Changes to remittance advice (RA) and explanation of benefit (EOB) codes effective Oct. 7, 2019
In response to recent provider feedback, we've identified areas for improvement and made changes in how we're using some claim adjustment reason codes (CARCs).
What are CARCs?
A CARC is a national administrative code set that communicates a reason for a payment adjustment. It describes why a claim or service paid differently than how it was billed.
New information shared on the paper RA and EOB
The tables below reflect the changes effective Oct. 7, 2019, for some CARC reporting for commercial, Medicare, and Medicaid claims. These changes will affect the paper remittance advice and member explanation of benefits (EOB). The old CARC 252 will now be CARC 22 or CARC 19 with the new reason code and description.
New CARC 22 with the reason code and description
| Reason Code | Description |
|---|---|
| B09 | Master Medical explanation |
| B10 | Medicare explanation of benefits required |
| B16 | Primary carrier explanation of benefits received-Secondary carrier explanation of benefits still required |
| B17 | Secondary carrier explanation of benefits received - Primary carrier explanation of benefits still required |
| H03 | Secondary carrier EOB is required before HRA benefits can be applied |
| H04 | Secondary carrier EOB is required before HRA benefits can be applied |
| J01 | Other insurance is primary - Primary carrier EOB required |
| J02 | Master Medical explanation of benefits required |
| J03 | Medicare explanation of benefits required |
| J09 | Primary carrier explanation of benefits received - Secondary carrier explanation of benefits still required |
| J10 | Secondary carrier explanation of benefits received - Primary carrier explanation of benefits still required |
| J27 | Explanation of Benefits attached denies primary claim as duplicate submission – submit original EOB |
| J36 | Other insurance is primary - Primary carrier EOB required |
| J42 | Primary carrier explanation of benefits received - Secondary carrier explanation of benefits still required |
| J48 | Secondary carrier explanation of benefits received - Primary carrier explanation of benefits still required |
| J49 | Master Medical explanation of benefits required |
| J50 | Explanation of Benefits attached denies primary claim as duplicate submission – submit original EOB |
| OH4 | Resubmit bill with copy of the primary Explanation of Benefits |
New CARC 19 with the reason code and description
| Reason Code | Description |
|---|---|
| M27 | Worker's compensation primary. Submit to WC carrier. Chapter 11 for further information Member cannot be billed |
New information shared on the electronic remits
Electronic remits only report the CARC code, and they do not include the reason code or description. The old CARC 252 will now be CARC 22 or CARC 19.
What do I need to do?
Update your system as needed, and if you have any questions, contact provider.services@priorityhealth.com.