Frequently Asked Questions - IV. CAQH CORE Payment & Remittance Uniform Use of CARCs and RARCs (835) Rule

Does my health plan organization have to support CORE Code Combinations that are not applicable to our business needs?

Submitted by caqh_admin on Mon, 12/21/2015 - 22:34
Does my health plan organization have to support CORE 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 Payment & Remittance Uniform Use of CARCs and RARCs (835) Rule vPR.1.0 does not require the health plan, or its PBM agent, to use the code combination(s). CAQH CORE Uniform Use of CARCs and RARCs 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.

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Do all the CARCs in the CORE Code Combinations tables have to be used with a corresponding RARC?

Submitted by caqh_admin on Mon, 12/21/2015 - 22:36
Do all the CARCs in the CORE 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 HERE.

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To what types of entities do the requirements in the Basic Requirements for Receivers of the X12 v5010 835 Section of the CAQH CORE Uniform Use of CARCs an RARCs Rule apply?

Submitted by caqh_admin on Mon, 12/21/2015 - 22:37
To what types of entities do the requirements in the Basic Requirements for Receivers of the X12 v5010 835 Section of the CAQH CORE Uniform Use of CARCs an RARCs Rule apply?

The CAQH CORE Payment & Remittance Uniform Use of CARCs and RARCs (835) Rule vPR.1.0 specifies requirements applicable to provider-facing vendor products that receive the X12 v5010 835 and extract the data content. The Basic Requirements for Receivers of the X12 v5010 835 (Section 4.2) specifies the descriptive text that the provider-facing products must display to the provider end-user.

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

Submitted by caqh_admin on Mon, 12/21/2015 - 22:39
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 Payment & Remittance Uniform Use of CARCs and RARCs (835) Rule vPR.1.0 were selected as they represent some of the most confusing and high volume scenarios that are exchanged between health plans and providers. CAQH 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 Uniform Use of CARCs and RARCs 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 Payment & Remittance Uniform Use of CARCs and RARCs (835) Rule vPR.1.0 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, the CORE-required Code Combinations for CORE-defined Business Scenarios are maintained and updated due to evolving code lists and industry needs.

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

Submitted by caqh_admin on Mon, 12/21/2015 - 22:44
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 RARCs 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-require Code Combinations for CORE-defined Business Scenarios. Once the Task Group agrees on adjustments a new version of the CORE-require Code Combinations for CORE-defined Business Scenarios is published, an announcement to the industry is distributed, and the CAQH CORE website is updated.

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

Submitted by caqh_admin on Mon, 12/21/2015 - 22:45
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 every other 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
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How can my organization submit new Business Scenarios for consideration during the CAQH CORE Code Combinations Market-based Review?

Submitted by caqh_admin on Mon, 12/21/2015 - 22:48
How can my organization submit new Business Scenarios for consideration during the CAQH CORE Code Combinations Market-based Review?

The Market-based Review (MBR) of the CORE-require Code Combinations for CORE-defined Business Scenarios will only consider adjustments to the code combinations in the existing four CORE-defined Business Scenarios. Requests for new CORE-defined Business Scenarios cannot be submitted via the Potential Market-based Adjustments Form. For more information on how to submit a request for a potential Market-based Adjustment to the CORE Code Combinations, contact core@caqh.org.

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How can we request addition of a code combination to the CORE-required maximum set that meets the definition of a CORE-defined Business Scenario?

Submitted by caqh_admin on Wed, 12/23/2015 - 03:38
How can we request addition of a code combination to the CORE-required maximum set that meets the definition of a CORE-defined Business Scenario?

To better align with the existing CORE-require 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-require 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 Payment & Remittance Uniform Use of CARCs and RARCs (835) Rule vPR.1.0, 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 a Market-based Review of the CORE-require Code Combinations for CORE-defined Business Scenarios. Market-based Reviews occur every other year and address ongoing and evolving industry business needs. For each 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 CMS, 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.

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Does the CAQH CORE Uniform Use of CARCs and RARCs Rule apply to batch, real time, or both batch and real time processing of the X12 v5010 835?

Submitted by caqh_admin on Mon, 12/21/2015 - 22:47
Does the CAQH CORE Uniform Use of CARCs and RARCs Rule apply to batch, real time, or both batch and real time processing of the X12 v5010 835?

The CAQH CORE Payment & Remittance Uniform Use of CARCs and RARCs (835) Rule vPR.1.0 applies to both batch and real time processing. Per Section 3.3, When the Rule Applies, of the CAQH CORE Uniform Use of CARCs and RARCs 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.

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

Submitted by caqh_admin on Sun, 12/27/2015 - 22:37
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 every other year. The MBR will consider adjustments to the code combinations in the existing four CORE-defined Business Scenarios.

Email core@caqh.org to be added to the distribution list.

For more information on how to submit a request for a potential Market-based Adjustment to the CORE Code Combinations, contact core@caqh.org.

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