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1.0 Bill Adjust Code-General - California Department of Industrial

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					1.0 California DWC Bill Adjustment Reason Code / CARC / RARC Matrix Crosswalk

  DWC Bill
                                                                                                                                        Claims Adjustment Reason Code                       Remittance Advice Remark Code
 Adjustment                  Issue                     DWC Explanatory Message              CA Payer Instructions        CARC                                                        RARC
                                                                                                                                             Descriptions (CARC)                                  Descriptions (RARC)
Reason Code


GENERAL
G1            Provider's charge exceeds fee         The charge exceeds the Official                                      W1       Workers‟ compensation jurisdictional fee
              schedule allowance.                   Medical Fee Schedule allowance.                                               schedule adjustment. Note: If adjustment is at
                                                    The charge has been adjusted to                                               the Claim Level, the payer must send and the
                                                    the scheduled allowance.                                                      provider should refer to the 835 Class of
                                                                                                                                  Contract Code Identification Segment (Loop
                                                                                                                                  2100 Other Claim Related Information REF). If
                                                                                                                                  adjustment is at the Line Level, the payer must
                                                                                                                                  send and the provider should refer to the 835
                                                                                                                                  Healthcare Policy Identification Segment (loop
                                                                                                                                  2110 Service Payment information REF).




G2            The OMFS does not include a code      The Official Medical Fee Schedule     Indicate code for comparable W1         Workers‟ compensation jurisdictional fee        N448      This drug/service/supply is not
              for the billed service.               does not list this code. An           service.                                schedule adjustment. Note: If adjustment is at            included in the fee schedule or
                                                    allowance has been made for a                                                 the Claim Level, the payer must send and the              contracted/legislated fee
                                                    comparable service.                                                           provider should refer to the 835 Class of                 arrangement.
                                                                                                                                  Contract Code Identification Segment (Loop
                                                                                                                                  2100 Other Claim Related Information REF). If
                                                                                                                                  adjustment is at the Line Level, the payer must
                                                                                                                                  send and the provider should refer to the 835
                                                                                                                                  Healthcare Policy Identification Segment (loop
                                                                                                                                  2110 Service Payment information REF).




G3            The OMFS does not list the code for   The Official Medical Fee Schedule                                         220 The applicable fee schedule does not contain
              the billed service                    does not list this code. No payment                                           the billed code. Please resubmit a bill with the
                                                    is being made at this time. Please                                            appropriate fee schedule code(s) that best
                                                    resubmit your claim with the OMFS                                             describe the service(s) provided and supporting
                                                    code(s) that best describe the                                                documentation if required.
                                                    service(s) provided and your
                                                    supporting documentation.



G4            Billed charges exceed amount          This charge was adjusted to comply Requires name of specific               45 Charge exceeds fee schedule/maximum
              identified in your contract.          with the rate and rules of the     Contractual agreement from                 allowable or contracted/legislated fee
                                                    contract indicated.                which the re-imbursement                   arrangement. (Use Group Codes PR or CO
                                                                                       rate and/or payment rules                  depending upon liability).
                                                                                       were derived.

G5            No standard EOR message applies.      This charge was adjusted for the      Message to be used when no          162 State-mandated Requirement for Property and        M118   Alert: Letter to follow containing
                                                    reasons set forth in the attached     standard EOR message                    Casualty, see Claim Payment Remarks Code                  further information
                                                    letter.                               applies and additional                  for specific explanation.
                                                                                          communication is required to
                                                                                          provide clear and concise
                                                                                          reason(s) for
                                                                                          adjustment/denial.
1.0 California DWC Bill Adjustment Reason Code / CARC / RARC Matrix Crosswalk

  DWC Bill
                                                                                                                                                 Claims Adjustment Reason Code                     Remittance Advice Remark Code
 Adjustment                    Issue                        DWC Explanatory Message                 CA Payer Instructions         CARC                                                      RARC
                                                                                                                                                      Descriptions (CARC)                                Descriptions (RARC)
Reason Code


GENERAL
G6            Provider charges for service that has     According to the Official Medical                                         W1      Workers‟ compensation jurisdictional fee        N130     Alert: Consult plan benefit
              no value.                                 Fee Schedule this service has a                                                   schedule adjustment. Note: If adjustment is at           documents/guidelines for
                                                        relative value of zero and therefore                                              the Claim Level, the payer must send and the             information about restrictions for this
                                                        no payment is due.                                                                provider should refer to the 835 Class of                service.
                                                                                                                                          Contract Code Identification Segment (Loop
                                                                                                                                          2100 Other Claim Related Information REF). If
                                                                                                                                          adjustment is at the Line Level, the payer must
                                                                                                                                          send and the provider should refer to the 835
                                                                                                                                          Healthcare Policy Identification Segment (loop
                                                                                                                                          2110 Service Payment information REF).




G7            Provider bills for a service included     No separate payment was made             Requires identification of the        97 The benefit for this service is included in the
              within the value of another.              because the value of the service is      specific payment policy or               payment/allowance for another
                                                        included within the value of another     rules applied. For example:              service/procedure that has already been
                                                        service performed on the same day.       CPT coding guidelines, CCI               adjudicated.
                                                                                                 Edits, fee schedule ground
                                                                                                 rules.


G8            Provider billed for a separate            A charge was made for a "separate                                              97 The benefit for this service is included in the   M15    Separately billed services/tests
              procedure that is included in the total   procedure” that does not meet the                                                 payment/allowance for another                            have been bundled as they are
              service rendered.                         criteria for separate payment. See                                                service/procedure that has already been                  considered components of the same
                                                        Physician‟s Fee Schedule General                                                  adjudicated.                                             procedure. Separate payment is not
                                                        Instructions for Separate                                                                                                                  allowed.
                                                        Procedures rule.

G9            Provider submitted bill with no           The unlisted or BR service was not                                             16 Claim/service lacks information which is          N350   Missing/incomplete/invalid
              supporting or lack of sufficient          received or sufficiently identified or                                            needed for adjudication. At least one Remark             description of service for a Not
              identification or documentation for the   documented. We are unable to                                                      Code must be provided (may be comprised of               Otherwise Classified (NOC) code or
              unlisted or BR Service reported.          make a payment without                                                            either the Remittance Advice Remark Code or              for an Unlisted/By Report procedure.
                                                        supplementary documentation                                                       NCPDP Reject Reason Code.)                               [Note: If specific documentation is
                                                        giving a clearer description of the                                                                                                        needed, use the specific RARC for
                                                        service. See OMFS General                                                                                                                  the report needed.]
                                                        Instructions for Procedures Without
                                                        Unit Values


G10           Bill is submitted without necessary       We cannot review this service      Identify documentation or                   16 Claim/service lacks information which is          N29    Missing
              documentation needed for bill             without necessary documentation.   report necessary for bill                      needed for adjudication. At least one Remark             documentation/orders/notes/summa
              processing.                               Please resubmit with indicated     processing.                                    Code must be provided (may be comprised of               ry/report/chart. [Note: Only use
                                                        documentation as soon as possible.                                                either the Remittance Advice Remark Code or              RARC N29 if none of the more
                                                                                                                                          NCPDP Reject Reason Code.)                               specific RARC report type codes
                                                                                                                                                                                                   below apply. (G11 – G52)]
1.0 California DWC Bill Adjustment Reason Code / CARC / RARC Matrix Crosswalk

  DWC Bill
                                                                                                     Claims Adjustment Reason Code                   Remittance Advice Remark Code
 Adjustment          Issue             DWC Explanatory Message   CA Payer Instructions   CARC                                                 RARC
                                                                                                          Descriptions (CARC)                              Descriptions (RARC)
Reason Code


GENERAL
G11                                                                                         16 Claim/service lacks information which is       M30    Missing pathology report.
                                                                                               needed for adjudication. At least one Remark
                                                                                               Code must be provided (may be comprised of
                                                                                               either the Remittance Advice Remark Code or
                                                                                               NCPDP Reject Reason Code.)



G12                                                                                         16 Claim/service lacks information which is       N236   Incomplete/invalid pathology report.
                                                                                               needed for adjudication. At least one Remark
                                                                                               Code must be provided (may be comprised of
                                                                                               either the Remittance Advice Remark Code or
                                                                                               NCPDP Reject Reason Code.)




G13                                                                                         16 Claim/service lacks information which is       N240   Incomplete/invalid radiology report.
                                                                                               needed for adjudication. At least one Remark
                                                                                               Code must be provided (may be comprised of
                                                                                               either the Remittance Advice Remark Code or
                                                                                               NCPDP Reject Reason Code.)




G14                                                                                         16 Claim/service lacks information which is       M31    Missing radiology report.
                                                                                               needed for adjudication. At least one Remark
                                                                                               Code must be provided (may be comprised of
                                                                                               either the Remittance Advice Remark Code or
                                                                                               NCPDP Reject Reason Code.)




G15                                                                                         16 Claim/service lacks information which is       N451   Missing Admission Summary
                                                                                               needed for adjudication. At least one Remark          Report.
                                                                                               Code must be provided (may be comprised of
                                                                                               either the Remittance Advice Remark Code or
                                                                                               NCPDP Reject Reason Code.)
1.0 California DWC Bill Adjustment Reason Code / CARC / RARC Matrix Crosswalk

  DWC Bill
                                                                                                             Claims Adjustment Reason Code                   Remittance Advice Remark Code
 Adjustment          Issue             DWC Explanatory Message      CA Payer Instructions        CARC                                                 RARC
                                                                                                                  Descriptions (CARC)                              Descriptions (RARC)
Reason Code


GENERAL
G16                                                                                                 16 Claim/service lacks information which is       N452   Incomplete/Invalid Admission
                                                                                                       needed for adjudication. At least one Remark          Summary Report.
                                                                                                       Code must be provided (may be comprised of
                                                                                                       either the Remittance Advice Remark Code or
                                                                                                       NCPDP Reject Reason Code.)




