for the CORE-defined Business Scenarios that identify a CARC with a CAGC but without an associated RARC?
  44. My organization is a health plan that uses Alert RARCs to send information to providers about our internal remittance processing. Does use of these Alert RARCs constitute nonconformance with the CAQH CORE 360 Rule and associated CORE Code Combinations?
  45. How should health plans, and their agents, use the Change Log tab included in the CORE-required Code Combinations for the CORE-defined Business Scenarios Excel Workbook?
  46. Why do the CORE-required Code Combinations for the CORE-defined Business Scenarios not include all CARCs and RARCs identified in the published lists?
  47. My organization is a health plan. Can we continue to use a CARC that has been removed from a CORE-defined Business Scenario in an updated version of the CORE-required Code Combinations for the CORE-defined Business Scenarios?
  48. My organization is a health plan. We have identified CARCs and RARCs in the published lists that are not included in the CORE Code Combinations. Does the CAQH CORE 360 Rule require that health plans only use CARCs and RARCs that are included in the CORE Code Combinations?
1. Does my health plan organization have to support CORE-required Code Combinations that are not applicable to our business needs?

No. If a health plan does not have a business requirement to use a specific combination(s) within the maximum set of CORE-required Code Combinations for each CORE-defined Business Scenario, the CAQH CORE 360 Rule does not require the health plan, or its PBM agent, to use the code combination(s). CAQH CORE 360 Rule, Section 4.1.3, Use of CORE-required CARC/RARC/CAGC/NCPDP Reject Code Combinations, specifies that: “When specific CORE-required CARC/RARC/CAGC or CARC/NCPDP Reject Code/CAGC combinations are not applicable to meet the health plan’s or its PBM agent’s business requirements within the CORE-defined Business Scenarios, the health plan and its PBM agent is not required to use them.

2. Do all of the CARCs in the CORE-required Code Combinations tables have to be used with a corresponding RARC?

No. Any CARC in the CORE-required Code Combinations tables that is not required, by definition, to be used with a corresponding RARC may be used without any associated RARCs.

Claim Adjustment Reason Codes (CARCs) communicate the reason for a financial adjustment to a particular claim or service referenced in the X12 v5010 835. Remittance Advice Remark Codes (RARCs) provide supplemental information about why claim or service line has not been paid in full.

The majority of CARCs do not require RARCs to complete the message; however, there are some specific CARCs that always require use of an explanatory RARC. The CARC definition identifies if the code requires the use of a RARC. The Claim Adjustment Reason Codes list, which includes the code definitions, is available at the Washington Publishing Company website HERE.

3. To what types of entities do the requirements in Section 4.2, Basic Requirements for Receivers of the X12 v5010 835, of the CAQH CORE 360 Rule apply?

Section 4.2 of the CAQH CORE 360 Rule specifies requirements applicable to provider-facing vendor products that receive the X12 v5010 835 and extract the data content. Section 4.2 specifies the descriptive text that the provider-facing products must display to the provider end-user.

4. Why does the CAQH CORE 360 Rule require a minimum set of CORE-defined Business Scenarios with a maximum set of CORE-required Code Combinations to be supported by all health plans and their PBM agents?

As outlined in Section 1, Background Summary, of the CAQH CORE 360 Rule, the X12 v5010 835 delivers information to the provider regarding the payment of a claim and why the claim has not been paid in full (or has been rejected). This information is delivered via combinations of codes from four code sets (CARCs, RARCs, CAGCs, and NCPDP Reject Codes), used to supply the provider with the necessary detailed information regarding the payment of the claim.

Extensive confusion throughout the healthcare industry due to the inconsistent and varied use of these codes led the CORE Participants to determine that the healthcare industry would greatly benefit from operating rules that establish a maximum set of code combinations to be used for common Business Scenarios (in order to drive consistent and uniform use of these codes).

A maximum set of code combinations was determined for four common, high-volume Business Scenarios in the CAQH CORE 360 Rule. The CAQH CORE 360 Rule allows a health plan to develop additional Business Scenarios to meet its business needs. Long-term, a goal for the industry is to develop a uniform maximum set of code combinations for all Business Scenarios, but a multi-step process is needed to reach such a goal—in order to provide clear, well-researched requirements and build upon real-world results.

5. How were the minimum CORE-defined Claim Adjustment/Denial Business Scenarios and applicable maximum set of CORE-required Code Combinations identified?

The four specific Business Scenarios in the CAQH CORE 360 Rule were selected as they represent some of the most confusing and high volume scenarios that are exchanged between health plans and providers. The CORE Participants then agreed on a maximum set of CORE-required Code Combinations for the four CORE-defined Business Scenarios based on extensive data, and with the knowledge that the CAQH CORE 360 Rule specifically requires the list of CORE-required Code Combinations to be revisited at least three times annually. The data used included a mix of public surveys to target the issue, in-depth analysis of real-world code combinations in use by many existing industry initiatives, and claims-based CARC/RARC usage data by public and private entities. This cross-industry analysis led to the development of the CORE-required Code Combinations.

NOTE: The CAQH CORE 360 Rule does allow health plans, or their PBM agents, to develop additional Business Scenarios, and applicable code combinations, when the CORE-defined Business Scenarios do not meet their business needs. Additionally, per the CAQH CORE Code Combinations Maintenance Process, the CORE-required Code Combinations for CORE-defined Business Scenarios are maintained and updated due to evolving code lists and industry needs.

6. CAQH CORE 360 Rule, Section 4.2, Basic Requirements for Receivers of the X12 v5010 835, requires that provider facing products display text describing the CORE-defined Claim Adjustment/Denial Business Scenarios and CORE-required Code Combinations to the end user. Is there specific text that such products must display?

Yes. Section 4.2 of the CAQH CORE 360 Rule requires that products extracting data from an X12 v5010 835 for manual processing must make available to the end user:

  • Text describing the CARC/RARC/CAGC and CARC/NCPDP Reject Codes included in the remittance advice, ensuring that the actual wording of the text displayed accurately represents the corresponding code description specified in the code lists without changing the meaning and intent of the description
  • Text describing the corresponding CORE-defined Claim Adjustment/Denial Business Scenario

Descriptions of each CORE-defined Claim Adjustment/Denial Business Scenario can be found in Table 4.1.1-1 in the CAQH CORE 360 Rule. For the text describing the CARC/RARC/CAGC and CARC/NCPDP Reject Codes/CAGC, see:

  • For descriptions of the CARCs and RARCs: The Washington Publishing Company website Claim Adjustment Reason Codes list HERE and Remittance Advice Remark Codes list HERE
  • For descriptions of the CAGC: The ASC X12N v5010 835 Technical Report Type 3
  • For descriptions of the NCPDP Reject Codes: The NCPDP External Code List HERE
7. Does my provider-facing product satisfy the requirements under Section 4.2, Basic Requirements for Receivers of the X12 v5010 835, of the CAQH CORE 360 Rule if it displays only the descriptions of the CARC/RARC/CAGC and CARC/NCPDP Reject Codes/CAGC include in the X12 v5010 835?

