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By: Gina Stinson, Senior Director, Revenue Cycle Management<\/strong><\/p>\n Did you know there are over 293 reasons why a claim payor doesn\u2019t pay a health insurance claim as billed?\u00a0 These reasons are called Claim Adjustment Reason Codes (CARC) and insurance carriers or claim administrators apply these codes to claim remits to identify why a claim, or line-item thereof, was not paid as billed.\u00a0 Identifying and managing these codes is critical to the financial health and success of medical providers that want to successfully navigate recover zero or partially paid claims \u2013 also known as denials.\u00a0\u00a0\u00a0\u00a0<\/span><\/p>\n Medical providers use denial mapping in their quest to combat denials. The extent to which a provider can map their denials is contingent upon system and reporting capabilities.\u00a0 Denial mapping should support system workflow, reporting and analytics, as well as denial prevention efforts. \u00a0 Denial mapping begins at the CARC level as not all codes represent denials \u2013 in other words, providers need to eliminate the weeds to get to the wheat.\u00a0\u00a0<\/span><\/p>\n Let\u2019s take a closer look at the CARC code and its associated codes found in the 835 EDI file.\u00a0 As previously touched on, the <\/span>Claim Adjustment Reason Codes (CARC) <\/b>is used to identify why a claim, in whole or part, was paid differently than billed. CARC codes may be further supplemented by a <\/span>Remittance Advice Remark Code (RARC) <\/b>which is when a CARCs description states \u201cat least one Remark Code must be provided\u2026\u201d or when the description is classified as an Alert.\u00a0\u00a0<\/span><\/p>\n Did you know there are 1,076 RARC codes in addition to the 293 CARC codes?\u00a0 It\u2019s true! CARC codes are also categorized into one of five <\/span>Claim Adjustment Group Codes<\/b> which are used to identify non-payment responsibility (e.g., patient, contractual, etc.). Understanding how these codes work together is important to robust denial mapping.<\/span><\/p>\n Before denial mapping begins, determine:<\/span><\/p>\n <\/p>\n Answering these and other questions will help determine how granular the denial mapping needs to be. \u00a0 Denial mapping used to support or optimize workflows should be very detailed, specific, and pointed; whereas mapping for general reporting doesn\u2019t require the same level of granularity.\u00a0 Once it\u2019s been determined how the mapped data will be used proceed with the general denial mapping process outlined.\u00a0 For the purposes of this blog, let\u2019s assume we\u2019re using denial mapping to support denial prevention\/mitigation analytics and reporting.<\/span><\/p>\n General Denial Mapping<\/b><\/p>\n Step 1 \u2013 For each CARC listed identify if the code is a <\/span>denial<\/span><\/i> or <\/span>not\u00a0<\/span><\/i><\/p>\n Step 2 \u2013 For each denial, CARC assigns an upstream data owner for associated denial prevention and reporting data (e.g., patient access, utilization review, case management, coding, etc.)<\/span><\/p>\n Step 3 \u2013 For each CARC listed identify if the denial is controllable or uncontrollable\u00a0\u00a0<\/span><\/p>\n Robust Denial Mapping<\/b><\/p>\n Providers with more advanced analytic capabilities are positioned to create a more robust denial mapping table \u2013 one that takes denial analytics from good to great.\u00a0 Providers can accomplish this by mapping sub-grouped data.\u00a0 To tackle this\u2026\u00a0\u00a0\u00a0\u00a0<\/span><\/p>\n While denial mapping is both tedious and laborious it is an eye-opening endeavor well worth the journey. <\/span><\/p>\n","protected":false},"excerpt":{"rendered":" By: Gina Stinson, Senior Director, Revenue Cycle Management Did you know there are over 293 reasons why a claim payor doesn\u2019t pay a health insurance claim as billed?\u00a0 These reasons are called Claim Adjustment Reason Codes (CARC) and insurance carriers or claim administrators apply these codes to claim remits to identify why a claim, or […]<\/p>\n","protected":false},"author":1,"featured_media":8696,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"content-type":"","om_disable_all_campaigns":false,"inline_featured_image":false,"_monsterinsights_skip_tracking":false,"_monsterinsights_sitenote_active":false,"_monsterinsights_sitenote_note":"","_monsterinsights_sitenote_category":0,"footnotes":"","_links_to":"","_links_to_target":""},"categories":[9],"tags":[],"acf":[],"yoast_head":"\n\n
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