G17                                                              If the payer needs                 16 Claim/service lacks information which is       M118   Alert: Letter to follow containing
                                                                 documentation supporting a            needed for adjudication. At least one Remark          further information
                                                                 prescription that was                 Code must be provided (may be comprised of
                                                                 Dispensed As Written, a               either the Remittance Advice Remark Code or
                                                                 request for additional                NCPDP Reject Reason Code.)
                                                                 information should be sent to
                                                                 the prescribing physician.



G18                                                                                                 16 Claim/service lacks information which is       N456   Incomplete/Invalid Physician Order.
                                                                                                       needed for adjudication. At least one Remark
                                                                                                       Code must be provided (may be comprised of
                                                                                                       either the Remittance Advice Remark Code or
                                                                                                       NCPDP Reject Reason Code.)

G19                                                                                                 16 Claim/service lacks information which is       N455   Missing Physician Order.
                                                                                                       needed for adjudication. At least one Remark
                                                                                                       Code must be provided (may be comprised of
                                                                                                       either the Remittance Advice Remark Code or
                                                                                                       NCPDP Reject Reason Code.)

G20                                                                                                 16 Claim/service lacks information which is       N497   Missing Medical Permanent
                                                                                                       needed for adjudication. At least one Remark          Impairment or Disability Report
                                                                                                       Code must be provided (may be comprised of
                                                                                                       either the Remittance Advice Remark Code or
                                                                                                       NCPDP Reject Reason Code.)

G21                                                                                                 16 Claim/service lacks information which is       N498   Incomplete/Invalid Medical
                                                                                                       needed for adjudication. At least one Remark          Permanent Impairment or Disability
                                                                                                       Code must be provided (may be comprised of            Report
                                                                                                       either the Remittance Advice Remark Code or
                                                                                                       NCPDP Reject Reason Code.)

G22                                                                                                 16 Claim/service lacks information which is       N499   Missing Medical Legal Report
                                                                                                       needed for adjudication. At least one Remark
                                                                                                       Code must be provided (may be comprised of
                                                                                                       either the Remittance Advice Remark Code or
                                                                                                       NCPDP Reject Reason Code.)
1.0 California DWC Bill Adjustment Reason Code / CARC / RARC Matrix Crosswalk

  DWC Bill
                                                                                                     Claims Adjustment Reason Code                   Remittance Advice Remark Code
 Adjustment          Issue             DWC Explanatory Message   CA Payer Instructions   CARC                                                 RARC
                                                                                                          Descriptions (CARC)                              Descriptions (RARC)
Reason Code


GENERAL
G23                                                                                         16 Claim/service lacks information which is       N500   Incomplete/Invalid Medical Legal
                                                                                               needed for adjudication. At least one Remark          Report
                                                                                               Code must be provided (may be comprised of
                                                                                               either the Remittance Advice Remark Code or
                                                                                               NCPDP Reject Reason Code.)

G24                                                                                         16 Claim/service lacks information which is       N501   Missing Vocational Report
                                                                                               needed for adjudication. At least one Remark
                                                                                               Code must be provided (may be comprised of
                                                                                               either the Remittance Advice Remark Code or
                                                                                               NCPDP Reject Reason Code.)

G25                                                                                         16 Claim/service lacks information which is       N502   Incomplete/Invalid Vocational
                                                                                               needed for adjudication. At least one Remark          Report
                                                                                               Code must be provided (may be comprised of
                                                                                               either the Remittance Advice Remark Code or
                                                                                               NCPDP Reject Reason Code.)

G26                                                                                         16 Claim/service lacks information which is       N503   Missing Work Status Report
                                                                                               needed for adjudication. At least one Remark
                                                                                               Code must be provided (may be comprised of
                                                                                               either the Remittance Advice Remark Code or
                                                                                               NCPDP Reject Reason Code.)

G27                                                                                         16 Claim/service lacks information which is       N504   Incomplete/Invalid Work Status
                                                                                               needed for adjudication. At least one Remark          Report
                                                                                               Code must be provided (may be comprised of
                                                                                               either the Remittance Advice Remark Code or
                                                                                               NCPDP Reject Reason Code.)

G28                                                                                         16 Claim/service lacks information which is       N453   Missing Consultation Report
                                                                                               needed for adjudication. At least one Remark
                                                                                               Code must be provided (may be comprised of
                                                                                               either the Remittance Advice Remark Code or
                                                                                               NCPDP Reject Reason Code.)

G29                                                                                         16 Claim/service lacks information which is       N454   Incomplete/Invalid Consultation
                                                                                               needed for adjudication. At least one Remark          Report
                                                                                               Code must be provided (may be comprised of
                                                                                               either the Remittance Advice Remark Code or
                                                                                               NCPDP Reject Reason Code.)

G30                                                                                         16 Claim/service lacks information which is       N26    Missing Itemized Bill/ Statement
                                                                                               needed for adjudication. At least one Remark
                                                                                               Code must be provided (may be comprised of
                                                                                               either the Remittance Advice Remark Code or
                                                                                               NCPDP Reject Reason Code.)
1.0 California DWC Bill Adjustment Reason Code / CARC / RARC Matrix Crosswalk

  DWC Bill
                                                                                                     Claims Adjustment Reason Code                   Remittance Advice Remark Code
 Adjustment          Issue             DWC Explanatory Message   CA Payer Instructions   CARC                                                 RARC
                                                                                                          Descriptions (CARC)                              Descriptions (RARC)
Reason Code


GENERAL
G31                                                                                         16 Claim/service lacks information which is       N455   Missing Physician's Report- Delete
                                                                                               needed for adjudication. At least one Remark          Comments
                                                                                               Code must be provided (may be comprised of
                                                                                               either the Remittance Advice Remark Code or
                                                                                               NCPDP Reject Reason Code.)

G32                                                                                         16 Claim/service lacks information which is       N456   Incomplete/Invalid Physician Report
                                                                                               needed for adjudication. At least one Remark
                                                                                               Code must be provided (may be comprised of
                                                                                               either the Remittance Advice Remark Code or
                                                                                               NCPDP Reject Reason Code.)

G33                                                                                         16 Claim/service lacks information which is       N394   Incomplete/invalid progress notes/
                                                                                               needed for adjudication. At least one Remark          report.
                                                                                               Code must be provided (may be comprised of
                                                                                               either the Remittance Advice Remark Code or
                                                                                               NCPDP Reject Reason Code.)

G34                                                                                         16 Claim/service lacks information which is       N393   Missing progress notes/report.
                                                                                               needed for adjudication. At least one Remark
                                                                                               Code must be provided (may be comprised of
                                                                                               either the Remittance Advice Remark Code or
                                                                                               NCPDP Reject Reason Code.)

G35                                                                                         16 Claim/service lacks information which is       N396   Incomplete/invalid laboratory report.
                                                                                               needed for adjudication. At least one Remark
                                                                                               Code must be provided (may be comprised of
                                                                                               either the Remittance Advice Remark Code or
                                                                                               NCPDP Reject Reason Code.)

G36                                                                                         16 Claim/service lacks information which is       N395   Missing laboratory report.
                                                                                               needed for adjudication. At least one Remark
                                                                                               Code must be provided (may be comprised of
                                                                                               either the Remittance Advice Remark Code or
                                                                                               NCPDP Reject Reason Code.)

G37                                                                                         16 Claim/service lacks information which is       N458   Incomplete/Invalid Diagnostic
                                                                                               needed for adjudication. At least one Remark          Report.
                                                                                               Code must be provided (may be comprised of
                                                                                               either the Remittance Advice Remark Code or
                                                                                               NCPDP Reject Reason Code.)

G38                                                                                         16 Claim/service lacks information which is       N457   Missing Diagnostic Report.
                                                                                               needed for adjudication. At least one Remark
                                                                                               Code must be provided (may be comprised of
                                                                                               either the Remittance Advice Remark Code or
                                                                                               NCPDP Reject Reason Code.)
1.0 California DWC Bill Adjustment Reason Code / CARC / RARC Matrix Crosswalk

  DWC Bill
                                                                                                     Claims Adjustment Reason Code                   Remittance Advice Remark Code
 Adjustment          Issue             DWC Explanatory Message   CA Payer Instructions   CARC                                                 RARC
                                                                                                          Descriptions (CARC)                              Descriptions (RARC)
Reason Code


GENERAL
G39                                                                                         16 Claim/service lacks information which is       N460   Incomplete/Invalid Discharge
                                                                                               needed for adjudication. At least one Remark          Summary.
                                                                                               Code must be provided (may be comprised of
                                                                                               either the Remittance Advice Remark Code or
                                                                                               NCPDP Reject Reason Code.)

G40                                                                                         16 Claim/service lacks information which is       N459   Missing Discharge Summary.
                                                                                               needed for adjudication. At least one Remark
                                                                                               Code must be provided (may be comprised of
                                                                                               either the Remittance Advice Remark Code or
                                                                                               NCPDP Reject Reason Code.)

G41                                                                                         16 Claim/service lacks information which is       N462   Incomplete/Invalid Nursing Notes.
                                                                                               needed for adjudication. At least one Remark
                                                                                               Code must be provided (may be comprised of
                                                                                               either the Remittance Advice Remark Code or
                                                                                               NCPDP Reject Reason Code.)