No. Section 4.2 of the CAQH CORE 360 Rule requires that products extracting data from an X12 v5010 835 for manual processing must make available to the end user:

  • Text describing the CARC/RARC/CAGC and CARC/NCPDP Reject Codes included in the remittance advice, ensuring that the actual wording of the text displayed accurately represents the corresponding code description specified in the code lists without changing the meaning and intent of the description
  • Text describing the corresponding CORE-defined Claim Adjustment/Denial Business Scenario

Displaying only the description of the CARCs and RARCs does not satisfy the Section 4.2 requirement.

Descriptions of each CORE-defined Claim Adjustment/Denial Business Scenario can be found in Table 4.1.1-1 in the CAQH CORE 360 Rule. For the text describing the CARC/RARC/CAGC and CARC/NCPDP Reject Codes, see:

  • For descriptions of the CARCs and RARCs: The Washington Publishing Company website Claim Adjustment Reason Codes list HERE and Remittance Advice Remark Codes list HERE
  • For descriptions of the CAGC: The ASC X12N v5010 835 Technical Report Type 3
  • For descriptions of the NCPDP Reject Codes: The NCPDP External Code List HERE
8. How does the CAQH CORE 360 Rule address the need for the CORE-required Code Combinations for CORE-defined Business Scenarios to align with changes to the published CARC and RARC lists made by the respective Code Maintenance Committees as well as ongoing and evolving industry business needs?

The goal of the CAQH CORE 360 Rule is to ensure consistent use of the CARCs and RARCs across the industry. Section 3.5, CORE Process for Maintaining CORE-defined Claim Adjustment Reason Code, Remittance Advice Remark Code & Claim Adjustment Group Code Combinations, of the CAQH CORE 360 Rule supports the concept that the CORE-defined Business Scenarios and the CORE-required Code Combinations will evolve over time to ensure ongoing compliance with the published code lists and evolving industry needs.

Section 3.5 of the CAQH CORE 360 Rule highlights key components for a CAQH CORE Code Combinations Maintenance Process; specifically, the rule:

  • Recognizes that the CAQH CORE 360 Rule supports the X12 v5010 835 mandated standard
  • Focuses on four key business scenarios (with associated code combinations) as a starting point
  • Recognizes that the CAQH CORE 360 Rule supports code sets that are subject to revision three or more times a year; for the CARCs and RARCs, Code Committees external to the ASC X12 Standards Committee are authors of the published codes and meet at least three times per year
  • Recognizes that the CAQH CORE 360 Rule enables immediate use by the industry of new codes added to the code lists since the last adjustments to the CORE-required Code Combinations for CORE-defined Business Scenarios and prohibits the use of deactivated codes
  • Establishes an open CAQH CORE process for soliciting feedback and input from the industry on a periodic basis, no less than three times per year for updating the CORE-required Code Combinations for CORE-defined Business Scenarios

Additionally, the CAQH CORE Guiding Principles require that the CAQH CORE Operating Rules align with current standards, codes sets, and other Federal initiatives.

Per the CAQH CORE Code Combinations Maintenance Process updated versions of the CORE-required Code Combinations for CORE-defined Business Scenarios have been released. For more detail on the CAQH CORE Code Combinations Maintenance Process see “How are the CORE-required Code Combinations for CORE-defined Business Scenarios maintained via the CAQH CORE Code Combinations Maintenance Process?

9. How are the CORE-required Code Combinations for CORE-defined Business Scenarios maintained via the CAQH CORE Code Combinations Maintenance Process?

To meet the requirements of the CAQH CORE 360 Rule for an open, consensus-based maintenance process and ensure ongoing alignment with the current published CARC and RARC lists maintained by their respective Code Maintenance Committees, the CAQH CORE Code Combinations Maintenance Process was launched in 2012 via the CAQH CORE Code Combinations Task Group.

CAQH CORE conducts two types of review and adjustment of the CORE Code Combinations:

  • Compliance-based Reviews: Occur three times per year and only consider additions, deactivations, or modifications to the current published CARC and RARC lists by the code committees since the last update to the CORE-required Code Combinations for CORE-defined Business Scenarios
  • Market-based Reviews: Occur once a year and address ongoing and evolving industry business needs, a Market-based Review considers industry submissions addressing:
    • Adjustments to the existing CORE-required Code Combinations for existing CORE-defined Business Scenarios (additions, removals, etc.) based on real world usage data and a strong business case
    • Addition of new CORE-defined Business Scenarios and associated code combinations based on real world usage data and a strong business case

The CAQH CORE Code Combinations Task Group, which is responsible for maintaining the CORE-required Code Combinations, is open to representatives from any CORE Participating Organization. Individuals from CORE Participating Organizations with knowledge of the related business process and work flow of the usage of the CARCs and RARCs are encouraged to join.

10. What is a CAQH CORE Code Combinations Compliance-based Review? When do these reviews occur?

Per the CAQH CORE Code Combinations Maintenance Process, Compliance-based Reviews occur three times per year and only consider additions, deactivations, or modifications to the published CARC and RARC lists by the code committees since the last update to the CORE-required Code Combinations for CORE-defined Business Scenarios.

A Compliance-based Review is triggered when the current published CARC and RARC lists are updated, which occurs three times per year. The CAQH CORE Code Combinations Task Group, which is responsible for maintaining the CORE-required Code Combinations, will review any additions, deactivations, or modifications to the published CARC and RARC lists by the code committees since the last update to the CORE-required Code Combinations for CORE-defined Business Scenarios. Once the Task Group agrees on adjustments a new version of the CORE-required Code Combinations for CORE-defined Business Scenarios is published, an announcement to the industry is distributed, and the CAQH CORE website is updated.

11. What is a CAQH CORE Code Combinations Market-based Review? When do these reviews occur?

Per the CAQH CORE Code Combinations Maintenance Process, Market-based Reviews occur once a year and address ongoing and evolving industry business needs, a Market-based Review considers industry submissions addressing:

  • Adjustments to the existing CORE-required Code Combinations for existing CORE-defined Business Scenarios (additions, removals, etc.) based on real world usage data and a strong business case
  • Addition of new CORE-defined Business Scenarios and associated code combinations based on real world usage data and a strong business case
12. How can my organization submit new Business Scenarios for consideration during the CAQH CORE Code Combinations Market-based Review?

The 2016 Market-based Review (MBR) of the CORE-required Code Combinations for CORE-defined Business Scenarios will only consider adjustments to the code combinations in the existing four CORE-defined Business Scenarios. Entities can submit requests for Market-based Adjustments to the existing CORE-defined Business Scenarios via the online CAQH CORE 2016 Market-based Adjustments Form. Requests for new CORE-defined Business Scenarios cannot be submitted via the 2016 Potential Market-based Adjustments Form.

NOTE: During its review of the potential new CORE-defined Business Scenarios submitted via the 2014 industry survey, the CORE Code Combinations Task Group agreed to defer additional collection and consideration of potential new CORE-defined Business Scenarios until such time as a process has been confirmed for regulatory adoption into the Federal mandate of any new Business Scenarios approved by the CORE Code Combinations Task Group. CAQH CORE is exploring the options for such a regulatory process. 

