CARC # / Descriptor / Is it an appealable denial? / What to do
1 / Deductible / No / N/A
2 / Coinsurance Amount / No / N/A
3 / Co-payment Amount / No / N/A
4 / The procedure code is inconsistent with the modifier used or a required modifier is missing. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. This change effective September 1, 2017: The procedure code is inconsistent with the modifier used or a required modifier is missing / Yes / Check the modifier on claim against payer policy. If the payer allows telephonic appeals, use this option to appeal or cancel claim and re-bill with correct modifier or if payer is wrong, appeal. Have appeal reviewed by a Certified Coder.
5 / The procedure code/bill type is inconsistent with the place of service. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. This change effective September 1, 2017: The procedure code/bill type is inconsistent with the place of service. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. / Yes / Check the place of service on the claim against where the item or service happened. If the payer is incorrect, try for a telephonic appeal. This is a rare denial code.
6 / The procedure/revenue code is inconsistent with the patient's age. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. This change effective September 1, 2017: The procedure/revenue code is inconsistent with the patient's age. / Yes / Check for typo’s in the patient’s birth date. If wrong, appeal by telephone or re-bill. If the payer is incorrect, call them to see why this edit came up because it is rare in Oncology.
7 / The procedure/revenue code is inconsistent with the patient's gender. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. This change effective September 1, 2017: The procedure/revenue code is inconsistent with the patient's gender. / Yes / Check gender and, in hospitals, check revenue codes. If wrong, appeal by telephone or re-bill. If the payer is incorrect, call them to see why this edit came up because it is rare in Oncology, EXCEPT in male breast cancer
8 / The procedure code is inconsistent with the provider type/specialty (taxonomy). Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. This change effective September 1, 2017: The procedure code is inconsistent with the provider type/specialty (taxonomy). / Yes / This may occur if the provider’s specialty is incorrect with the payer OR the provider is not on a specialty panel for a certain types of procedures. Check with payer. Then, rebill or try to correct by telephone.
9 / The diagnosis is inconsistent with the patient's age. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. This change effective September 1, 2017: The diagnosis is inconsistent with the patient's age / Yes / Make sure that the diagnosis is not transposed or incorrect. Then, check the birth date for errors. Cancel claim and re-bill, if errors are found. Call the payer if your data is correct and ascertain reason for this code.
10 / The diagnosis is inconsistent with the patient's gender. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. This change effective September 1, 2017: The diagnosis is inconsistent with the patient's gender / Yes / Check the diagnosis and make sure there are no errors. Also, check the patient’s gender for errors. Cancel claim and re-bill, if errors are found. Call the payer if your data is correct and ascertain reason for this code.
11 / The diagnosis is inconsistent with the procedure. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. This change effective September 1, 2017: The diagnosis is inconsistent with the procedure. / Yes / If this is a typo, you may be able to appeal by phone. Otherwise, appeal claim defending use of this diagnosis. If ‘off-label’, be sure to have compendia or articles of accepted journals to accompany the appeal. Hopefully, the patient also signed an ABN and you registered for drug replacement as applicable.
12 / The diagnosis is inconsistent with the provider type. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. This change effective September 1, 2017: The diagnosis is inconsistent with the provider type. / Yes / Cancel claim and correct ICD-10 or the physician specialty code. If this is a Nurse Practitioner or PA claim, check that they are registered with the panel for this payer. Appeal if both are correct on the initial claim.
13 / The date of death precedes the date of service / Yes / All payers disallow billings after the official date of death. If the payer allows telephonic appeals, use this option or cancel claim and re-bill with correct modifier or appeal if payer is wrong
14 / The date of birth follows the date of service / Yes / This is a rare error in Oncology. This is an obvious key punch error. Cancel claim and re-bill using the correct date of birth or service.
15 / The authorization number is missing, invalid or does not apply to billed services. / Yes / Remember that most new oncology treatments, services, or drugs require authorization. Cancel claim and apply valid authorization number, if one exists. If no auth is valid, appeal use of authorization with proof of medical necessity AND apply for patient assistance. Some programs will not cover this.
16 / Claim/service lacks information or has submission/billing error(s) which is needed for adjudication. Do not use this code for claims attachment(s)/other documentation. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.) Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. This change effective September 1, 2017: Claim/service lacks information or has submission/billing error(s) which is needed for adjudication. Do not use this code for claims attachment(s)/other documentation / Yes / This denial code can be turned around by submitting the proper documentation. Read the Remark Code on the claim and take the necessary action to complete billing.