G42                                                                                         16 Claim/service lacks information which is       N461   Missing Nursing Notes.
                                                                                               needed for adjudication. At least one Remark
                                                                                               Code must be provided (may be comprised of
                                                                                               either the Remittance Advice Remark Code or
                                                                                               NCPDP Reject Reason Code.)

G43                                                                                         16 Claim/service lacks information which is       N464   Incomplete/Invalid support data for
                                                                                               needed for adjudication. At least one Remark          claim.
                                                                                               Code must be provided (may be comprised of
                                                                                               either the Remittance Advice Remark Code or
                                                                                               NCPDP Reject Reason Code.)

G44                                                                                         16 Claim/service lacks information which is       N463   Missing support data for claim.
                                                                                               needed for adjudication. At least one Remark
                                                                                               Code must be provided (may be comprised of
                                                                                               either the Remittance Advice Remark Code or
                                                                                               NCPDP Reject Reason Code.)




G45                                                                                         16 Claim/service lacks information which is       N466   Incomplete/Invalid Physical Therapy
                                                                                               needed for adjudication. At least one Remark          Notes.
                                                                                               Code must be provided (may be comprised of
                                                                                               either the Remittance Advice Remark Code or
                                                                                               NCPDP Reject Reason Code.)
1.0 California DWC Bill Adjustment Reason Code / CARC / RARC Matrix Crosswalk

  DWC Bill
                                                                                                     Claims Adjustment Reason Code                   Remittance Advice Remark Code
 Adjustment          Issue             DWC Explanatory Message   CA Payer Instructions   CARC                                                 RARC
                                                                                                          Descriptions (CARC)                              Descriptions (RARC)
Reason Code


GENERAL
G46                                                                                         16 Claim/service lacks information which is       N465   Missing Physical Therapy Notes.
                                                                                               needed for adjudication. At least one Remark
                                                                                               Code must be provided (may be comprised of
                                                                                               either the Remittance Advice Remark Code or
                                                                                               NCPDP Reject Reason Code.)




G47                                                                                         16 Claim/service lacks information which is       N468   Incomplete/Invalid Report of Tests
                                                                                               needed for adjudication. At least one Remark          and Analysis Report.
                                                                                               Code must be provided (may be comprised of
                                                                                               either the Remittance Advice Remark Code or
                                                                                               NCPDP Reject Reason Code.)
1.0 California DWC Bill Adjustment Reason Code / CARC / RARC Matrix Crosswalk

  DWC Bill
                                                                                                     Claims Adjustment Reason Code                   Remittance Advice Remark Code
 Adjustment          Issue             DWC Explanatory Message   CA Payer Instructions   CARC                                                 RARC
                                                                                                          Descriptions (CARC)                              Descriptions (RARC)
Reason Code


GENERAL
G48                                                                                         16 Claim/service lacks information which is       N467   Missing Report of Tests and
                                                                                               needed for adjudication. At least one Remark          Analysis Report.
                                                                                               Code must be provided (may be comprised of
                                                                                               either the Remittance Advice Remark Code or
                                                                                               NCPDP Reject Reason Code.)

G49                                                                                         16 Claim/service lacks information which is       N493   Missing Doctor First Report of Injury
                                                                                               needed for adjudication. At least one Remark
                                                                                               Code must be provided (may be comprised of
                                                                                               either the Remittance Advice Remark Code or
                                                                                               NCPDP Reject Reason Code.)

G50                                                                                         16 Claim/service lacks information which is       N494   Incomplete/invalid Doctor First
                                                                                               needed for adjudication. At least one Remark          Report of Injury.
                                                                                               Code must be provided (may be comprised of
                                                                                               either the Remittance Advice Remark Code or
                                                                                               NCPDP Reject Reason Code.)

G51                                                                                         16 Claim/service lacks information which is       N495   Missing Supplemental Medical
                                                                                               needed for adjudication. At least one Remark          Report
                                                                                               Code must be provided (may be comprised of
                                                                                               either the Remittance Advice Remark Code or
                                                                                               NCPDP Reject Reason Code.)

G52                                                                                         16 Claim/service lacks information which is       N496   Incomplete/invalid Supplemental
                                                                                               needed for adjudication. At least one Remark          Medical Report.
                                                                                               Code must be provided (may be comprised of
                                                                                               either the Remittance Advice Remark Code or
                                                                                               NCPDP Reject Reason Code.)
1.0 California DWC Bill Adjustment Reason Code / CARC / RARC Matrix Crosswalk

  DWC Bill
                                                                                                                                              Claims Adjustment Reason Code                     Remittance Advice Remark Code
 Adjustment                    Issue                     DWC Explanatory Message                 CA Payer Instructions           CARC                                                    RARC
                                                                                                                                                   Descriptions (CARC)                                Descriptions (RARC)
Reason Code


GENERAL
G53                                                                                                                                175 Prescription is incomplete                        N378   Missing/incomplete/invalid
                                                                                                                                                                                                prescription quantity


                                                                                                                                   176 Prescription is not current                       N388   Missing/incomplete/invalid
                                                                                                                                                                                                prescription number


                                                                                                                                        CARC 175 and 176 may be used with any of         N349   The administration method and drug
                                                                                                                                        the listed RARC Codes                                   must be reported to adjudicate this
                                                                                                                                                                                                service.



                                                                                                                                                                                         N389   Duplicate prescription number
                                                                                                                                                                                                submitted.


                                                                                                                                                                                         M123   Missing/incomplete/invalid name,
                                                                                                                                                                                                strength, or dosage of the drug
                                                                                                                                                                                                furnished.

G54           Provider's documentation and/or code The documentation does not                Indicate alternate OMFS               150 Payer deems the information submitted does        N22    This procedure code was added/
              does not support level of service billed support the level of service billed.  code on which payment                     not support this level of service.                       changed because it more accurately
                                                       Reimbursement was made for a          amount is based.                                                                                   describes the services rendered.
                                                       code that is supported by the
                                                       description and documentation
                                                       submitted with the billing.
G55           Provider bills for service that is not   This service appears to be                                                   11 The diagnosis is inconsistent with the
              related to the diagnosis.                unrelated to the patient's diagnosis.                                           procedure.

G56           Provider bills a duplicate charge.     This appears to be a duplicate           Indicate date original charge         18 Duplicate claim/service.
                                                     charge for a bill previously reviewed,   was reviewed for payment.
                                                     or this appears to be a “balance         This code may be used to
                                                     forward bill” containing a duplicate     reject a bill that is a complete
                                                     charge and billing for a new service.    duplicate or to reject an
                                                                                              entire bill that fits the
                                                                                              definition of “balance forward
                                                                                              bill” under section 5.0 (c).

G57           Service or procedure requires prior    This service requires prior                                                   197 Precertification/authorization/notification
              authorization and none was identified. authorization and none was                                                        absent.
                                                     identified.




G58           Provider bills separately for report   Reimbursement for this report is         Message shall not be used to          97 The benefit for this service is included in the   N390   This service/report cannot be billed
              included as part of another service.   included with other services             deny separately                          payment/ allowance for another service/                  separately.
                                                     provided on the same day; therefore      reimbursable special and/or              procedure that has already been adjudicated.
                                                     a separate payment is not                duplicate reports requested
                                                     warranted.                               by the payer.
1.0 California DWC Bill Adjustment Reason Code / CARC / RARC Matrix Crosswalk

  DWC Bill
                                                                                                                                               Claims Adjustment Reason Code                       Remittance Advice Remark Code
 Adjustment                    Issue                     DWC Explanatory Message                CA Payer Instructions           CARC                                                        RARC
                                                                                                                                                    Descriptions (CARC)                                  Descriptions (RARC)
Reason Code


GENERAL
G59           Provider bills inappropriate modifier   The appended modifier code is not      If modifier is incorrect, billed          4 The procedure code is inconsistent with the
              code.                                   appropriate with the service billed.   OMFS code should still be                   modifier used or a required modifier is missing.
                                                                                             considered for payment
                                                                                             either without use of the
                                                                                             modifier or with adjustment
                                                                                             by the reviewer to the correct
                                                                                             modifier, when the service is
                                                                                             otherwise payable. Indicate
                                                                                             alternative modifier if
                                                                                             assigned
1.0 California DWC Bill Adjustment Reason Code / CARC / RARC Matrix Crosswalk

  DWC Bill
                                                                                                                                            Claims Adjustment Reason Code                        Remittance Advice Remark Code
 Adjustment                    Issue                       DWC Explanatory Message                CA Payer Instructions        CARC                                                       RARC
                                                                                                                                                 Descriptions (CARC)                                   Descriptions (RARC)
Reason Code


GENERAL
G60           Billing is for a service unrelated to the Payment for this service has been                                        191 Not a work related injury/illness and thus not
              work illness or injury.                   denied because it appears to be                                              the liability of the workers‟ compensation
                                                        unrelated to the claimed work illness                                        carrier. Note: If adjustment is at the Claim
                                                        or injury.                                                                   Level, the payer must send and the provider
                                                                                                                                     should refer to the 835 Insurance Policy
                                                                                                                                     Number Segment (Loop 2100 Other Claim
                                                                                                                                     Related Information REF qualifier 'IG') for the
                                                                                                                                     jurisdictional regulation. If adjustment is at the
                                                                                                                                     Line Level, the payer must send and the
                                                                                                                                     provider should refer to the 835 Healthcare
                                                                                                                                     Policy Identification Segment (loop 2110
                                                                                                                                     Service Payment information REF).