13. Our health plan uses a code combination that meets the definition of a CORE-defined Business Scenario but is not currently included in the scenario’s maximum set of CORE-required Code Combinations in the CORE-required Code Combinations for CORE-defined Business Scenarios. How can we request addition of this code combination to the CORE-required maximum set?

To better align with the existing CORE-required Code Combinations for CORE-defined Business Scenarios, your health plan should first consider if there is CORE-required Code Combination already in the current, published version of the CORE-required Code Combinations for CORE-defined Business Scenarios that conveys the same meaning as the excluded code. If so, your health plan could use the published code combination in order to align with the goals of the CAQH CORE 360 Rule, which promotes uniform and consistent code usage across the industry.

Additionally, your health plan may elect to submit a request for the code combination to be added to the CORE-defined Business Scenario for consideration during the annual Market-based Review of the CORE Code Combinations. Market-based Reviews occur once a year and address ongoing and evolving industry business needs. For each annual Market-based Review, CAQH CORE will distribute a call for industry submissions with a link to an online form that entities can use to submit recommendations for potential Market-based Adjustments. For more information on how to submit a request for a potential Market-based Adjustment to the CORE Code Combinations, contact core@caqh.org.

Health plans can also evaluate if the code combination constitutes a potential “emergency code combination addition” to the CORE Code Combinations. A criteria-based CAQH CORE Emergency Code Combination Addition Process, developed in collaboration with and response to the CMS National Standards Group (NSG), enables a nimble emergency review and potential emergency addition of existing code combinations. Such an emergency addition would mean the codes are not included in the most current version of the CORE Code Combinations and the entity cannot wait until the next Compliance-based or Market-based Review due to new legislation, regulation, or a brand new product. The process outlines steps and criteria to ensure adherence to the term “emergency” and a focus by the industry on planning for the reoccurring Market-based and Compliance-based Reviews. The CAQH CORE Emergency Code Combination Addition Process will evolve over time based on industry experience. If you determine the code combinations meets the criteria outlined, please submit an Emergency Update Request using the form found HERE.

14. Does the CAQH CORE 360 Rule apply to batch, real time, or both batch and real time processing of the X12 v5010 835?

The CAQH CORE 360 Rule applies to both batch and real time processing. Per Section 3.3, When the Rule Applies, of the CAQH CORE 360 Rule, “This rule applies when an entity uses, conducts or processes the X12 v5010 835.” Therefore, anytime an entity uses, conducts, or processes the X12 v5010 835, whether in real time or in batch processing mode, the rule applies.

15. How can my organization submit codes for consideration during the CAQH CORE Code Combinations Market-based Review?

Per the established CAQH CORE Code Combinations Maintenance Process, Market-based Reviews occur once a year. The 2016 Market-based Review (MBR) of the CORE-required Code Combinations for CORE-defined Business Scenarios launched in November 2016. The 2016 MBR will consider adjustments to the code combinations in the existing four CORE-defined Business Scenarios.

CAQH CORE distributed a call for industry submissions with a link to an online form that entities can use to submit recommendations for potential Market-based Adjustments during the 60-day submission period. Email core@caqh.org to be added to the distribution list. You can also access the online CAQH CORE 2016 Market-based Adjustments Form HERE during the 60-day submission period. 

For more information on submitting potential adjustments to the CORE-defined Business Scenarios during the 2016 Market-based Review see “What type of adjustments to the CORE-required Code Combinations for CORE-defined Business Scenarios will be considered during the 2016 Market-based Review?”

16. My organization is a health plan. What adjustments do we need to make to our internal system to conform to the CAQH CORE 360 Rule requirements for health plan use of the CORE-defined Claim Adjustment/Denial Business Scenarios and CORE-required Code Combinations?

The CAQH CORE 360 Rule specifies a minimum set of CORE-defined Claim Adjustment/Denial Business Scenarios with an associated maximum set of CORE-required Code Combinations. CAQH CORE 360 Rule Sections 4.1.2, Uniform Use of Claim Adjustment Reason Codes, Remittance Advice Remark Codes, Claim Adjustment Group Codes & NCPDP Reject Codes, and 4.1.3, Use of CORE-required CARC/RARC/CAGC/NCPDP Reject Code Combinations, require a health plan, or its PBM agent, to:

  • Align its internal codes and corresponding business scenarios to the CORE-defined Business Scenarios and code combinations specified in the CORE-required Code Combinations for CORE-defined Business Scenarios
    • NOTE: If a health plan does not have a business requirement to use a specific CORE-required Code Combination(s), the health plan, or its PBM agent, is not required to use the code combination(s).
  • Support the maximum set of CORE-required code combinations as specified in the CORE-required Code Combinations for CORE-defined Business Scenarios; no other code combinations beyond the CORE-required set are allowed for use with the CORE-defined Business Scenarios.
    • NOTE: When a new code is created or an existing code adjusted by the respective code maintenance committees, the new or adjusted code can be used with the CORE-defined Business Scenarios until its continued used is reviewed per the CAQH CORE Code Combinations Maintenance Process.

Additionally, the CAQH CORE 360 Rule allows a health plan, or its PBM agent, to use additional business scenarios, and associated code combinations, beyond those specified in the CORE-required Code Combinations for CORE-defined Business Scenarios when the CORE-defined Business Scenarios do not meet its business needs.

17. As a health plan, are we allowed by the CAQH CORE 360 Rule to use code combinations that are not included in the CORE-required Code Combinations for CORE-defined Business Scenarios for other business scenarios beyond the minimum set of CORE-defined Business Scenarios?

Yes. The CAQH CORE 360 Rule allows a health plan, or its PBM agent, to develop additional business scenarios, and associated code combinations, when the CORE-defined Business Scenarios do not meet its business needs.

However, per Section 4.1.3, Use of CORE-required CARC/RARC/CAGC/NCPDP Reject Code Combinations, of the CAQH CORE 360 Rule, a health plan, or its PBM agent, cannot use other code combinations beyond the CORE-required maximum set with the CORE-defined Business Scenarios. Additionally, per Section 4.1.1, CORE-defined Claim Adjustment/Denial Business Scenarios, any additional business scenarios must not conflict with the CORE-defined Business Scenarios.

NOTE: Per the CAQH CORE Code Combinations Maintenance Process, the CORE-defined Business Scenarios and CORE-required Code Combinations will evolve over time; new CORE-defined Business Scenarios and associated code combinations will be added based on real world usage data and a strong business case. For information on how to submit Business Scenarios for consideration to be added to the CORE-defined set, see “How can my organization submit new Business Scenarios for consideration during the CAQH CORE Code Combinations Market-based Review?

18. Within the CORE-required Code Combinations for CORE-defined Business Scenarios, there are code combinations that include the same RARC in multiple CORE-defined Business Scenarios. As a health plan, to which CORE-defined Business Scenario should we map this RARC within our internal system?