18 / Duplicate claim/service / No / Stop sending duplicate claims and find out why the claim is not being paid. You can be targeted for an audit with too many duplicate claims.
19 / This is a work-related illness or injury and should be the responsibility of Workers’ Comp / Yes / Check out whether patient has a work related problem. If they do, change the diagnosis and re-bill to the appropriate party.
20 / This illness or injury is covered by the liability insurance / Yes / Check out whether patient has an accident related problem or change the patient’s diagnosis and re-bill to the appropriate party.
21 / This illness or injury is covered by the no-fault insurance / Yes / Check out whether patient has an accident related problem or change the diagnosis and re-bill to the appropriate party.
22 / This care may be covered by another payer per coordination of benefits / Yes / This appears to e an intake problem. Check patient intake to ensure that billed payer is the proper insurance. If not, cancel claim and bill to right payer. If not, appeal claim based on intake information. For Medicare, this is an MSP edit so Medicare thinks someone else should pay for it.
23 / The impact of another payer’s adjudication including payments and/or adjustments (Used only with OA-) / No / The payment is being adjusted based on coordination of benefits. There is nothing to be done.
24 / Charges are covered under a capitation agreement or managed care contract. / No / What you are billing for is covered under a capitation agreement. You, according to this code, do not have a ‘carve out’ for the billed service. Appeal only if contract does not exist or you have a contracted carve out.
26 / Expenses incurred prior to coverage. / Yes / Re-verify first date of coverage. Make sure insurance numbers, dates, and identification numbers are correct on claim and then re-bill if correction is made. If patient is still uninsured, contact employee benefits manager to verify. Lastly, apply for patient assistance, if patient rendered uninsured.
27 / Expenses incurred after coverage terminated. / Yes / Did the patient lose employment since their last visit? Do they now have COBRA that is not accounted for? Make sure insurance numbers, dates, and identification numbers are correct on claim and then re-bill if correction is made. Otherwise, contact employee benefits manager to verify. Lastly, apply for patient assistance, if patient rendered uninsured.
29 / The time limit for filing has expired. / Yes / Make sure that this is true via the contract with the payer and the service date is correct. Medicare’s time limit is one calendar year, exactly 365 days from service.
31 / The patient cannot be identified as our insured / Yes / Check patient demographics and insurance numbers—with employer if necessary. Correct and re-bill as appropriate or try for a telephone appeal. Check for fraudulent insurance cards next. If no insurance evidenced, apply for patient assistance.
32 / Our records indicate that the dependent was not a dependent as defined. / Yes / Ensure through payer or employer that the dependent was registered as such or that there is dependent coverage. Also check identification for birthdate. Children can have coverage until the December 31st of the year they turned 26. Apply for patient assistance as necessary.
33 / Insured has no dependent coverage. / Yes / Ensure through payer or employer that there is dependent coverage. Under the law, children can use their parents coverage until December 31st the year they become 26. Apply for patient assistance as necessary.
34 / Insured has no coverage for newborns. / Yes / Verify that this is true through insurer or employer. Sometimes can negotiate with obstetrical Carrier to pay for newborn. Apply for assistance as necessary.
35 / Lifetime maximum has been reached. / Yes / Call employer or caregiver to verify lifetime maximum amount and status. Then request a complete audit of patient expenses to verify max has been reached. In the meantime, apply for patient assistance.
39 / Services denied at the time pre-auth or pre-cert was requested. / Yes / Make sure this is not a mistake. This can be appealed with low probability of success, unless misleading or insufficient information was given. The patient is rendered uninsured; apply for patient assistance or make the patient Self-Pay.
40 / Charges do not meet qualifications for urgent/emergent care / Yes / Check the diagnosis code and billing to see why this decision was made. Next, check your contract to see if you can appeal. Re-bill or appeal as necessary.
44 / Prompt pay discount / No / Nothing
45 / Charge exceeds fee schedule/maximum allowable or contracted/legislated fee arrangement. Note: This adjustment amount cannot equal the total service or claim charge amount; and must not duplicate provider adjustment amounts (payments and contractual reductions) that have resulted from prior payer(s) adjudication. (Use only with Group Codes PR or CO depending upon liability) This change effective September 1, 2017: Charge exceeds fee schedule/maximum allowable or contracted/legislated fee arrangement. Usage: This adjustment amount cannot equal the total service or claim charge amount; and must not duplicate provider adjustment amounts (payments and contractual reductions) that have resulted from prior payer(s) adjudication. / No / Make sure this amount is your contracted allowable. If this is a drug without a J-code, make sure this amount matches your contracted rate.