G61           Provider did not document the service The charge was denied as the                                                 112 Service not furnished directly to the patient
              that was performed.                   report / documentation does not                                                  and/or not documented.
                                                    indicate that the service was
                                                    performed.
G62           Provider inappropriately billed for   Reimbursement was made for a          For use in cases where the              40 Charges do not meet qualifications for
              emergency services.                   follow-up visit, as the documentation emergency physician directs                emergent/urgent care.
                                                    did not reflect an emergency.         the patient to return to the
                                                                                          emergency department for
                                                                                          non-emergent follow-up
                                                                                          medical treatment.

G63           Provider bills for services outside      The billed service falls outside your                                       8 The procedure code is inconsistent with the
              his/her scope of practice.               scope of practice.                                                            provider type/specialty (taxonomy).
G64           Provider charge of professional and/or   Provider charge of professional          Indicate name of other           134 Technical fees removed from charges.
              technical component is submitted after   and/or technical component is            provider who received global
              global payment made to another           submitted after global payment           payment.
              provider.                                made to another provider.
1.0 California DWC Bill Adjustment Reason Code / CARC / RARC Matrix Crosswalk

  DWC Bill
                                                                                                                                         Claims Adjustment Reason Code                     Remittance Advice Remark Code
 Adjustment                   Issue                       DWC Explanatory Message               CA Payer Instructions        CARC                                                   RARC
                                                                                                                                              Descriptions (CARC)                                Descriptions (RARC)
Reason Code


GENERAL
G65           Provider charge of professional and/or   Provider charge of professional       Indicate name of other             89 Professional fees removed from charges.          N130   Alert: Consult plan benefit
              technical component is submitted after   and/or technical component is         provider who received global                                                                  documents/guidelines for
              global payment made to another           submitted after global payment        payment.                                                                                      information about restrictions for this
              provider.                                made to another provider.                                                                                                           service.
G66           Timed code is billed without             Documentation of the time spent                                          16 Claim/service lacks information which is         N443   Missing/incomplete/invalid total time
              documentation.                           performing this service is needed for                                       needed for adjudication. At least one Remark            or begin/end time.
                                                       further review.                                                             Code must be provided (may be comprised of
                                                                                                                                   either the Remittance Advice Remark Code or
                                                                                                                                   NCPDP Reject Reason Code.)




G67           Charge is for a different amount than    Payment based on individual pre-     Identify name of specific          131 Claim specific negotiated discount.
              what was pre-negotiated.                 negotiated agreement for this        contracting entity,
                                                       specific service.                    authorization # if provided,
                                                                                            and pre- negotiated fee or
                                                                                            terms. This EOR is for
                                                                                            individually negotiated items/

G68           Charge submitted for service in          Service exceeds pre-authorized                                          198 Precertification/authorization exceeded.         N435   Exceeds number/frequency
              excess of pre-authorization.             approval. Please provide                                                                                                            approved /allowed within time period
                                                       documentation and/or additional                                                                                                     without supporting documentation.
                                                       authorization for the service not
                                                       included in the original
                                                       authorization.




G69           Charge is made by provider outside of Payment is denied as the service        Indicate name of HCO or             38 Services not provided or authorized by
              HCO or MPN.                           was provided outside the                MPN designated network.                designated (network/primary care) providers.
                                                    designated Network.                     This message is not to be
                                                                                            used to deny payment to out-
                                                                                            of-network providers when
                                                                                            the employee is legally
                                                                                            allowed to treat out of
                                                                                            network.

                                                                                            For example: when the
                                                                                            employer refers the injured
                                                                                            worker to the provider.

G70           Charge denied during Prospective or      This charge is denied as the service Optional: Provide Utilization       39 Services denied at the time authorization/pre-   N175   Missing review organization
              Concurrent Utilization Review            was not authorized during the        Review phone number.                   certification was requested.                            approval.
                                                       Utilization Review process. If you
                                                       disagree, please contact our
                                                       Utilization Review Unit.
1.0 California DWC Bill Adjustment Reason Code / CARC / RARC Matrix Crosswalk

  DWC Bill
                                                                                                                                                 Claims Adjustment Reason Code                       Remittance Advice Remark Code
 Adjustment                    Issue                        DWC Explanatory Message                  CA Payer Instructions         CARC                                                       RARC
                                                                                                                                                      Descriptions (CARC)                                  Descriptions (RARC)
Reason Code


GENERAL
G71           Charge denied during a Retrospective This charge was denied as part of a Optional: Provide Utilization                   216 Based on the findings of a review organization
              Utilization Review.                  Retrospective Review. If you        Review phone number.
                                                   disagree, please contact our
                                                   Utilization Review Unit.




G72           Charge being submitted for                 This charge is being sent to                                                   15 The authorization number is missing, invalid, or N175     Missing review organization
              Retrospective Review                       Retrospective Review as there is no                                               does not apply to the billed service                      approval
                                                         indication that prior authorization
                                                         has been sought.


G73           Provider bills with missing, invalid or    Payment adjusted because the                                                   15 The authorization number is missing, invalid, or
              inappropriate authorization number         submitted authorization number is                                                 does not apply to the billed service.
                                                         missing, invalid, or does not apply to
                                                         the billed services or provider.



G74           Provider bills and does not provide        Requested documentation to               Identify the necessary items.        226 Information requested from the                 N66        Missing/incomplete/invalid
              requested documentation or the             support the bill was absent or                                                    Billing/Rendering Provider was not provided or            documentation.
              documentation was insufficient or          incomplete.                                                                       was insufficient/incomplete. At least one
              incomplete                                                                                                                   Remark Code must be provided (may be
                                                                                                                                           comprised of either the NCPDP Reject Reason
                                                                                                                                           Code, or Remittance Advice Remark Code that
                                                                                                                                           is not an ALERT.)



G75           Provider bills payer/employer when         Bill payment denied as the patient                                       A1       Claim/Service denied. At least one Remark    MA61         Missing/in-complete/invalid social
              there is no claim on file                  cannot be identified as having a                                                  Code must be provided (may be comprised of                security number or health insurance
                                                         claim against this claims                                                         either the NCPDP Reject Reason Code, or                   claim number.
                                                         administrator.                                                                    Remittance Advice Remark Code that is not an
                                                                                                                                           ALERT.)


G76           Provider bills for services that are not   These are non-covered services                                                 50 These are non-covered services because this
              medically necessary                        because this is not deemed a                                                      is not deemed a 'medical necessity' by the
                                                         'medical necessity' by the payer.                                                 payer.



G77           Provider submits bill to incorrect         Claim not covered by this                                                     109 Claim not covered by this payer/contractor. You
              payer/contactor                            payer/contractor. You must send the                                               must send the claim to the correct
                                                         claim to the correct                                                              payer/contractor. (CARC) 109 is to be used
                                                         payer/contractor.                                                                 with qualifier PR in NM1 to indicate the
                                                                                                                                           employer entity.
1.0 California DWC Bill Adjustment Reason Code / CARC / RARC Matrix Crosswalk

  DWC Bill
                                                                                                                                         Claims Adjustment Reason Code                       Remittance Advice Remark Code
 Adjustment                    Issue                       DWC Explanatory Message                CA Payer Instructions      CARC                                                     RARC
                                                                                                                                              Descriptions (CARC)                                  Descriptions (RARC)
Reason Code


GENERAL
G78           Provider bills for multiple services with Payment adjusted because the                                           151 Payment adjusted because the payer deems
              no or inadequate information to           payer deems the information                                                the information submitted does not support this
              support this many services.               submitted does not support this                                            many/frequency of services.
                                                        many services.

G79           Bill exceeds or is received after         This claim has not been accepted     .                                 119 Benefit maximum for this time period or            N436   The injury claim has not been
              $10,000 cap has been reached on a         and the mandatory $10,000 medical                                          occurrence has been reached.                              accepted and a mandatory medical
              delayed claim                             reimbursements have been made.                                                                                                       reimbursement has been made. For
                                                        Should the claim be accepted, your                                                                                                   additional clarification to the
                                                        bill will then be reconsidered. This                                                                                                 provider, use Remark Code N437 –
                                                        determination must be made by 90                                                                                                     Alert: If the injury claim is accepted,
                                                        days from the date of injury but may                                                                                                 these charges will be reconsidered.
                                                        be made sooner.




G80           Bill is submitted that is for a greater   Until the employee‟s claim is                                          119 Benefit maximum for this time period or            N437   Alert: If the injury claim is accepted,
              amount than remains in the $10,000        accepted or rejected, liability for                                        occurrence has been reached.                              these charges will be reconsidered.
              cap.                                      medical treatment is limited to
                                                        $10,000 (Labor Code § 5402(c)).
                                                        Your bill is being partially paid as
                                                        this payment will complete the Labor
                                                        Code § 5402(c) mandatory $10,000
                                                        reimbursement. Should the claim be
                                                        accepted, your bill will then be
                                                        reconsidered. This determination
                                                        must be made by 90 days from the
                                                        date of injury but may be made
                                                        sooner.