Per Section 4.1.2, Uniform Use of Claim Adjustment Reason Codes, Remittance Advice Remark Codes, Claim Adjustment Group Codes & NCPDP Reject Codes, of the CAQH CORE 360 Rule, a health plan (or its PBM agent) must “align its internal codes and corresponding business scenarios to the CORE-defined Claim Adjustment/Denial Business Scenarios specified in §4.1.1 and the CARC, RARC, CAGC and NCPDP Reject Code combinations specified in the CORE-required Code Combinations for CORE-defined Business Scenarios.doc.”

If a single RARC is included in code combinations for multiple CORE-defined Business Scenarios, the health plan should map the RARC to all associated CORE-defined Business Scenarios.

NOTE: If a health plan does not have a business requirement to use a specific CORE-required Code Combination(s), the health plan, or its PBM agent, is not required to use the code combination(s).

19. Within the CORE-required Code Combinations for CORE-defined Business Scenarios, the same RARC is included in multiple code combinations for a single CORE-defined Business Scenario. As a health plan, to which code combination should we map this RARC within our internal system?

Per Section 4.1.2, Uniform Use of Claim Adjustment Reason Codes, Remittance Advice Remark Codes, Claim Adjustment Group Codes & NCPDP Reject Codes, of the CAQH CORE 360 Rule, a health plan (or its PBM agent) must “align its internal codes and corresponding business scenarios to the CORE-defined Claim Adjustment/Denial Business Scenarios specified in §4.1.1 and the CARC, RARC, CAGC and NCPDP Reject Code combinations specified in the CORE-required Code Combinations for CORE-defined Business Scenarios.doc.”

If a single RARC is included in multiple code combinations for a single CORE-defined Business Scenario, the health plan should map the RARC to one or all associated code combinations for the specific CORE-defined Business Scenario.

NOTE: If a health plan does not have a business requirement to use a specific CORE-required Code Combination(s), the health plan, or its PBM agent, is not required to use the code combination(s).

20. My organization is a health plan. All of the CORE-required Code Combinations for a specific CORE-defined Business Scenario are not applicable to our business needs. Does the CAQH CORE 360 Rule require a health plan to use CORE-defined Business Scenarios for which none of the maximum set of CORE-required Code Combinations is applicable to its business needs?

No. If a health plan does not adjust or deny claims according to any of the CORE-required Code Combinations for a specific CORE-defined Business Scenario, the CAQH CORE 360 Rule does not require the health plan, or its PBM agent, to use that Business Scenario.

Section 4.1.3, Use of CORE-required CARC/RARC/CAGC/NCPDP Reject Code Combinations, of the CAQH CORE 360 Rule specifies that: “When specific CORE-required CARC/RARC/CAGC or CARC/NCPDP Reject Code/CAGC combinations are not applicable to meet the health plan’s or its PBM agent’s business requirements within the CORE-defined Business Scenarios, the health plan and its PBM agent is not required to use them”. If all of the CORE-required Code Combinations for a specific CORE-defined Business Scenario are not applicable to a health plan’s business needs, the health plan is not required to use any of the code combinations and, therefore, would not use the CORE-defined Business Scenario.

21. My organization is a health plan. We currently use some of the CARCs and RARCs in the CORE-required Code Combinations for additional business scenarios (and associated code combinations) that we maintain in conjunction with the four CORE-defined Business Scenarios. Does the CAQH CORE 360 Rule permit us to continue to use these codes in our additional (non-CORE) business scenarios and code combinations?

Yes. A health plan, or its PBM agent, may use any CARCs, RARCs, NCPDP Reject Codes, and/or CAGCs included in the CORE-required Code Combinations for additional (non-CORE) business scenarios, and associated code combinations, providing that the additional business scenarios, and code combinations, do not conflict with the CORE-required Code Combinations for the CORE-defined Business Scenarios, e.g. the same code combination cannot be used for multiple business scenarios.

Per Sections 4.1.1, CORE-defined Claim Adjustment/Denial Business Scenarios, and 4.1.2, Uniform Use of Claim Adjustment Reason Codes, Remittance Advice Remark Codes, Claim Adjustment Group Codes & NCPDP Reject Codes, of the CAQH CORE 360 Rule, a health plan (or its PBM agent):

  • Must align its internal codes and corresponding business scenarios to the CORE-defined Business Scenarios, and associated code combinations, as specified in the CORE-required Code Combinations for CORE-defined Business Scenarios. No additional code combinations beyond the CORE-required maximum set are allowed for use with the CORE-defined Business Scenarios.
    • NOTE: Per Section 4.1.3, Use of CORE-required CARC/RARC/CAGC/NCPDP Reject Code Combinations, when a new code is created or an existing code adjusted by the respective code maintenance committees, the new or adjusted code can be used with the CORE-defined Business Scenarios until its continued used is reviewed per the CAQH CORE Code Combinations Maintenance Process.
  • May develop additional business scenarios, and associated code combinations, when the CORE-defined Business Scenarios do not meet its business needs. Any additional business scenarios must not conflict with the CORE-defined Business Scenarios.

Please Note: The intent of the CAQH CORE 360 Rule is that all CARCs should be mapped to a single claim denial/adjustment business scenario in order to promote uniform and consistent CARC use across the industry. This intent is highlighted in the evaluation criteria that were used by the CORE Participants to develop the CORE-required Code Combinations and are also used by the CAQH CORE Code Combinations Task Group to evaluate potential adjustments to the CORE-required Code Combinations. The criteria state that “Each (CORE-required) CARC must be used with only one CORE-defined Business Scenario”.

22. Some of the CORE-required Code Combinations in the CORE-required Code Combinations for CORE-defined Business Scenarios include only a CARC and CAGC (i.e., these is no RARC listed for use). As a health plan, does the CAQH CORE 360 Rule allow us to include a RARC in this CORE-required Code Combination for use with the CORE-defined Business Scenario?

No. A health plan must not add a RARC to any CORE-required Code Combinations that include only a CARC and a CAGC. Including an unlisted RARC constitutes creation of a new code combination beyond the maximum CORE-required Code Combinations. As noted below, the CAQH CORE 360 Rule prohibits a health plan, and its PBM agent, from using additional code combinations beyond the CORE-required maximum set with the CORE-defined Business Scenarios.

Per Sections 4.1.1, CORE-defined Claim Adjustment/Denial Business Scenarios, and 4.1.2, Uniform Use of Claim Adjustment Reason Codes, Remittance Advice Remark Codes, Claim Adjustment Group Codes & NCPDP Reject Codes, of the CAQH CORE 360 Rule, a health plan (or its PBM agent):

  • Must align its internal codes and corresponding business scenarios to the CORE-defined Business Scenarios, and associated code combinations, as specified in the CORE-required Code Combinations for CORE-defined Business Scenarios. No additional code combinations beyond the CORE-required maximum set are allowed for use with the CORE-defined Business Scenarios.
    • NOTE: Per Section 4.1.3, Use of CORE-required CARC/RARC/CAGC/NCPDP Reject Code Combinations, when a new code is created or an existing code adjusted by the respective code maintenance committees, the new or adjusted code can be used with the CORE-defined Business Scenarios until its continued used is reviewed per the CAQH CORE Code Combinations Maintenance Process.
  • May develop additional business scenarios, and associated code combinations, when the CORE-defined Business Scenarios do not meet its business needs. Any additional business scenarios must not conflict with the CORE-defined Business Scenarios.
23. Does the CAQH CORE 360 Rule specify a maximum length for the description of the CARCs and RARCs that provider facing products extracting data from the X12 v5010 835 must display to the end user, per Rule Section 4.2?

