CARC and RARC Codes Required When Objecting to Payment …

1 CARC and RARC Codes Required when Objecting to Payment of medical Bills EFFECTIVE JULY 1, 2022, payers will be Required to use the following Claim Adjustment Reason Codes (CARCs) and Remittance Advice Remark Codes (RARCs) on an explanation of benefits/explanation of review (EOB/EOR) sent to a health care provider to object to Payment of a medical bill. The payer must send the New York State Workers' Compensation Board (Board) a timely filed Notice of Treatment Issue/Disputed Bill (Form ) or Notice to Health Care Provider and Injured Worker of a Carrier's Refusal to Pay All (or a Portion of) a medical Bill Due to Valuation Objection(s) (Form ) with the same objection reason noted to properly object to such Payment . Current Form Line Proposed EOB Objection CARC. Part Scenario Law/Reg/Notes # Objections Form RARC. Objections Payer uses CARC P8 (claim is under investigation) to Claim has been Claim has been object to Payment of a bill for medical services.

2 The payer controverted by a controverted by a denial has disputed liability for the claim by filing a Notice of 1 denial dated _____ dated __ and: P8 Controversy pursuant to Workers' Compensation Law WCL 10. and liability has not 1. Establishment is (WLC) 25(2)(b) AND the claim is being investigated for been resolved pending compensability. Payer uses CARC P4 (workers' compensation claim adjudicated as noncompensable; this payer not liable for Claim has been claim or service/treatment) to object to Payment of a bill controverted by a denial for medication services. Payer has disputed liability for 2 N/A dated __ and: P4 the claim by filing a Notice of Controversy pursuant to WCL 10. 2. The case has been WCL 25(2)(b) AND the claim has been adjudicated and disallowed the payer has been found not liable for the claim (claim was disallowed).

3 CARCs & RARCs | PAGE 1 Of 9. Current Form Line Proposed EOB Objection CARC. Part Scenario Law/Reg/Notes # Objections Form RARC. Objections Prior authorization was not granted: for: Payer uses CARC 198 (precertification/authorization 1. treatment for a WCL 13-a(5). exceeded) to object to Payment of a bill when prior Prior authorization non-emergency special authorization was not granted for medical services (line 12 NYCRR* was not granted service not covered in the 198 plus 1. 3 for treatment over Workers' Compensation + RARCs or claim level amount >$1,000). These are services for 12 NYCRR body parts not covered by the MTGs, or non-emergency $1, Board's New York medical services or special services. Payer should use Treatment Guidelines *New York Codes , appropriate RARC(s). (MTGs) that was over Rules and Regulations $1, Prior authorization was not granted for: Payer uses CARC 198 (precertification/authorization 2.)

4 Continuous course of exceeded) to object to Payment of a bill when prior WCL 13-a(5). 198 plus 1. 4 N/A treatment for physical + RARCs authorization was not granted for continuous course of 12 NYCRR therapy/occupational treatment for PT/OT medical services (line or claim level 12 NYCRR therapy (PT/OT) over amount >$1,000). Payer should use appropriate RARC(s). $1, Payer uses CARC 198 (precertification/authorization Prior authorization exceeded) to object to Payment of a bill when prior was not granted for: authorization was not granted for MTGs procedure/ WCL 13-a(5). 198 plus 1. 5 N/A 3. MTGs procedure/ + RARCs treatment. Payer should use appropriate RARC(s). 12 NYCRR treatment requiring prior (Section of the MTGs, General Guideline 12 NYCRR authorization Principles, lists procedures that require prior authorizations.). 39 w/wo 1 Payer uses CARC 39 (services denied at the time + RARCs authorization/pre-certification was requested) to object M62, N30, to Payment of a bill when: authorization has been denied Request for treatment Request for treatment has by the payer; the health care provider has withdrawn 6 has been denied, been denied, withdrawn, N202, the request for authorization; or the injured worker has withdrawn, or refused or refused N362, decided to not proceed with the requested treatment.

5 N473, Payer can also use any of the following RARCs M62, N474 N30, N202, N362, N473, N474. CARCs & RARCs | PAGE 2 Of 9. Current Form Line Proposed EOB Objection CARC. Part Scenario Law/Reg/Notes # Objections Form RARC. Objections Treatment provided was: Payer uses CARC P2 (not a work-related injury/illness and Treatment provided 1. for a non-established WCL 2(7). thus not the liability of the workers' compensation insurer). was not causally body site or for a body site 7 related to the that the employer/carrier P2 to object to Payment of a bill for a non-established body WCL 10. site or for a body site that the insurer has not accepted WCL 13. compensable injury has not accepted liability liability for. for Treatment provided was: Payer uses CARC 50 (non-covered services because it is WCL 2(7). 2. for an established not deemed a medical necessity by the payer) to object 8 N/A body site, but was not 50 to Payment of a bill for an established body site, but was WCL 10.

