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Ongoing Maintenance of the CORE Code Combinations
Keeping Up with the CORE Code Combinations
If you have been tasked with implementing the CAQH CORE Payment & Remittance Uniform Use of CARCs and RARCs (835) Rule, part of the Affordable Care Act (ACA)-mandated Payment & Remittance Operating Rules, you will find all the necessary tools and information here to comply with this operating rule.
These resources are provided free of charge by CAQH CORE, author of the operating rules, and are intended to help organizations comply with the law.
Background
The CAQH CORE Payment & Remittance Operating Rules, among other things, simplify the language used to communicate about claim payment and remittance information. The CAQH CORE Payment & Remittance Uniform Use of CARCs and RARCs (835) Rule brings uniformity to use of Claim Adjustment Reason Codes (CARCs), Remittance Advice Remark Codes (RARCs), and Claim Adjustment Group Codes (CAGCs) by identifying a limited set of CARC/RARC/CAGC combinations to be used in defined universal business scenarios. These codes are used in combination to convey details about a claim adjustment or denial in the X12 v5010 835.
Together, the business scenarios and code combinations make up the CORE-required Code Combinations for CORE-defined Business Scenarios (CORE Code Combinations), a companion document to the CAQH CORE Payment & Remittance Uniform Use of CARCs and RARCs (835) Rule.
The published CARC and RARC lists and, in turn, the CORE Code Combinations are updated three times per year.
- Current and Past Versions of the CORE Code Combinations
The current version of CORE Code Combinations for use with the CAQH CORE Payment & Remittance Uniform Use of CARCs and RARCs (835) Rule is the CORE Code Combinations v3.7.3 February 2023.
As the table illustrates, this version aligns with CARC and RARC list updates published November 1, 2022. NOTE: The table below contains 5 columns. Depending on your browser, you may need to scroll right using the scroll bar at the end of the section to view all 5 columns.
High-level Summary of Adjustments in Version 3.7.3 of the CORE Code Combinations Version 3.7.3 of the CORE Code Combinations includes updates based on Compliance-based Adjustments as part of the CAQH CORE Code Combinations Maintenance Process based on published CARC and RARC lists as of November 2022.
The table below summarizes the Compliance-based Adjustments approved by the CAQH CORE Code Combinations Task Group for inclusion in the current version of the CORE Code Combinations by CORE-defined Business Scenario.
Type of Adjustment
CORE-defined Business Scenario #1
CORE-defined Business Scenario #2
CORE-defined Business Scenario #3
CORE-defined Business Scenario #4
February 2023
Compliance-based Review
- N/A
- N/A
- N/A
- N/A
Summary of Compliance-based Adjustments in Version 3.7.3 of the CORE Code CombinationsOctober 2022 Adjustments to Published Code Lists
CORE Code Combinations v3.7.3 February 2023 Compliance-based Adjustments
Deactivations
(0 CARCs and 0 RARCs deactivated by Code Committees)
N/A Modifications
(0 CARC descriptions and 0 RARC descriptions modified by Code Committees)
N/A Additions
( 0 new CARCs and 0 new RARCs added by Code Committees)
N/A
Overview of Market-based Review Process and Scope
CAQH CORE facilitates a public 60-day period during which industry entities can submit potential Market-based Adjustments to code combinations in the existing CORE-defined business scenarios. Industry entities can submit three categories of potential code combination adjustments:
- Addition of new CORE Code Combinations
- Removal of existing CORE Code Combinations
- Relocation of an existing CORE Code Combination from an existing CORE-defined Business Scenario to another existing CORE-defined Business Scenario
Summary of Market-based Adjustments in the February 2023 Version of the CORE Code Combinations
Type of Adjustment
CORE-defined Business Scenario #1
CORE-defined Business Scenario #2
CORE-defined Business Scenario #3
CORE-defined Business Scenario #4
Additions - N/A
- N/A
- N/A
- N/A
Removals - N/A
- N/A
- N/A
- N/A
- Timeline for Updates and Compliance with Updated CORE Code Combinations
The CORE Code Combinations are updated at scheduled intervals to align with updates to the published CARC and RARC lists, which are maintained by CARC/RARC Code Committees external to CAQH CORE. The following table illustrates the timeline.
Timeline for Updates to the CORE Code Combinations Projected Dates of CARC & RARC List Updates Scheduled Publication Date of CORE Code Combinations
(approximately 3 months after list updates)Mandated Compliance Date for CORE Code Combinations
(90 days after date of publication)
~November 1 February 1 May 1 ~March 1 June 4 September 4 ~July 1 October 1 January 1 Beginning January 1, 2014, HIPAA-covered entities have 90 days to comply with published updates to the CORE Code Combinations.