G81           Payer is paying self-executing            This bill has been paid beyond the     Add 15% penalty and             225 Penalty or Interest Payment by Payer (Only
              penalties and interest to the provider    time frame required under L.C.         appropriate interest to the         used for plan to plan encounter reporting within
              due to late payment.                      4602.3. Per Section 7.2 (b)            payment.                            the 837) Note: for CA workers‟ compensation,
                                                        penalties and interest are self-                                           ignore the parenthetical section.
                                                        executing
1.0 California DWC Bill Adjustment Reason Code / CARC / RARC Matrix Crosswalk
   DWC Bill            Issue             DWC Explanatory            CA Payer     CARC Claims Adjustment Reason           RARC     Remittance Advice Remark
  Adjustment                                Message               Instructions        Code Descriptions (CARC)                    Code Descriptions (RARC)
 Reason Code
PHYSICAL
MEDICINE
PM1            Non-RPT provider       This charge was denied                         8 The procedure code is
               bills Physical         as the Physical Therapy                          inconsistent with the provider
               Therapy                Assessment and                                   type/specialty (taxonomy).
               Assessment and         Evaluation codes are
               Evaluation code.       billable by Registered
                                      Physical Therapists
                                      only.

PM2            Provider bills both    Documentation justifying                      16 Claim/service lacks              N435    Exceeds number/ frequency
               E/M or A/E, and test   charges for both test                            information which is needed              approved /allowed within time
               and measurement        and measurements and                             for adjudication. At least one           period without support
               codes on the same      evaluation and                                   Remark Code must be                      documentation.
               day.                   management or                                    provided (may be comprised
                                      assessment and                                   of either the Remittance
                                      evaluation on the same                           Advice Remark Code or
                                      day is required in                               NCPDP Reject Reason
                                      accordance with                                  Code.)
                                      Physical Medicine rule 1
                                      (h).

PM3            Provider bills three   When billing for                             119 Benefit maximum for this time N362       The number of Days or Units of
               or more modalities     modalities only, you are                         period or occurrence has                 Service exceeds our acceptable
               only, in same visit.   limited to two modalities                        been reached.                            maximum.
                                      in any single visit
                                      pursuant to Physical
                                      Medicine rule 1 (b).
                                      Payment has been
                                      made in accordance
                                      with Physician Fee
                                      Schedule guidelines.

PM4            Provider bills         This physical medicine                       107 The related or qualifying        N122    Add-on code cannot be billed by
               “additional 15         extended time service                            claim/ service was not                   itself.
               minute” code           was billed without the                           identified on this claim.
               without billing the    “initial 30 minutes” base
               “initial 30 minute”    code.
               base code.
1.0 California DWC Bill Adjustment Reason Code / CARC / RARC Matrix Crosswalk
   DWC Bill           Issue            DWC Explanatory             CA Payer     CARC Claims Adjustment Reason        RARC     Remittance Advice Remark
  Adjustment                              Message                Instructions        Code Descriptions (CARC)                 Code Descriptions (RARC)
 Reason Code
PHYSICAL
MEDICINE
PM5            Provider bills a     Only one assessment                           119 Benefit maximum for this time N130    Alert: Consult plan benefit
               second physical      and evaluation is                                 period or occurrence has              documents/guidelines for
               therapy A/E within   reimbursable within a 30                          been reached.                         information about restrictions for
               30 days of the last  day period. The                                                                         this service.
               evaluation.          provider has already
                                    billed for a physical
                                    therapy evaluation within
                                    the last 30 days. See
                                    Physical Medicine rule 1
                                    (a).
PM6            Provider billing     Reimbursement for                             119 Benefit maximum for this time N362    The number of Days or Units of
               exceeds 60 minutes physical medicine                                   period or occurrence has              Service exceeds our acceptable
               of physical medicine procedures, modalities,                           been reached.                         maximum.
               or acupuncture       including Chiropractic
               services.            Manipulation and
                                    acupuncture codes are
                                    limited to 60 minutes per
                                    visit without prior
                                    authorization pursuant to
                                    Physical Medicine rule
                                    1 (c).

PM7            Provider bills more   No more than four                            151 Payment adjusted because      N362    The number of Days or Units of
               than four physical    physical medicine                                the payer deems the                   Service exceeds our acceptable
               medicine              procedures including                             information submitted does            maximum.
               procedures and/or     Chiropractic                                     not support this
               chiropractic          Manipulation and                                 many/frequency of services.
               manipulation and/or   Acupuncture codes are
               acupuncture codes     reimbursable during the
               during the same       same visit without prior
               visit without prior   authorization pursuant to
               authorization.        Physical Medicine rule 1
                                     (d).
1.0 California DWC Bill Adjustment Reason Code / CARC / RARC Matrix Crosswalk
   DWC Bill            Issue               DWC Explanatory             CA Payer     CARC Claims Adjustment Reason          RARC     Remittance Advice Remark
  Adjustment                                  Message                Instructions        Code Descriptions (CARC)                   Code Descriptions (RARC)
 Reason Code
PHYSICAL
MEDICINE
PM8            Provider bills full      Physical Medicine rule 1                         59 Processed based on multiple
               value for services       (e) regarding multiple                              or concurrent procedure
               subject to the           services (cascade) was                              rules.
               multiple service         applied to this service.
               cascade.


PM9            Provider bills office    Billing for evaluation and                       59 Processed based on multiple N130      Alert: Consult plan benefit
               visit in addition to     management service in                               or concurrent procedure               documents/ guidelines for
               physical                 addition to physical                                rules.                                information about restrictions for
               medicine/acupunctu       medicine/acupuncture                                                                      this service.
               re code or               code or OMT/CMT code
               OMT/CMT code at          resulted in a 2.4 unit
               same visit.              value deduction from the
               Specified special        treatment codes in
               circumstances not        accordance with
               applicable.              Physical Medicine rule 1
                                        (g).


PM10           Provider fails to note   Payment for this service                    W1      Workers‟ compensation         N435    Exceeds number/frequency
               justification for        was denied because                                  jurisdictional fee schedule           approved /allowed within time
               follow-up E/M            documentation of the                                adjustment. Note: If                  period without support
               charge during            circumstances justifying                            adjustment is at the Claim            documentation.
               treatment.               both a follow-up                                    Level, the payer must send
                                        evaluation and                                      and the provider should refer
                                        management visit and                                to the 835 Class of Contract
                                        physical medicine                                   Code Identification Segment
                                        treatment has not been                              (Loop 2100 Other Claim
                                        provided as required by                             Related Information REF). If
                                        physical medicine rule 1                            adjustment is at the Line
                                        (f).                                                Level, the payer must send
                                                                                            and the provider should refer
                                                                                            to the 835 Healthcare Policy
                                                                                            Identification Segment (loop
                                                                                            2110 Service Payment
                                                                                            information REF).
1.0 California DWC Bill Adjustment Reason Code / CARC / RARC Matrix Crosswalk
   DWC Bill            Issue               DWC Explanatory             CA Payer     CARC Claims Adjustment Reason          RARC   Remittance Advice Remark
  Adjustment                                  Message                Instructions        Code Descriptions (CARC)                 Code Descriptions (RARC)
 Reason Code
PHYSICAL
MEDICINE
PM11           Physical Therapist       Charge was denied as                          170 Payment is denied when
               charged for E/M          Physical Therapists may                           performed/billed by this type
               codes which are          not bill Evaluation and                           of provider.
               limited to               Management services.
               physicians, nurse
               practitioners, and
               physician
               assistants.

PM12           Pre-surgical visits in   Charge is denied as          Optional:        198 Precertification/authorization
               excess of 24 are         there is a 24 visit          Provide              exceeded.
               charged without          limitation on pre-surgical   Utilization
               prior authorization      Physical Therapy,            Review phone
               for additional visits.   Chiropractic and             number.
                                        Occupational Therapy
                                        encounters for injuries
                                        on/after January 1, 2004
                                        without prior
                                        authorization for
                                        additional visits.
1.0 California DWC Bill Adjustment Reason Code / CARC / RARC Matrix Crosswalk
   DWC Bill           Issue              DWC Explanatory            CA Payer   CARC   Claims Adjustment Reason        RARC   Remittance Advice Remark
  Adjustment                                Message               Instructions        Code Descriptions (CARC)               Code Descriptions (RARC)
 Reason Code
SURGERY
S1           Physician billing         Recommended                               59 Processed based on multiple
             exceeds fee schedule      payment reflects                             or concurrent procedure rules.
             guidelines for multiple   Physician Fee
             surgical services.        Schedule Surgery
                                       Section, rule 7
                                       guidelines for multiple
                                       or bi-lateral surgical
                                       services.
S2             Physician billed for    The value of the initial                  97 The benefit for this service is
               initial casting service casting service is                           included in the
               included in value of    included within the                          payment/allowance for another
               fracture or dislocation value of a fracture or                       service/procedure that has
               reduction allowed on dislocation reduction                           already been adjudicated.
               the same day.           service.



S3             Physician bills office   The visit or service                     97 The benefit for this service is M144     Pre-/post-operative care
               visit or service which   billed, occurred within                     included in the                          payment is included in the
               is not separately        the global surgical                         payment/allowance for another            allowance for the
               reimbursable as it is    period and is not                           service/procedure that has               surgery/procedure.
               within the global        separately                                  already been adjudicated.
               surgical period.         reimbursable.




