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.