No. The CAQH CORE 360 Rule does not specify requirements regarding the length of the text describing the CARC/RARC/CAGC and CARC/NCPDP Reject Codes that provider facing products extracting data from the X12 v5010 835 must display to the end user per Section 4.2, Basic Requirements for Receivers of the X12 v5010 835.

To meet the Section 4.2 requirements for descriptions of the CARC/RARC/CAGC and CARC/NCPDP Reject Code/CAGC vendor products should provide text using the code descriptions issued in the published code lists which are authored by the code committees. For the code descriptions, see:

  • For descriptions of the CARCs and RARCs: The Washington Publishing Company website Claim Adjustment Reason Codes list HERE and Remittance Advice Remark Codes list HERE
  • For descriptions of the CAGC: The ASC X12N v5010 835 Technical Report Type 3
  • For descriptions of the NCPDP Reject Codes: The NCPDP External Code List HERE
24. Does the CAQH CORE 360 Rule require health plans to develop and use additional business scenarios beyond those included in the minimum set of CORE-defined Business Scenarios?

No, the CAQH CORE 360 Rule does not require health plans to develop and use additional business scenarios beyond the CORE-defined Business Scenarios.

Section 4.1.1, CORE-defined Claim Adjustment/Denial Business Scenarios, of the CAQH CORE 360 Rule specifies that, “When a specific CORE-defined Business Scenario is not applicable to meet the health plan’s, or its PBM agent’s, business needs, a health plan or its PBM agent may develop additional Business Scenarios and code combinations for them. Any additional Business Scenarios must not conflict with the CORE-defined Claim Adjustment/Denial Business Scenarios defined in this section.” This language is included to clarify that the CAQH CORE Rule allows health plans to develop additional business scenarios to fulfill business needs not addressed by the minimum set of CORE-defined Business Scenarios. However, the CAQH CORE Rule does not require health plans to develop these scenarios.

25. My organization is a health plan. We currently use CARCs, RARCs, and/or CAGCs that are not included in the maximum set of CORE-required Code Combinations and do not apply to any of the CORE-defined Business Scenarios. Does the CAQH CORE 360 Rule require us to make any changes to our internal system mappings specific to these CARCs, RARCs, or CAGCs?

No. The CAQH CORE 360 Rule does not require health plans to alter their internal system mappings for CARC, RARC, or CAGC codes that are not included in the CORE-required Code Combinations for CORE-defined Business Scenarios. Beyond the requirement for health plans to align their internal codes and business scenarios with the CORE-required Code Combinations, the CAQH CORE 360 Rule does not require additional changes to a health plan’s internal code mapping.

Please Note:

  • Per Section 4.1.3, Use of CORE-required CARC/RARC/CAGC/NCPDP Reject Code Combinations, of the CAQH CORE 360 Rule, a health plan, or its PBM agent, cannot use other code combinations beyond the CORE-required maximum set with the CORE-defined Business Scenarios. If a health plan’s internal system currently maps additional code combinations beyond the CORE-required maximum set to the CORE-defined Business Scenarios, the health plan will have to remediate it system to remove these non-conformant mappings.
  • The CAQH CORE Code Combinations Maintenance Process anticipates that the CORE-required Code Combinations for CORE-defined Business Scenarios will be adjusted at least three times per year to ensure ongoing compliance with the published code lists and address evolving industry needs. New Business Scenarios, and associated code combinations, will be added based on real world usage data and a strong business case. Your organization should check the CAQH CORE website periodically as reviews occur. CAQH CORE also sends an email notification when an updated version of the CORE-required Code Combinations for CORE-defined Business Scenarios is published; email core@caqh.org to be added to the distribution list.
26. Section 4.2 of the CAQH CORE Rule specifies requirements for text that a product extracting the data from the X12 v5010 835 for manual processing must make available to the end user. How is “manual processing” defined for this requirement?

Section 4.2, Basic Requirements for Receivers of the X12 v5010 835, of the CAQH CORE 360 Rule requires products extracting the data from the v5010 X12 835 for manual processing to display:

  • Text describing the CARC/RARC/CAGC and CARC/NCPDP Reject Codes included in the remittance advice, ensuring that the actual wording of the text displayed accurately represents the corresponding code description specified in the code lists without changing the meaning and intent of the description
  • Text describing the corresponding CORE-defined Claim Adjustment/Denial Business Scenario

As referenced in the CAQH CORE 360 Rule, “manual processing” refers to any data processing conducted via human manipulation, i.e., processing not done automatically by a machine. This reference includes any manual intervention by a human that is required to post the X12 v5010 835 to the provider’s Practice Management System (PMS).

27. Per Section 3.3, the CAQH CORE 360 Rule applies when entities process the X12 v5010 835 in either real time or batch. Does this requirement mean that the CAQH CORE 360 Rule requires entities to support both batch and real time processing of the X12 v5010 835?

No. Per Section 3.3, When the Rule Applies, of the CAQH CORE 360 Rule, the CAQH CORE 360 Rule applies when an entity uses, conducts, or processes the X12 v5010 835, either in real time or batch processing mode. The CAQH CORE 360 Rule does not specify requirements regarding what processing mode entities must support for the X12 v5010 835.

The CAQH CORE 350: Health Care Claim Payment/Advice (835) Infrastructure Rule does specify one processing mode that entities must offer for the X12 v5010 835 (other processing modes can also be offered). Section 4.1, Health Care Claim Payment/Advice Connectivity Requirements, of the CAQH CORE 350 Rule requires entities to support the use of the CORE Connectivity Safe Harbor, as described in the CAQH CORE 270: Connectivity Rule Version 2.2.0, to send/receive the X12 v5010 835. Per Section 4.1, “This requirement addresses usage patterns for batch transactions, the exchange of security identifiers, and communications-level errors and acknowledgements.”

To comply with the CAQH CORE 350 Rule requirements, entities must support batch processing of the X12 v5010 835, in conformance with the CAQH CORE 270 Rule requirements for batch processing mode. While the CAQH 350 CORE Rule does not require the exchange of the X12 v5010 835 in real time, it does not prohibit it. Therefore, conducting the X12 v5010 835 in real time could be mutually agreed to between trading partners.

28. How will organizations be notified about and access new versions of the CORE-required Code Combinations for CORE-defined Business Scenarios?