S4             Multiple arthroscopic    Additional                               59 Processed based on multiple N130         Alert: Consult plan benefit
               services to same joint   arthroscopic services                       or concurrent procedure rules.           documents/ guidelines for
               same session are         were reduced to 10                                                                   information about restrictions
               billed at full value.    percent of scheduled                                                                 for this service.
                                        values pursuant to
                                        Surgery Section, rule
                                        7 re: Arthroscopic
                                        Services.
1.0 California DWC Bill Adjustment Reason Code / CARC / RARC Matrix Crosswalk
   DWC Bill            Issue              DWC Explanatory           CA Payer   CARC   Claims Adjustment Reason          RARC   Remittance Advice Remark
  Adjustment                                 Message              Instructions        Code Descriptions (CARC)                 Code Descriptions (RARC)
 Reason Code
SURGERY
S5             Physician bills initial   This initial visit was              W1       Workers‟ compensation            N22     This procedure code was
               visit in addition to      converted to code                            jurisdictional fee schedule              added/changed because it
               starred service, which    99025 in accordance                          adjustment. Note: If                     more accurately describes
               constituted the major     with the starred                             adjustment is at the Claim               the services rendered.
               service.                  service Surgery                              Level, the payer must send
                                         Section, rule 10 (b)                         and the provider should refer
                                         (1).                                         to the 835 Class of Contract
                                                                                      Code Identification Segment
                                                                                      (Loop 2100 Other Claim
                                                                                      Related Information REF). If
                                                                                      adjustment is at the Line Level,
                                                                                      the payer must send and the
                                                                                      provider should refer to the
                                                                                      835 Healthcare Policy
                                                                                      Identification Segment (loop
                                                                                      2110 Service Payment
                                                                                      information REF).
1.0 California DWC Bill Adjustment Reason Code / CARC / RARC Matrix Crosswalk
   DWC Bill           Issue            DWC Explanatory           CA Payer   CARC   Claims Adjustment Reason         RARC   Remittance Advice Remark
  Adjustment                              Message              Instructions        Code Descriptions (CARC)                Code Descriptions (RARC)
 Reason Code
SURGERY
S6             Assistant Surgeon      Assistant Surgeon                   W1       Workers‟ compensation            N130   Alert: Consult plan benefit
               charged greater than   services have been                           jurisdictional fee schedule             documents/ guidelines for
               20% of the surgical    reimbursed at 20% of                         adjustment. Note: If                    information about restrictions
               procedure.             the surgical                                 adjustment is at the Claim              for this service.
                                      procedure. (See                              Level, the payer must send
                                      Modifier 80 in the                           and the provider should refer
                                      Surgery Section of the                       to the 835 Class of Contract
                                      Physician‟s Fee                              Code Identification Segment
                                      Schedule).                                   (Loop 2100 Other Claim
                                                                                   Related Information REF). If
                                                                                   adjustment is at the Claim
                                                                                   Level, the payer must send
                                                                                   and the provider should refer
                                                                                   to the 835 Class of Contract
                                                                                   Code Identification Segment
                                                                                   (Loop 2100 Other Claim
                                                                                   Related Information REF). If
                                                                                   adjustment is at the Line Level,
                                                                                   the payer must send and the
                                                                                   provider should refer to the
                                                                                   835 Healthcare Policy
                                                                                   Identification Segment (loop
                                                                                   2110 Service Payment
                                                                                   information REF).
1.0 California DWC Bill Adjustment Reason Code / CARC / RARC Matrix Crosswalk
   DWC Bill            Issue           DWC Explanatory            CA Payer   CARC   Claims Adjustment Reason         RARC   Remittance Advice Remark
  Adjustment                              Message               Instructions        Code Descriptions (CARC)                Code Descriptions (RARC)
 Reason Code
SURGERY
S7             Non-physician         Non-physician                         W1       Workers‟ compensation            N130   Alert: Consult plan benefit
               assistant charged     assistant surgeon has                          jurisdictional fee schedule             documents/ guidelines for
               greater than 10% of   been reimbursed at                             adjustment. Note: If                    information about restrictions
               the surgical          10% of the surgical                            adjustment is at the Claim              for this service.
               procedure.            procedure. (See                                Level, the payer must send
                                     Modifier 83 in the                             and the provider should refer
                                     Surgery Section of the                         to the 835 Class of Contract
                                     Physician‟s Fee                                Code Identification Segment
                                     Schedule).                                     (Loop 2100 Other Claim
                                                                                    Related Information REF). If
                                                                                    adjustment is at the Line Level,
                                                                                    the payer must send and the
                                                                                    provider should refer to the
                                                                                    835 Healthcare Policy
                                                                                    Identification Segment (loop
                                                                                    2110 Service payment
                                                                                    information REF).


S8             Surgeon‟s bill does   The surgeon‟s bill has                     16 Claim/service lacks            M29       Missing operative note/report.
               not include operative been rejected as we                           information which is needed
               report                have not received the                         for adjudication. At least one
                                     operative report.                             Remark Code must be
                                     Resubmit bill with the                        provided (may be comprised of
                                     operative report for                          either the Remittance Advice
                                     reconsideration.                              Remark Code or NCPDP
                                                                                   Reject Reason Code.)

S9             Operative Report      Incomplete/invalid                         16 Claim/service lacks            N233      Incomplete/       invalid
               does not cite the     operative report (billed                      information which is needed              operative report.
               billed procedure.     service is not                                for adjudication. At least one
                                     identified in the                             Remark Code must be
                                     Operative Report)                             provided (may be comprised of
                                                                                   either the Remittance Advice
                                                                                   Remark Code or NCPDP
                                                                                   Reject Reason Code.)
1.0 California DWC Bill Adjustment Reason Code / CARC / RARC Matrix Crosswalk
   DWC Bill            Issue             DWC Explanatory            CA Payer   CARC         Claims Adjustment Reason        RARC   Remittance Advice Remark
  Adjustment                                Message               Instructions              Code Descriptions (CARC)               Code Descriptions (RARC)
 Reason Code
SURGERY
S10            Surgeon‟s bill           Administration of                          W1      Workers‟ compensation            N514   Consult plan benefit
               includes separate        Local Anesthetic is                                jurisdictional fee schedule             documents/guidelines for
               charge for delivery of   included in the                                    adjustment. Note: If                    information about restrictions
               local anesthetic.        Surgical Service per                               adjustment is at the Claim              for this service.
                                        Surgery Section, rule                              Level, the payer must send
                                        16.                                                and the provider should refer
                                                                                           to the 835 Class of Contract
                                                                                           Code Identification Segment
                                                                                           (Loop 2100 Other Claim
                                                                                           Related Information REF). If
                                                                                           adjustment is at the Claim
                                                                                           Level, the payer must send
                                                                                           and the provider should refer
                                                                                           to the 835 Class of Contract
                                                                                           Code Identification Segment
                                                                                           (Loop 2100 Other Claim
                                                                                           Related Information REF). If
                                                                                           adjustment is at the Line Level,
                                                                                           the payer must send and the
                                                                                           provider should refer to the
                                                                                           835 Healthcare Policy
                                                                                           Identification Segment (loop
                                                                                           2110 Service Payment
                                                                                           information REF).
S11            Procedure does not       Assistant surgeon         Identify the          54 Multiple physicians/ assistants N130    Alert: Consult plan benefit
               normally require an      services have been        reference                are not covered in this case.           documents/ guidelines for
               Assistant surgeon or     denied as not             source listing                                                   information about restrictions
               multiple surgeons        normally warranted        of approved                                                      for this service.
               and no                   for this procedure        Assistant
               documentation was        according to the listed   Surgeon
               provided to              citation.                 services.
               substantiate a need
               in this case.
1.0 California DWC Bill Adjustment Reason Code / CARC / RARC Matrix Crosswalk
    DWC Bill            Issue              DWC Explanatory          CA Payer     CARC     Claims Adjustment         RARC       Remittance Advice
   Adjustment                                 Message             Instructions               Reason Code                         Remark Code
 Reason Code                                                                             Descriptions (CARC)                  Descriptions (RARC)
ANESTHESIA
A1              Physician bills for      Modifier -47 was used                      97 The benefit for this service N130   Alert: Consult plan benefit
                additional anesthesia    to indicate regional                          is included in the                  documents/ guidelines for
                time units not allowed   anesthesia by the                             payment/allowance for               information about
                by schedule              surgeon. In                                   another service/procedure           restrictions for this service.
                                         accordance with the                           that has already been
                                         Physician Fee                                 adjudicated.
                                         Schedule, time units
                                         are not reimbursed.

A2              No anesthesia            Please submit                              16 Claim/service lacks         N463    Missing support data for
                records provided for     anesthesia records for                        information which is                claim.
                payment                  further review.                               needed for adjudication. At
                determination.                                                         least one Remark Code
                                                                                       must be provided (may be
                                                                                       comprised of either the
                                                                                       Remittance Advice Remark
                                                                                       Code or NCPDP Reject
                                                                                       Reason Code.)

A3              Insufficient             Please submit                              16 Claim/service lacks         N464    Incomplete/invalid support
                information provided     complete/valid                                information which is                data for claim.
                for payment              anesthesia records for                        needed for adjudication. At
                determination.           further review.                               least one Remark Code
                                                                                       must be provided (may be
                                                                                       comprised of either the
                                                                                       Remittance Advice Remark
                                                                                       Code or NCPDP Reject
                                                                                       Reason Code.)

A4              Insufficient             Please submit                              16 Claim/service lacks         N203    Missing/incomplete/invalid
                information provided     anesthesia records                            information which is                anesthesia time/units
                for payment              time units for further                        needed for adjudication. At
                determination.           review.                                       least one Remark Code
                                                                                       must be provided (may be
                                                                                       comprised of either the
                                                                                       Remittance Advice Remark
                                                                                       Code or NCPDP Reject
                                                                                       Reason Code.)
1.0 California DWC Bill Adjustment Reason Code / CARC / RARC Matrix Crosswalk
   DWC Bill           Issue           DWC Explanatory          CA Payer     CARC     Claims Adjustment        RARC       Remittance Advice
  Adjustment                             Message             Instructions               Reason Code                        Remark Code
 Reason Code                                                                        Descriptions (CARC)                 Descriptions (RARC)
ANESTHESIA
A5             Documentation does   Qualifying                                 40 Charges do not meet
               not describe         circumstances for                             qualifications for
               emergency status.    emergency status not                          emergent/urgent care.
                                    established.