Exception: In some instances, the effective date for code modifications and deactivations approved by the code maintenance committees is more than six months after publication of the updated code list. To accommodate code modifications or deactivations that go into effect after the compliance date for the new version of the CORE-required Code Combinations for CORE-defined Business Scenarios (e.g. adjustments with effective dates greater than six months from the code list publication date), CAQH CORE has incorporated the following exceptions to the 90 day compliance timeframe:
- Any deactivated CORE-required CARCs and RARCs may continue to be used until the effective deactivation/stop date as published by the respective code maintenance committee
- Any modified CORE-required CARCs and RARCs may continue to be used with their previous description until the effective date of the code description modification as published by the respective code maintenance committee
After the effective date, the unmodified or deactivated code can only continue to be used in “derivative business transactions”. Derivative business transactions are business messages where the CARC or RARC is being reported from an original business message that was initiated prior to the code adjustment effective date.
NOTE: The 04/19/13 CMS Notice to the Industry states that because the Maintenance Process was adopted in the IFC, covered entities should understand that revised and updated versions of the CORE Code Combinations are part of the regulation (applies to both Compliance and Market-based Adjustments to current CORE-defined Business Scenarios); covered entities are responsible for complying with the latest version.
- Impact by Stakeholder Type
The CAQH CORE Payment & Remittance Uniform Use of CARCs and RARCs (835) Rule requirements and the impact of updated versions of the CORE Code Combinations vary depending on an entity’s stakeholder type.
NOTE: ACA Section 1104 mandates that all HIPAA covered entities comply with the Payment & Remittance Operating Rules; however non-HIPAA covered entities play a crucial role in enabling their provider and health plan clients to realize the benefits of industry adoption and often act as Business Associates on behalf of a HIPAA covered entity.
Creators of the X12 v5010 835 Receivers of the X12 v5010 835 Applicable Stakeholder Types Any organization with systems that creates the X12 v5010 835, which may include:
· Health plans and/or PMB agents
· Health plan-facing clearinghouses
· Health plan-facing vendors
· Health plan business associates
Any organization with systems that receive the X12 v5010 835 and extracts data for manual processing, which may include:
· Providers
· Provider-facing clearinghouses
· Provider-facing vendors
· Provider business associates
What requirements apply to my organization?
(Please refer to CAQH CORE Payment & Remittance Uniform Use of CARCs and RARCs (835) Rule for a full list of applicable rule requirements)
Systems creating the X12 v5010 835 must have the ability to:
· Align its internal codes and corresponding business scenarios to the CORE-defined Business Scenarios CARC, RARC, CAGC and NCPDP Reject Code combinations specified in the CORE Code Combinations
· Support the maximum CORE-required Code Combinations in the v5010 X12 835 as specified in CORE Code Combinations
o No other code combinations are allowed for use in the CORE-defined Business Scenarios.
o When specific CORE-required Code 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
o The only exception to this maximum set of CORE-required Code Combinations is when the respective code committees responsible for maintaining the codes create a new code or adjust an existing code. Then the new or adjusted code can be used with the Business Scenarios and a Compliance-based Review will consider the ongoing use of these codes within the maximum set of codes for the Business Scenarios
o A deactivated code must not be used
· In the case where a health plan or its PBM agent wants to use an existing code combination that is not included in the maximum code combination set for a given CORE-defined Business Scenario, a new code combination must be requested in accordance with the CORE Code Combinations Maintenance Process
· When receiving a v5010 X12 835, a product extracting the data from the X12 v5010 835 for manual processing must make available to the end user:
o 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
And
o Text describing the corresponding CORE-defined Business Scenario
· The requirement to make available text describing the corresponding CORE-defined Business Scenario to the end user does not apply to retail pharmacy
· This requirement does not apply to an entity that is simply forwarding the X12 v5010 835 to another system for further processing
What does my organization need to do when an updated version of the CORE Code Combinations is published? Organizations with systems that create the X12 v5010 835 should:
· Adjust systems to support the maximum set of CORE-required Code Combinations and minimum set of CORE-defined Business Scenarios as specified in the updated version of the CORE Code Combinations for each version update
· Implement an ongoing maintenance process given the CORE Code Combinations will be updated three times per year
Organizations with products that receive the X12 v5010 835 and extract data for manual processing should:
· Adjust systems to ensure appropriate text is displayed as specified in the updated version of the CORE Code Combinations for each version update
· Implement an ongoing maintenance process given the CORE Code Combinations will be updated three times per year
Providers should:
· Ensure vendor /clearinghouse/other business associate (e.g. receiver of the v5010 X12 835) has updated its systems to align with the updated version of the CORE Code Combinations
· Monitor code combinations sent via the v5010 X12 835 to ensure alignment with the updated version of the CORE Code Combinations
o Report non-compliance to CMS as appropriate
- The CORE Code Combinations Maintenance Process
The CARC and RARC lists are authored and maintained by CARC/RARC Code Committees designated by the Secretary of Health and Human Services. Addition, modification, or removal of codes must be addressed by the appropriate committee, either the Claim Adjustment Status Code Maintenance Committee or Remittance Advice Remark Code Committee; this is out of scope for CAQH CORE. The CARC/RARC Code Committees meet and publish updates on the Washington Publishing Company’s website three times per year. The CAGCs are part of the X12 835 standard and are thus maintained by ASC X12.
