CARC / RARC Combinations - Business Scenarios
The CARC / RARC Combinations Payers report in the 835 must be reported within one of the four Business Scenarios as per the CAQH CORE 360 Rule.
| CORE defined Claim Adjustment/Denial Business Scenario | CORE Business Scenario Description |
|---|---|
| Additonal Information Required - Missing/Invalid/Incomplete Documentation | Refers to situations where additional documentation is needed from the billing provider or an ERA from a prior payer. |
| Additonal Information Required - Missing/Invalid/Incomplete Data from Submitted Claim | Refers to situations where additional data are needed from the billing provider for missing or invalid data on the submitted claims. |
| Billed Service Not Covered by Health Plan | Refers to situations where the billed service is not covered by the health plan. |
| Benefit for Billed Service Not Seperately Payable | Refers to situations where the billed service or benefit is not seperately payable by the health plan. |