CARC and RARC Codes

Table 1. Acronyms and Definitions
Council/Codes	Description
Council for Affordable Quality Healthcare (CAQH)	An American non-profit organization that collaborates with healthcare providers, trade associations, and insurers.
Committee on Operating Rules for Information Exchange (CORE)	A multi-stakeholder initiative developing operating rules that streamline electronic healthcare administrative data exchange and support interoperability between payers and providers.
Claim Adjustment Reason Codes (CARC)	Used to provide an overall explanation for the financial adjustment to the amount submitted on a claim.
Remittance Advice Remark Codes (RARC)	There are two types of RARC codes: Supplemental: Used to provide additional explanation for an adjustment already described by a CARC. Informational: Used to convey information about remittance processing. These codes are prefaced with "Alert" and are not related to a specific adjustment or CARC.

Help Guide for NextGen® Enterprise PM 8

Reason Code Options

The following table lists each option available in the Reason Codes Library with a description of how it works and how it may be used. Reason Code Option How it Works How it is Used Force Item Rebill Select this check box to flag line items with the reason code to "Rebill" to the current payer. Note: This option applies to Line Item reason codes only. When trends are identified for a reason code that always require rebilling. Write Off Remaining Balance Select this check box to adjust the remaining balance to $0.00 for line items with the reason code. The adjustment occurs when the transaction batch is posted. Note: This option applies to Line Item reason codes only. Sometimes used with payers of last resort, such as Medicaid. Note: ERA uses the Adjustment Code selected below to make the adjustment. Manual payment entry uses the Write Off Remaining Payer Balance adjustment code selected in Practice Preferences > Transactions to make the adjustment. Display on Patient Statements Select

Help Guide for NextGen® Enterprise PM 8

CARC and RARC Codes

The following table states the various councils and abbreviations used for remittance operating rule. Table 1. Acronyms and Definitions Council/Codes Description Council for Affordable Quality Healthcare (CAQH) An American non-profit organization that collaborates with healthcare providers, trade associations, and insurers. Committee on Operating Rules for Information Exchange (CORE) A multi-stakeholder initiative developing operating rules that streamline electronic healthcare administrative data exchange and support interoperability between payers and providers. Claim Adjustment Reason Codes (CARC) Used to provide an overall explanation for the financial adjustment to the amount submitted on a claim. Remittance Advice Remark Codes (RARC) There are two types of RARC codes: Supplemental: Used to provide additional explanation for an adjustment already described by a CARC. Informational: Used to convey information about remittance processing. These codes are prefaced with "Alert" and ar

Help Guide for NextGen® Enterprise PM 8

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. Parent topic: CARC and RARC Codes

Help Guide for NextGen® Enterprise PM 8

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. Parent topic: CARC and RARC Codes

Help Guide for NextGen® Enterprise PM 8

CARC and RARC Maintenance Utility

NextGen Healthcare has developed a web-based import utility to publish the new versions of CARC and RARC combinations. To obtain access to CARC and RARC utility, go to NextGen Healthcare Success Community Parent topic: CARC and RARC Codes

File Maintenance Help for NextGen® Enterprise 8

Reason Codes Library

You can create and maintain reason codes in a Reason Codes library. A reason code is a brief description that is added to a transaction to explain how that transaction was handled. When ERA files are involved, reason codes are returned in the file by the payer to describe how the service was reimbursed. Reason code libraries group related reason codes together. For example, you can have a reason code library that contains the reasons that a claim can be cancelled. You can generate the Reason Codes Master report from the Reason Codes library. For more information go to NextGen Healthcare Success Community and download the latest Reports User Guide for NextGen® Enterprise PM. Reason Code Library Maintenance You can add or modify an existing reason code on the Reason Code Library Maintenance window. Write Off Remaining Line Item Balances After the Batch is Posted Write Off Remaining Line Item Balances at ERA Import Assign a Reason Code Library to a Payer Select Reason Codes Options in Pra

CARC and RARC Codes

CARC / RARC Import Posting Report Columns

Recommendations

Reason Code Options

CARC and RARC Codes

CARC / RARC Combinations - Business Scenarios

CARC / RARC Combinations - Business Scenarios

CARC and RARC Maintenance Utility

Reason Codes Library

CARC and RARC Codes

CARC / RARC Import Posting Report Columns

Reason Code Options

CARC and RARC Codes

CARC / RARC Combinations - Business Scenarios

CARC / RARC Combinations - Business Scenarios

CARC and RARC Maintenance Utility

Reason Codes Library