A6             Documentation does Patient‟s physical                           16 Claim/service lacks         N439   Missing anesthesia physical
               not describe physical status/condition not                         information which is               status report/indicators.
               status/condition.     identified. Please                           needed for adjudication. At
                                     provide documentation                        least one Remark Code              Incomplete/invalid
                                     using ASA Physical                           must be provided (may be N440      anesthesia physical status
                                     Status indicators.                           comprised of either the            report/indicators.
                                                                                  Remittance Advice Remark
                                                                                  Code or NCPDP Reject
                                                                                  Reason Code.)
1.0 California DWC Bill Adjustment Reason Code / CARC / RARC Matrix Crosswalk
  DWC Bill           Issue              DWC Explanatory           CA Payer       CARC      Claims Adjustment     RARC     Remittance Advice Remark
 Adjustment                                Message              Instructions                  Reason Code                 Code Descriptions (RARC)
   Reason                                                                                 Descriptions (CARC)
    Code
E/M
EM1         Physician bills for        No reimbursement        This EOR              95 Plan procedures not     M15     Separately billed services/tests
            office visit which is      was made for the        should only be           followed.                       have been bundled as they are
            already included in a      E/M service as the      used if                                                  considered components of the
            service performed on       documentation does      documentation                                            same procedure. Separate
            the same day.              not support a           does not                                                 payment is not allowed.
                                       separate significant,   support the
                                       identifiable E&M        use of modifier
                                       service performed       25, 57, or 59.
                                       with other services
                                       provided on the
                                       same day.

EM2          Documentation does The billed service                                  150 Payer deems the         N130    Alert: Consult plan benefit
             not support        does not meet the                                       information submitted           documents/ guidelines for
             Consultation code. requirements of a                                       does not support this           information about restrictions for
                                Consultation (See                                       level of service.               this service.
                                the General
                                Information and
                                Instructions Section
                                of the Physician‟s
                                Fee Schedule).

EM3          Documentation does        Documentation                                152 Payer deems the
             not support billing for   provided does not                                information submitted
             Prolonged Services        justify payment for a                            does not support this
             code.                     Prolonged Evaluation                             length of service.
                                       and Management
                                       service.
1.0 California DWC Bill Adjustment Reason Code / CARC / RARC Matrix Crosswalk
   DWC Bill             Issue         DWC Explanatory         CA Payer     CARC    Claims Adjustment    RARC     Remittance Advice Remark
  Adjustment                             Message            Instructions              Reason Code                Code Descriptions (RARC)
 Reason Code                                                                      Descriptions (CARC)

CLINICAL LAB
CL1            Physician bills for   This service is                          97 The benefit for this   M15    Separately billed services/tests
               individual service    normally part of a                          service is included in        have been bundled as they are
               normally part of a    panel and is                                the payment/                  considered components of the
               panel.                reimbursed under the                        allowance for another         same procedure. Separate
                                     appropriate panel                           service/ procedure            payment is not allowed.
                                     code.                                       that has already been
                                                                                 adjudicated.
1.0 California DWC Bill Adjustment Reason Code / CARC / RARC Matrix Crosswalk
  DWC Bill            Issue          DWC Explanatory             CA Payer      CARC    Claims Adjustment      RARC   Remittance Advice Remark Code
 Adjustment                             Message                Instructions               Reason Code                      Descriptions (RARC)
Reason Code                                                                           Descriptions (CARC)

PHARMACY
P1            Charge for Brand      Payment was made                          W1      Workers‟                N447   Payment is based on a generic
              Name was submitted    for a generic                                     compensation                   equivalent as required
              without “No           equivalent as “No                                 jurisdictional fee             documentation was not provided.
              Substitution”         Substitution”                                     schedule adjustment.
              documentation.        documentation was                                 Note: If adjustment is
                                    absent.                                           at the Claim Level, the
                                                                                      payer must send and
                                                                                      the provider should
                                                                                      refer to the 835 Class
                                                                                      of Contract Code
                                                                                      Identification Segment
                                                                                      (Loop 2100 Other
                                                                                      Claim Related
                                                                                      Information REF). If
                                                                                      adjustment is at the
                                                                                      Line Level, the payer
                                                                                      must send and the
                                                                                      provider should refer
                                                                                      to the 835 Healthcare
                                                                                      Policy Identification
                                                                                      Segment (loop 2110
                                                                                      Service Payment
                                                                                      information REF).



P2            Provider charges a    A dispensing fee is                            91 Dispensing fee
              dispensing fee for    not applicable for over-                          adjustment.
              over-the-counter      the-counter
              medication or         medication or
              medication            medication
              administered at the   administered at the
              time of the visit.    time of a visit.
1.0 California DWC Bill Adjustment Reason Code / CARC / RARC Matrix Crosswalk
DWC Bill Adjustment            Issue             DWC Explanatory          CA Payer     CARC    Claims Adjustment     RARC    Remittance Advice
  Reason Code                                       Message             Instructions              Reason Code                  Remark Code
                                                                                              Descriptions (CARC)           Descriptions (RARC)

DME
DME1                  Billed amount exceeds     Payment for this item                     108 Rent/purchase         N446    Incomplete/invalid
                      formula using             was based on the                              guidelines were not           document for actual
                      documented actual         documented actual                             met.                          cost or paid amount.
                      cost for DMEPOS           cost.

DME2                  Billed amount exceeds     Payment for this item                     108 Rent/purchase         N445    Missing document for
                      formula using             was based on the                              guidelines were not           actual cost or paid
                      documented actual         documented actual                             met.                          amount.
                      cost for DMEPOS           cost.

DME3                  Billing for purchase is   Charge is denied as                       108 Rent/purchase
                      received after cost of    total rental cost of                          guidelines were not
                      unit was paid through     DME has met or                                met.
                      rental charges.           exceeded the
                                                purchase price of the
                                                unit.
1.0 California DWC Bill Adjustment Reason Code / CARC / RARC Matrix Crosswalk
DWC Bill Adjustment          Issue             DWC Explanatory          CA Payer      CARC    Claims Adjustment         RARC    Remittance Advice
  Reason Code                                     Message             Instructions               Reason Code                      Remark Code
                                                                                             Descriptions (CARC)               Descriptions (RARC)

DME
DME4                  Billed amount exceeds   Payment for this item                  W1      Workers‟
                      formula using           was based on the                               compensation
                      documented actual       documented actual                              jurisdictional fee
                      cost for DMEPOS         cost.                                          schedule adjustment.
                                                                                             Note: If adjustment is
                                                                                             at the Claim Level, the
                                                                                             payer must send and
                                                                                             the provider should
                                                                                             refer to the 835 Class
                                                                                             of Contract Code
                                                                                             Identification Segment
                                                                                             (Loop 2100 Other
                                                                                             Claim Related
                                                                                             Information REF). If
                                                                                             adjustment is at the
                                                                                             Line Level, the payer
                                                                                             must send and the
                                                                                             provider should refer to
                                                                                             the 835 Healthcare
                                                                                             Policy Identification
                                                                                             Segment (loop 2110
                                                                                             Service Payment
                                                                                             Information REF).
1.0 California DWC Bill Adjustment Reason Code / CARC / RARC Matrix Crosswalk
     DWC Bill               Issue               DWC Explanatory           CA Payer      CARC    Claims Adjustment      RARC     Remittance Advice Remark
Adjustment Reason                                  Message              Instructions               Reason Code                  Code Descriptions (RARC)
      Code                                                                                     Descriptions (CARC)

SPECIAL SERVICES

SS1                 A physician, other than   The Progress report                      B7      This provider was not N450     Covered only when performed by
                    the Primary Treating      and or Permanent and                             certified/eligible to be       the primary treating physician or
                    Physician or designee     Stationary Report were                           paid for this                  the designee.
                    submits a Progress        disallowed as you are                            procedure/service on
                    and or Permanent and      not the Primary                                  this date of service.
                    Stationary Report for     Treating Physician or
                    reimbursement.            his/her designee.

SS2                 Non-reimbursable          This report does not                     W1      Workers‟                N390   This service/report cannot be
                    report is billed.         fall under the                                   compensation                   billed separately.
                                              guidelines for a                                 jurisdictional fee
                                              Separately                                       schedule adjustment.
                                              Reimbursable Report                              Note: If adjustment is
                                              found in the General                             at the Claim Level, the
                                              Instructions Section of                          payer must send and
                                              the Physician‟s Fee                              the provider should
                                              Schedule.                                        refer to the 835 Class
                                                                                               of Contract Code
                                                                                               Identification Segment
                                                                                               (Loop 2100 Other
                                                                                               Claim Related
                                                                                               Information REF). If
                                                                                               adjustment is at the
                                                                                               Line Level, the payer
                                                                                               must send and the
                                                                                               provider should refer
                                                                                               to the 835 Healthcare
                                                                                               Policy Identification
                                                                                               Segment (loop 2110
                                                                                               Service Payment
                                                                                               information REF).
1.0 California DWC Bill Adjustment Reason Code / CARC / RARC Matrix Crosswalk
     DWC Bill               Issue           DWC Explanatory       CA Payer      CARC    Claims Adjustment      RARC     Remittance Advice Remark
Adjustment Reason                              Message          Instructions               Reason Code                  Code Descriptions (RARC)
      Code                                                                             Descriptions (CARC)

SPECIAL SERVICES

SS3                 No request was made Chart Notes/Duplicate                       96 Non-covered           N390     This service/report cannot be
                    for Chart Notes or  Reports were not                               charge(s). At least            billed separately.
                    Duplicate Report.   requested.                                     one Remark Code
                                                                                       must be provided
                                                                                       (may be comprised of
                                                                                       either the Remittance
                                                                                       Advice Remark Code
                                                                                       or NCPDP Reject
                                                                                       Reason Code.)