Per the CAQH CORE Code Combinations Maintenance Process, CAQH CORE conducts two types of review and adjustment to the CORE-required Code Combinations and CORE-defined Business Scenarios:

  • Compliance-based Reviews: Occur three times per year and only consider additions, deactivations, or modifications to the current published CARC and RARC lists by the code committees since the last update to the CORE-required Code Combinations for CORE-defined Business Scenarios
  • Market-based Reviews: Occur once a year and address ongoing and evolving industry business needs; consider industry submissions for adjustments to the existing CORE-required Code Combinations for existing CORE-defined Business as well as addition of new CORE-defined Business Scenarios, and associated code combinations, based on real world usage data and a strong business case
    • NOTE: Any organization can submit potential adjustments for consideration during the Market-based Review. A call for submissions of Market-based Adjustments via a pre-defined template will be distributed by CAQH CORE and recommendations can be submitted via the template during the submission timeframe.

Once the Compliance-based and/or Market-based Adjustments have been approved, an updated version of the CORE-required Code Combinations for CORE-defined Business Scenarios will be published. Publication of an updated version of the CORE-required Code Combinations for the CORE-defined Business Scenarios will be announced on the CAQH CORE webpage. CAQH CORE will also send email notifications when updated versions of the CORE-required Code Combinations for CORE-defined Business Scenarios are published; email core@caqh.org to be added to the distribution list. Updated versions of the CORE-required Code Combinations for CORE-defined Business can be accessed free of charge via the CAQH CORE website HERE.

For more detail on the CAQH CORE Code Combinations Maintenance Process see “How are the CORE-required Code Combinations for CORE-defined Business Scenarios maintained via the CAQH CORE Code Combinations Maintenance Process?

29. What is the schedule for adjustments to be made to the CORE-required Code Combinations for CORE-defined Business Scenarios?

Per the CAQH CORE Code Combinations Maintenance Process, CAQH CORE conducts two types of review and adjustment to the CORE-required Code Combinations and CORE-defined Business Scenarios:

  • Compliance-based Reviews: Occur three times per year and only consider additions, deactivations, or modifications to the current published CARC and RARC lists by the code committees since the last update to the CORE-required Code Combinations for CORE-defined Business Scenarios
    • Compliance-based Reviews are triggered when the current published CARC and RARC lists are updated, which occurs three times per year.
  • Market-based Reviews: Occur once a year and address ongoing and evolving industry business needs; consider industry submissions for adjustments to the existing CORE-required Code Combinations for existing CORE-defined Business as well as addition of new CORE-defined Business Scenarios, and associated code combinations, based on real world usage data and a strong business case
    • NOTE: Any organization can submit potential adjustments for consideration during the Market-based Review. A call for submissions of Market-based Adjustments via a pre-defined template will be distributed by CAQH CORE and recommendations can be submitted via the template during the submission timeframe.

The goal for the CAQH CORE Code Combinations is to publish three versions of the CORE-required Code Combinations for CORE-defined Business Scenarios per year to ensure ongoing compliance with the published code lists and address evolving industry needs. One version of the document will include both Compliance and Market-based updates. As entities align their systems to the CORE-required Code Combinations and CORE-defined Business Scenarios, they should incorporate processes that allow system remediation to occur three times per year.

Timeline for Maintenance of CORE-required Code Combinations for CORE-defined Business Scenario

For more detail on the CAQH CORE Code Combinations Maintenance Process see “How are the CORE-required Code Combinations for CORE-defined Business Scenarios maintained via the CAQH CORE Code Combinations Maintenance Process?

30. What is an Entry Confirmation Email?

An Entry Confirmation Email is sent to the submitter after each new entry (e.g., a specific code combination addition, removal, or relocation) is received by CAQH CORE. The Entry Confirmation Email is useful to submitters as it includes a copy of that entry for their records (including evaluation criteria selected, business case, usage data, etc.).

The Entry Confirmation Email also includes a Unique Entry ID. The Unique Entry ID allows the submitter to track the progress of their submissions and avoid duplicate entries given you can delete entries. Submitters will receive an Entry Confirmation Email for each entry made in Part II of the online CAQH CORE 2016 Market-based Adjustments Form. As an example, if a submitter includes 5 code additions, 2 code deletions, and 2 code relocations in their organization’s total submission, they will receive 9 confirmation emails. You MUST complete all required fields in order to finalize an entry and receive your Entry Confirmation Email.

31. What is the purpose of the Unique Entry ID?

The Unique Entry ID allows the submitter to track the progress of their submissions and avoid duplicate entries. For submitters that start and stop their submission over multiple days, these emails will help them track where they are in the submission process. Additionally, submitters can use the Unique Entry ID to identify an entry if they decide to delete it.

32. How can an entry be deleted?

To delete an entry, submitters will need either the Unique Entry ID associated with the entry to be deleted or the specific codes submitted in the entry. From the Navigation Page for 2016 Market-based Adjustments Submissions webpage, select “Delete a Previous Entry". A drop down list will be provided from which submitters can select a previously entered submission. The submissions will be identified by the Unique Entry ID and the CARC/RARC/CAGC combination submitted. 

33. What type of adjustments to the CORE-required Code Combinations for CORE-defined Business Scenarios will be considered during the 2016 Market-based Review?

The 2016 Market-based Review (MBR) will consider adjustments to the code combinations in the existing four CORE-defined Business Scenarios. As shown in the table below, the online CAQH CORE 2016 Market-based Adjustments Form enables entities to submit requests for additions, removals, and relocations to the code combinations in the existing four CORE-defined Business Scenarios. 

34. Can adjustments for potential new CORE-defined Business Scenarios can be submitted via the online CAQH CORE 2016 Market-based Adjustments Form?

No, adjustments for new CORE-defined Business Scenarios cannot be submitted via the CAQH CORE 2016 Market-based Adjustments Form. During its review of the potential new CORE-defined Business Scenarios submitted via the 2014 industry survey, the CORE Code Combinations Task Group agreed to defer additional collection and consideration of potential new CORE-defined Business Scenarios until such time as a process has been confirmed for regulatory adoption into the Federal mandate of any new Business Scenarios approved by the CORE Code Combinations Task Group. CAQH CORE is exploring the options for such a regulatory process.

35. Does the Market-based Review (MBR) Form validate the CARCs and RARCs to ensure that they are valid codes?

Yes, the online CAQH CORE 2016 Market-based Adjustments Form validates CARC and RARC entries against the 11/01/16 code lists published by the Washington Publishing Company (WPC), the authorized publisher of the CARC and RARC lists. CAQH CORE is validating the codes against these lists given all entities must use the codes that the independent CARC and RARC Committees publish three times a year; the 11/01/16 lists are the current list of codes.

NOTE: CAQH CORE is not the entity that develops and maintains the CARC and RARC lists:

  • The CARC list is maintained by ASC X12. The published CARC list is updated in March, July, and November and published online by WPC.
  • The RARC list is maintained by the CMS Remittance Advice Remark Code Committee. The published RARC list is updated tri-annually at the end of March, July, and November and published online by WPC.
36. When will the approved Market-based Adjustments be published?

After the Market-based Review (MBR) Submission Period closes, the CORE Code Combinations Task Group (CCTG) will begin its review of submissions. CAQH CORE anticipates that the updated version of the CORE-required Code Combinations for CORE-defined Business Scenarios, scheduled for publication on 06/09/17, will include both the Market-based and Compliance-based adjustments (due to the 03/01/17 published code list updates) approved by the CCTG.