49 / Routine preventive services done in conjunction with a routine exam. / Yes / Check the coding of separate services and ensure that these were preventative and not separately billable. Re-bill or appeal as necessary.
50 / These are non-covered services because this is not deemed a 'medical necessity' by the payer. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. This change effective September 1, 2017: These are non-covered services because this is not deemed a 'medical necessity' by the payer. / Yes / First, check diagnosis codes against payer guidelines. If these are correct, make sure you get clinical information that justifies the decision to use the item or service. Consult State Off-Label Laws as necessary. If the patient signed an Advance Beneficiary Notice, apply for assistance or Drug Replacement as possible.
51 / Non-covered services due a pre-existing condition / Yes / First, this is no longer legal per ACA. Check with employee benefits manager to see if the employer wants to go down this road. Apply for Patient Assistance as necessary and applicable.
53 / Delivery of service by an immediate family member or relative of payer / Yes / Rarely happens, but this should not occur
54 / Multiple physicians/ assistants are not covered in this case. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. / Yes / Usually more than one E/M service per physician or specialist in a day. Can also mean Assistant Surgeon was billed and procedure does not typically require one. Appeal only for extraordinary circumstances.
55 / Procedure/treatment/drug is deemed experimental/investigational by the payer. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. This change effective September 1, 2017: Procedure/treatment/drug is deemed experimental/investigational by the payer. / Yes / Appeal the case based on compendia coverage, community standard, or other scientific evidence. Make sure a physician or other provider is involved in the appeal.
56 / Procedure/treatment has not been deemed 'proven to be effective' by the payer. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. This change effective September 1, 2017: Procedure/treatment has not been deemed 'proven to be effective' by the payer. / Yes / Find the product information and match it to diagnosis codes. If diagnosis codes are correct, find supporting literature to prove that the product is effective for the diagnosis billed. Appeal.
58 / Treatment was deemed by the payer to have been rendered in an inappropriate or invalid place of service. / Yes / Procedure usually done in the hospital was done in the office or vice versa. Make sure the place of service is correct. Not appealable if this is true.
59 / Processed based on multiple or concurrent procedure rules. (For example multiple surgery or diagnostic imaging, concurrent anesthesia). / Yes / Fluids cannot be given concurrent to IV drugs (Re-bill and use -59, if hydration and/or fluids ARE NOT CONCURRENT). Certain anesthesia cannot be given in some minor procedures. Some imaging cannot be billed together. This could also be true for CCM (Chronic Care Management) codes. Appeal if concurrent procedure was warranted due to unusual care.
60 / Charges for outpatient services are not covered when performed within a period of time prior to or after inpatient services. / Yes / Usually this is a denial due to the Medicare 72-hour rule or due to a bundled inpatient procedure. If it is and you are not billing on a UB-04 (CMS-1450), check your payer contract for bundled services.
61 / Penalty for failure to obtain second surgical opinion. / Yes / Make sure the second opinion has been obtained and re-bill. Otherwise, it is no appealable, unless highly emergent surgery.
66 / Blood deductible / No / Three-unit blood deductible in a calendar year from Medicare. Patient or secondary must pay.
69 / Day outlier amount / No / Nothing—it is a payment to hospitals.
70 / Cost outlier adjustment / No / Nothing—it is a payment to hospitals.
74 / Indirect Medical Adjustment / No / Payment for educating House Staff.
75 / Direct Medical Education Adjustment / No / Payment for educating House Staff.
76 / Disproportionate Share Adjustment / No / Payment to DSH hospitals
78 / Non-covered days or room charge / No / Payer is not paying for days in the hospital or outpatient room charge for coverage reasons
85 / Patient interest adjustment / No / Interest charges are the responsibility of the patient. This could be due to past premium delinquency.
89 / Professional fees are removed from payment / No / Only the technical portion is paid as the professional fees have been paid for S&I previously or were not covered.
90 / Ingredient cost adjustment / Yes / Might be for compounded drugs. This also means there was an adjustment in drug pricing because the payer thought there was a comparable drug at a lower price. This is sometimes known as the Least Costly Alternative. Contact the drug company of branded drugs ASAP for this one.
91 / Dispensing fee adjustment / No / Adjustment for a dispensing fee---that’s a good thing!