CARCs
(Claim Adjustment Status Code Maintenance Committee)
RARCs
(Remittance Advice Remark Code Committee)
CAGCs
(ASC X12)
- Total # of CARCs: 268
- not all in CORE Code Combinations
- There are approximately 35 CARC Committee members representing a variety of stakeholder including health plans, associations, vendors, and government entities
- Entities can complete the CARC Change Request Form
- Total # of RARCs: 932
- not all in CORE Code Combinations
- The RARC Committee members represent various components of CMS
- Entities can complete the RARC Change Request Form
- Total # of CAGCs: 4
- All are in CORE Code Combinations
- Part of the ASC X12 standard, therefore, can only be revised when a new HIPAA mandated version of X12 standards is issued; current version is ASC X12 v5010
- Entities can submit a request to ASC X12
The CORE Code Combinations are maintained by the CAQH CORE Code Combinations Task Group.
The CAQH CORE Code Combinations Task Group conducts two types of reviews and adjustments of the CORE Code Combinations as part of its ongoing CAQH CORE Code Combinations Maintenance Process required by the CAQH CORE Payment & Remittance Uniform Use of CARCs and RARCs (835) Rule:
Compliance-based Reviews: Occur three times per year and consider only additions, deactivations, or modifications to the current published CARC and RARC lists by the code committees since the last update to the CORE Code Combinations
Market-based Reviews: Occur once every two years and address ongoing and evolving industry business needs. A Market-based Review considers industry submissions addressing:
· Adjustments to the existing CORE Code Combinations for existing CORE-defined Business Scenarios (additions, removals, etc.) based on real-world usage data and/or a strong business case
· Addition of new CORE-defined Business Scenarios and associated CORE-required Code Combinations based on real-world usage data and a strong business case
CAQH CORE has also established a Code Combinations Emergency Update Process.
The timeline below lays out the general timeframes for the CARC/RARC Code Committees and the CAQH CORE Code Combinations Maintenance Process.
*Goal is to publish the Market Adjustments with Compliance-based Adjustments to ensure only 3 annual updates to the CORE Code Combinations.
To learn more about the CORE Code Combinations Maintenance Process, see the FAQs for CAQH CORE Use of CARCs & RARCs Rule.
- Total # of CARCs: 268
- How to Submit Market-based Adjustments
Market-based Reviews enable the industry to adjust the CORE Code Combinations to address ongoing and evolving industry business needs such as new products and regulations.
In 2023, CAQH CORE will launch the 2023 Industry-wide Market-based Adjustments Submissions Period. During this period, industry entities will be able to submit potential adjustments to the CORE Code Combinations via an online form for consideration by the Task Group. To receive a notification when the 2023 industry submissions period opens, email core@caqh.org.
- Get Involved in the CAQH CORE Code Combinations Maintenance Process
Entities are encouraged to join CAQH CORE as a Participating Organization to:
- Contribute to the evolution of CAQH CORE Use of CARCs & RARCs Rule and the CORE Code Combinations via the CAQH CORE Code Combinations Task Group
- Have a voice in the development of operating rules
- Be part of a solution that is taking cost and complexity out of the healthcare system
CAQH CORE welcomes Participating Organizations representing a range of stakeholder groups.
Entities can also contribute a number of other ways, for example:
- Submission of Market-based Adjustments to the CORE Code Combinations
- Work directly with CMS, standard setting bodies like ASC X12, and the various industry code committees to advance industry knowledge
- Respond to public surveys or submit requests to CORE@caqh.org
Trading Partner Collaboration: Conformance Testing and Voluntary CORE Certification
- Conformance testing with your trading partners is a critical aspect to making your operating rules implementation a success
- HIPAA covered entities can quickly communicate their organization’s readiness to testing their conformance with trading partners by adding their company information to the CORE Partner Testing page of the CAQH website
- Entities should consider voluntary CORE Certification to publicly communicate their systems meet the CAQH CORE Payment & Remittance Operating Rule requirements