For more information on the CCTG and timeline for publication of new versions of the CORE-required Code Combinations see What is the schedule for adjustments to be made to the CORE-required Code Combinations for CORE-defined Business Scenarios?

37. If I submit an adjustment via the Market-based Review (MBR), will it automatically be added to the CORE-required Code Combinations?

No. The CORE Code Combinations Task Group (CCTG) will review all entries and supporting information for each entry (i.e., Evaluation Criteria, Business Case, and Discretionary Usage Data) submitted via the MBR submission process.

Using the CORE-required Code Combinations Evaluation Criteria, the CCTG will discuss and conduct straw polls as needed to determine CCTG support for Market-based code combination adjustments to the CORE-required Code Combinations and the addition of new CORE-defined Business Scenarios. These evaluation criteria were used by the CORE Participants to develop the CORE-required Code Combinations and are also used by the Task Group to evaluate potential adjustments to the CORE-required Code Combinations.

The CCTG may not approve all MBR submissions received given the goal of the CAQH CORE 360 Rule is to enable more uniform use of the CARC, RARC, and CAGCs across the industry. Rather than increasing the number of code combinations in use in the industry, the CAQH CORE 360 Rule aims to identify CARC/RARC/CAGC combinations that clearly convey the reason for a claim payment adjustment/denial while avoiding redundant code combinations.

For more information on the CCTG and the CAQH CORE Code Combinations Maintenance Process see “How are the CORE-required Code Combinations for CORE-defined Business Scenarios maintained via the CAQH CORE Code Combinations Maintenance Process?

38. Why do I have to submit supporting information (i.e., an assessment of the CORE-required Code Combination Evaluation Criteria, a Business Case, and discretionary Real World Usage Data) for each Market-based Review (MBR) entry in my submission?

The CORE Code Combinations Task Group (CCTG) spent significant time and effort to design the CAQH CORE Market-based Adjustments Form. The CCTG reached agreement on a set of evaluation criteria and useful supporting information to ensure meaningful submissions from the industry to help to inform their review process. Thus, the online MBR Form includes collection of critical supporting information related to each individual entry on a submission, i.e., an assessment of the CORE Code Combinations Evaluation Criteria, a Business Case, and discretionary Real World Usage Data.

The purpose of collecting this supporting information for each entry is two-fold:

  1. It prevents entities from submitting lists of code combinations without fully considering the rationale for an adjustment or denial and the value it adds to the CORE-required Code Combinations. This ensures a clean, useful set of code combinations is received.
  2. It will inform CCTG discussion and decisions related to MBR submissions and help ensure thoughtful maintenance occurs.
39. Does CAQH CORE offer additional methods that organizations can use to submit Market-based Review (MBR) submissions beyond the online CAQH CORE 2016 Market-based Adjustments Form?

No. The online Market-based Adjustments Form is the only method entities may use to submit requests for additions/removals and/or relocations to the code combinations in the existing CORE-defined Business Scenarios. Use of the online form ensures proper tracking and aggregation of submissions. 

40. If I hit “Finish Survey” on Part II of my organization’s online CAQH CORE 2016 Market-based Adjustments Form and realize, prior to the 01/31/17 submission deadline that I need to add additional entries to my submission, is a process available for my organization to add these entries?

Yes. Your organization may use your unique survey link from your Part I confirmation email to add any additional entries prior to the 01/31/17 submission deadline even if you selected “Finish Survey” previously. 

41. My organization is a subsidiary of a much larger company. The online Market-based Review (MBR) Form requires one submission per organization. However, I do not know who will be submitting from my organization. Can I submit a separate online MBR Form?

No. Only one MBR Form may be submitted per legal entity. Entities are encouraged to coordinate within their organization to ensure only one MBR Form is submitted. The online MBR Form allows multiple users within one organization to access and submit entries. This functionality allows organizations to coordinate their submission entry in the most appropriate way for their individual organization. For example, an organization may choose to have a single individual responsible for submitting each entry or choose to have several individuals located in various subsidiaries each submit individual entries that are coordinated within your organization prior to entry on the MBR.

42. What resources are available to assist entities in submitting potential Market-based Adjustments for consideration during the CAQH CORE 2016 Market-based Review of the CORE-required Code Combinations for CORE-defined Business Scenarios?

There are several resources available to assist entities in submitting a response to the Market-based Adjustments industry survey for the 2016 Market-based Review (MBR):

  • Detailed instructions to assist in the completion of the online form are available HERE.
  • A sample completed CAQH CORE 2016 Market-based Adjustments Form is also available HERE for consultation as entities plan their submission. NOTE: The Sample Form is to be used only as a guide for entities to consider their submissions The Sample Form cannot be used to submit requests for Market-based Adjustments to the CORE-required Code Combinations for the CORE-defined Business Scenarios for consideration by the CORE Code Combinations Task Group.
  • CAQH CORE holds a training session to provide the industry with guidance on completing the MBR submission process. Materials from this training, including a video recording of the training, are available via the online CAQH CORE Education and Implementation Resource Center.

 

43. How should entities implement code combinations in the CORE-required Code Combinations for the CORE-defined Business Scenarios that identify a CARC with a CAGC but without an associated RARC?

As noted in the Introduction to the CORE-required Code Combinations for the CORE-defined Business Scenarios (i.e., CORE Code Combinations), any CARC in the CORE Code Combinations tables that is not required, by definition, to be used with a corresponding RARC may be used without any associated RARCs. The majority of CARCs do not require RARCs to complete the message. However, there are some specific CARCs that always require use of an explanatory RARC. The CARC description identifies if the code requires the use of a RARC. To clarify this intended use of the CARCs, in May 2014, the CAQH CORE Code Combinations Task Group agreed to adjust the CORE Code Combinations to include rows showing only the CARC and applicable CAGCs for each CARC that, per its description, can be used without an associated RARC.

NOTE: The CAQH CORE Code Combinations Task Group is responsible for maintaining the CORE Code Combinations via the CAQH CORE Code Combinations Maintenance Process. Participation in the CAQH CORE Code Combinations Task Group is open to representatives from any CAQH CORE Participating Organization. For more information on joining CAQH CORE and/or becoming involved in the CAQH CORE Code Combinations Task Group, please contact core@caqh.org.

44. My organization is a health plan that uses Alert RARCs to send information to providers about our internal remittance processing. Does use of these Alert RARCs constitute nonconformance with the CAQH CORE 360 Rule and associated CORE Code Combinations?

The CAQH CORE 360: Uniform Use of CARCs and RARCs (835) Rule builds upon and supports a range of standards including:

  • The published CARC and RARC lists, maintained by the Claim Adjustment Status Code Maintenance Committee and Centers for Medicare & Medicaid Services respectively and published by Washington Publishing Company (WPC)
  • The NCPDP Reject Code list maintained by NCPDP
  • The HIPAA-mandated ASC X12N v5010 835 TR3 developed and maintained by ASC X12.