6 Causally related to the WCL 13. not causally related to the compensable injury. compensable injury Treatment provided was: Payer uses CARC 109 (claim/service not covered by 3. for a body site that is WCL 2(7). this payer/contractor; you must send the claim/service the subject of multiple 9 N/A. claims and the injury is 109 to the correct payer/contractor) to object to Payment WCL 10. of a bill for a body site that is the subject of multiple WCL 13. not related to claim at claims and the injury is not related to claim at issue. issue Treatment provided Treatment provided within Payer uses CARC 279 (services not provided by preferred 12 NYCRR within 30 days of 30 days of initial treatment provider network) to object to Payment of a bill when the initial treatment was (See list of active 10 outside of preferred was outside of preferred 279 injured worker sought treatment from a provider who is not PPOs on Board provider organization part of a contracted New York State workers' compensation provider organization website).

7 (PPO) (NYS WC) certified PPO. (PPO). Payer uses CARC 164 (attachment/other documentation medical report for WCL 13-a(4)(a). medical report for referenced on the claim was not received in a timely treatment was not 164 w/wo 1. 11 timely filed or is treatment was: fashion) to object to Payment of a bill when the medical + RARCs report for treatment was not timely filed. Payer can also use 12 NYCRR 1. Not timely filed 12 NYCRR legally defective any appropriate RARCs. medical report for Payer uses CARC 251 (attachment/other documentation WCL 13-a(4)(a). treatment was: 251 w/wo 1 was incomplete or deficient) to object to Payment of a bill 12 N/A. 2. Incomplete or not in + RARCs when the medical report is incomplete or deficient. Payer 12 NYCRR prescribed format can also use any appropriate RARCs. 12 NYCRR CARCs & RARCs | PAGE 3 Of 9. Current Form Line Proposed EOB Objection CARC.

8 Part Scenario Law/Reg/Notes # Objections Form RARC. Objections Payer uses CARC P13 ( Payment reduced or denied based medical appliance or medical appliance on workers' compensation jurisdictional regulations or program is not covered or program is not P13 plus Payment policies use only if no other code is applicable). 13 covered under the under the WCL WCL 13(a). 1. letter of medical RARC M60 to deny Payment of a bill when letter of medical necessity WCL is not included. Payer should also use RARC M60 (missing necessity not included certificate of medical necessity ). Payer uses CARC P13 ( Payment reduced or denied based medical appliance or on workers' compensation jurisdictional regulations or program is not covered P13 plus Payment policies use only if no other code is applicable). 14 N/A under the WCL WCL 13(a). 2. Insufficient RARC M135 to deny Payment of a bill when insufficient documentation is provided.

9 Payer should also use RARC M135 (missing/. documentation provided incomplete/invalid plan of treatment). Payer uses CARC P16 ( medical provider not authorized/. certified to provide treatment to injured workers in this Provider is not authorized jurisdiction to be used for workers' compensation Provider is not under the WCL and only) to object to Payment of a bill when treatment was WCL 13-a 15 authorized under WCL exceptions under WCL P16 rendered by a provider who is not authorized under the WCL 13-b 13-b do not apply WCL. Payers are not obligated to pay for treatment by unauthorized physician except for enumerated exceptions listed in WCL 13-b. Bill is not for treatment, Payer uses CARC 96 (non-covered charge) to object but for an evidentiary to Payment of a bill when the bill is for an evidentiary Bill is not for opinion/review of records opinion or a review of records or submission of a report 96 plus 12 NYCRR (b).

10 16 treatment, but for an or submission of a report made without physical examination ( , IME exam, (12). evidentiary opinion made without physical RARC N717 records review, etc.). Payer should use appropriate RARC. examination as defined in N717 (incomplete/invalid documentation of face-to-face 12 NYCRR (b)(12) examination). Diagnostic test was Diagnostic test was Payer uses CARC 243 (services not authorized by network/ WCL 13-a (7). performed outside of 17 performed outside of diagnostic testing network 243 primary care providers) to object to Payment of a bill when 12 NYCRR 325-7. network diagnostic testing was performed outside of DTN. (DTN). CARCs & RARCs | PAGE 4 Of 9. Current Form Line Proposed EOB Objection CARC. Part Scenario Law/Reg/Notes # Objections Form RARC. Objections Diagnostic test was Pharmacy outside Payer uses CARC 242 (services not provided by network/ WCL 13-a (7).)