1. 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 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.

2. 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.

3. 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 Market-based Review 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 to receive the call for submissions.

4. 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.

5. 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.

6. 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 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.

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 does not require the health plan, or its PBM agent, to use the code combination(s).

8. 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.

9. 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. Should 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.

10. 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 Payment & Remittance Uniform Use of CARCs and RARCs (835) Rule vPR.1.0 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:

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