The CORE-required Code Combinations for the CORE-defined Business Scenarios (i.e., CORE Code Combinations) address use of supplemental RARCs which provide additional explanation for an adjustment already described by a CARC. The CORE Code Combinations do not address use of informational or “Alert” RARCs as, per the WPC website, these codes “convey information about remittance processing and are never related to a specific adjustment or CARC.” Therefore, entities may use Alert RARCs in addition to the CORE Code Combinations as they deem necessary. Additionally, the CAQH CORE 360 Rule does not require health plans to alter their internal system mappings for codes not included in the CORE Code Combinations, such as Alert RARCs.

45. How should health plans, and their agents, use the Change Log tab included in the CORE-required Code Combinations for the CORE-defined Business Scenarios Excel Workbook?

Per the CAQH CORE Code Combinations Maintenance Process, CAQH CORE conducts two types of review and adjustment to the CORE-required Code Combinations for the CORE-defined Business Scenarios (i.e., CORE Code Combinations): Compliance-based Reviews which address triennial changes to the published CARC and RARC lists and Market-based Reviews which consider industry submissions to address ongoing and evolving industry business needs. The purpose of the Change Log in the CORE Code Combinations workbook is to provide a summary of the individual CARCs, RARCs, and CAGCs that have been added to and/or removed from each CORE-defined Business Scenario since the last published version of the CORE Code Combinations. The “Reasons” column in the Change Log tab identifies the source of each code combination adjustment, either a Task Group Compliance-based Review or a Market-based Review.

NOTE: The information in the Change Log tab, including the source of each code combination adjustment, is provided for informational purposes only. Health plans (and their agents) are not required to build the source of each code combinations adjustment into their transaction processing system.

46. Why do the CORE-required Code Combinations for the CORE-defined Business Scenarios not include all CARCs and RARCs identified in the published lists?

The CAQH CORE 360: Uniform Use of CARCs and RARCs (835) Rule and associated CORE-required Code Combinations for the CORE-defined Business Scenarios (i.e., CORE Code Combinations) build upon and support a range of standards including:

  • The published CARC and RARC lists, maintained by the Claim Adjustment Status Code Maintenance Committee and Centers for Medicare & Medicaid Services respectively and published by Washington Publishing Company (WPC)
  • The NCPDP Reject Code list maintained by NCPDP.
  • The HIPAA-mandated ASC X12N v5010 835 TR3 developed and maintained by ASC X12.

The CORE Code Combinations include just those CARCs and RARCs that apply to the four CORE-defined Business Scenarios, rather than all of the CARCs and RARCs included on the code lists published by WPC.

NOTE: The CAQH CORE 360 Rule does not require health plans to alter their internal system mappings for CARC, RARC, or CAGC codes that are not included in the CORE Code Combinations. Beyond the requirement for health plans to align their internal codes and business scenarios with the CORE-required Code Combinations, the CAQH CORE 360 Rule does not require additional changes to a health plan’s internal code mapping.

47. My organization is a health plan. Can we continue to use a CARC that has been removed from a CORE-defined Business Scenario in an updated version of the CORE-required Code Combinations for the CORE-defined Business Scenarios?

The CAQH CORE 360: Uniform Use of CARCs and RARCs (835) Rule and associated CORE-required Code Combinations for the CORE-defined Business Scenarios (i.e., CORE Code Combinations) build upon and support a range of standards including:

  • The published CARC and RARC lists, maintained by the Claim Adjustment Status Code Maintenance Committee and Centers for Medicare & Medicaid Services respectively and published by Washington Publishing Company (WPC)
  • The NCPDP Reject Code list maintained by NCPDP.
  • The HIPAA-mandated ASC X12N v5010 835 TR3 developed and maintained by ASC X12.

The CAQH CORE Code Combinations Task Group is responsible for maintaining the CORE Code Combinations via the CAQH CORE Code Combinations Maintenance Process. Per the CAQH CORE Code Combinations Maintenance Process, the Task Group conducts two types of review and adjustment to the CORE Code Combinations: Compliance-based Reviews and Market-based Reviews. As part of its review of the CORE Code Combinations, the Task Group may agree to remove a CORE-required CARC from a CORE-defined Business Scenario. When this occurs, health plans can no longer report code combinations using the removed CARC to identify a situation that falls within the CORE-defined Business Scenario, although the CARC may continue to be used to identify non-CORE-defined Business Scenarios. This said, CARCs removed from the CORE Code Combinations can continue to be used in the ASC X12N/005010X221 Health Care Claim Payment/Advice (835) and associated errata (hereafter referenced as ASC X12N v5010 835) to identify non-CORE-defined Business Scenarios, in accordance with the current standard CARC list and the ASC X12N v5010 835 TR3. Please Note: Any additional business scenarios must not conflict with the CORE-defined Business Scenarios.

48. My organization is a health plan. We have identified CARCs and RARCs in the published lists that are not included in the CORE Code Combinations. Does the CAQH CORE 360 Rule require that health plans only use CARCs and RARCs that are included in the CORE Code Combinations?

No, the CORE Code Combinations identifies only those code combinations that health plans, and their agents, must use when reporting the CORE-defined Business Scenarios in the X12N v5010 835.

The ACA-mandated CAQH CORE Rule 360: Uniform Use of CARCs and RARCs (835) Rule establishes a minimum set of CORE-defined Claim Adjustment/Denial Business Scenarios as defined in the rule and an associated maximum set of CORE-required CARC/RARC/CAGC and CARC/NCPDP Reject Code/CAGC Combinations to convey detailed information about the payment adjustment or denial for each business scenario. The CAQH CORE 360 Rule builds upon and supports a range of standards including:

  • The HIPAA-mandated ASC X12N v5010 835 Technical Report Type 3 (TR3) developed and maintained by ASC X12.
  • The published CARC and RARC lists, maintained by the Claim Adjustment Status Code Maintenance Committee and Centers for Medicare & Medicaid Services respectively and published by Washington Publishing Company (WPC).
  • The NCPDP Reject Code list maintained by NCPDP.

The CORE-required Code Combinations and CORE-defined Business Scenarios (i.e., CORE Code Combinations) specifies the maximum set of CORE-required code combinations that must be supported by all health plans and their PBM agents for use with the CORE-defined Business Scenarios.

Note that the CORE Code Combinations do not include all of the CARCs and RARCs in the standard code lists published by WPC. Instead, the CORE Code Combinations include just those CARCs and RARCs that apply to the four CORE-defined Business Scenarios. The CAQH CORE 360 Rule does not require health plans to alter their internal system mappings or usage for CARCs, RARCs, or CAGCs that are not included in the CORE Code Combinations. Beyond the requirement for health plans to align their internal codes and business scenarios with the CORE-required Code Combinations, the CAQH CORE 360 Rule does not require additional changes to a health plan’s internal code mapping.

For more information on the health plan compliance requirements for the CAQH CORE 360 Rule see “My organization is a health plan. What adjustments do we need to make to our internal system to conform to the CAQH CORE 360 Rule requirements for health plan use of the CORE-defined Claim Adjustment/Denial Business Scenarios and CORE-required Code Combinations?