SS4                 Missed appointment is No payment is being                  W1      Workers‟                N441   This missed appointment is not
                    billed.               made, as none is                             compensation                   covered.
                                          necessarily owed                             jurisdictional fee
                                                                                       schedule adjustment.
                                                                                       Note: If adjustment is
                                                                                       at the Claim Level, the
                                                                                       payer must send and
                                                                                       the provider should
                                                                                       refer to the 835 Class
                                                                                       of Contract Code
                                                                                       Identification Segment
                                                                                       (Loop 2100 Other
                                                                                       Claim Related
                                                                                       Information REF). If
                                                                                       adjustment is at the
                                                                                       Line Level, the payer
                                                                                       must send and the
                                                                                       provider should refer
                                                                                       to the 835 Healthcare
                                                                                       Policy Identification
                                                                                       Segment (loop 2110
                                                                                       Service Payment
                                                                                       information REF).
1.0 California DWC Bill Adjustment Reason Code / CARC / RARC Matrix Crosswalk
     DWC Bill               Issue            DWC Explanatory           CA Payer     CARC    Claims Adjustment      RARC   Remittance Advice Remark
Adjustment Reason                               Message              Instructions              Reason Code                Code Descriptions (RARC)
      Code                                                                                 Descriptions (CARC)

FACILITY
F1                  Procedure is on the     No reimbursement is                        197 Precertification/
                    Inpatient Only list.    being made as this                             authorization/
                    Needs advanced          procedure is not                               notification absent.
                    authorization in order  usually performed in
                    to be performed on an   an outpatient surgical
                    outpatient basis.       facility. Prior
                                            authorization is
                                            required but was not
                                            submitted.
F2                  Charge submitted for Treatment rooms                                40 Charges do not meet
                    facility treatment room used by the physician                          qualifications for
                    for non-emergent        and/or hospital                                emergent/urgent care.
                    service.                treatment rooms for
                                            non-emergency
                                            services are not
                                            reimbursable per the
                                            Physician‟s Fee
                                            Schedule Guidelines.
1.0 California DWC Bill Adjustment Reason Code / CARC / RARC Matrix Crosswalk
     DWC Bill               Issue            DWC Explanatory         CA Payer       CARC    Claims Adjustment      RARC     Remittance Advice Remark
Adjustment Reason                               Message            Instructions                Reason Code                  Code Descriptions (RARC)
      Code                                                                                 Descriptions (CARC)

FACILITY
F3                  Paid under a different Service not             Specify which   W1      Workers‟                N442   Payment based on an alternate
                    fee schedule.          reimbursable under      other fee               compensation                   fee schedule.
                                           Outpatient Facility Fee schedule.               jurisdictional fee
                                           Schedule. Charges                               schedule adjustment.
                                           are being paid under a                          Note: If adjustment is
                                           different fee schedule.                         at the Claim Level, the
                                                                                           payer must send and
                                                                                           the provider should
                                                                                           refer to the 835 Class
                                                                                           of Contract Code
                                                                                           Identification Segment
                                                                                           (Loop 2100 Other
                                                                                           Claim Related
                                                                                           Information REF). If
                                                                                           adjustment is at the
                                                                                           Line Level, the payer
                                                                                           must send and the
                                                                                           provider should refer
                                                                                           to the 835 Healthcare
                                                                                           Policy Identification
                                                                                           Segment (loop 2110
                                                                                           Service Payment
                                                                                           information REF).
1.0 California DWC Bill Adjustment Reason Code / CARC / RARC Matrix Crosswalk
     DWC Bill               Issue           DWC Explanatory           CA Payer      CARC    Claims Adjustment        RARC      Remittance Advice Remark
Adjustment Reason                              Message              Instructions               Reason Code                     Code Descriptions (RARC)
      Code                                                                                 Descriptions (CARC)

FACILITY
F4                  No payment required Service not paid under                     W1      Workers‟                     130 Alert: Consult plan benefit
                    under Outpatient      Outpatient Facility Fee                          compensation                     documents/ guidelines for
                    Facility Fee Schedule Schedule.                                        jurisdictional fee               information about restrictions for
                                                                                           schedule adjustment.             this service.
                                                                                           Note: If adjustment is
                                                                                           at the Claim Level, the
                                                                                           payer must send and
                                                                                           the provider should
                                                                                           refer to the 835 Class
                                                                                           of Contract Code
                                                                                           Identification Segment
                                                                                           (Loop 2100 Other
                                                                                           Claim Related
                                                                                           Information REF). If
                                                                                           adjustment is at the
                                                                                           Line Level, the payer
                                                                                           must send and the
                                                                                           provider should refer
                                                                                           to the 835 Healthcare
                                                                                           Policy Identification
                                                                                           Segment (loop 2110
                                                                                           Service Payment
                                                                                           information REF).
1.0 California DWC Bill Adjustment Reason Code / CARC / RARC Matrix Crosswalk
     DWC Bill              Issue          DWC Explanatory      CA Payer      CARC    Claims Adjustment      RARC     Remittance Advice Remark
Adjustment Reason                            Message         Instructions               Reason Code                  Code Descriptions (RARC)
      Code                                                                          Descriptions (CARC)

FACILITY
F5                  Billing submitted   In accordance with                  W1      Workers‟                M20    Missing/incomplete/invalid
                    without HCPCS codes OPPS guidelines                             compensation                   HCPCS.
                                        billing requires                            jurisdictional fee
                                        HCPCS coding.                               schedule adjustment.
                                                                                    Note: If adjustment is
                                                                                    at the Claim Level, the
                                                                                    payer must send and
                                                                                    the provider should
                                                                                    refer to the 835 Class
                                                                                    of Contract Code
                                                                                    Identification Segment
                                                                                    (Loop 2100 Other
                                                                                    Claim Related
                                                                                    Information REF). If
                                                                                    adjustment is at the
                                                                                    Line Level, the payer
                                                                                    must send and the
                                                                                    provider should refer
                                                                                    to the 835 Healthcare
                                                                                    Policy Identification
                                                                                    Segment (loop 2110
                                                                                    Service Payment
                                                                                    information REF).
1.0 California DWC Bill Adjustment Reason Code / CARC / RARC Matrix Crosswalk
     DWC Bill                Issue            DWC Explanatory            CA Payer      CARC    Claims Adjustment      RARC      Remittance Advice Remark
Adjustment Reason                                Message               Instructions               Reason Code                   Code Descriptions (RARC)
      Code                                                                                    Descriptions (CARC)

FACILITY
F6                  Facility has not filed   This facility has not                    W1      Workers‟                N444   Alert: This facility has not filed the
                    for High Cost Outlier    filed the Election for                           compensation                   Election for High Cost Outlier form
                    reimbursement            High Cost Outlier form                           jurisdictional fee             with the Division of Workers'
                    formula.                 with the Division of                             schedule adjustment.           Compensation.
                                             Workers‟                                         Note: If adjustment is
                                             Compensation. The                                at the Claim Level, the
                                             bill will be reimbursed                          payer must send and
                                             using the regular                                the provider should
                                             reimbursement                                    refer to the 835 Class
                                             methodology.                                     of Contract Code
                                                                                              Identification Segment
                                                                                              (Loop 2100 Other
                                                                                              Claim Related
                                                                                              Information REF). If
                                                                                              adjustment is at the
                                                                                              Line Level, the payer
                                                                                              must send and the
                                                                                              provider should refer
                                                                                              to the 835 Healthcare
                                                                                              Policy Identification
                                                                                              Segment (loop 2110
                                                                                              Service Payment
                                                                                              information REF).
1.0 California DWC Bill Adjustment Reason Code / CARC / RARC Matrix Crosswalk
   DWC Bill              Issue             DWC Explanatory            CA Payer     CARC     Claims Adjustment          RARC   Remittance Advice Remark
  Adjustment                                  Message               Instructions               Reason Code                    Code Descriptions (RARC)
 Reason Code                                                                               Descriptions (CARC)
MISC.
M1             Bill submitted for non   Workers‟ compensation                         214 Workers‟
               compensable claim        claim adjudicated as non-                         Compensation claim
                                        compensable. Carrier                              adjudicated as non-
                                        not liable for claim or                           compensable. This
                                        service/     treatment.                           Payer not liable for
                                                                                          claim or
                                                                                          service/treatment.
                                                                                          Note: If adjustment is
                                                                                          at the Claim Level, the
                                                                                          payer must send and
                                                                                          the provider should
                                                                                          refer to the 835
                                                                                          Insurance Policy
                                                                                          Number Segment
                                                                                          (Loop 2100 Other
                                                                                          Claim Related
                                                                                          Information REF
                                                                                          qualifier „IG‟) for the
                                                                                          jurisdictional regulation.
                                                                                          If adjustment is at the
                                                                                          Line Level, the payer
                                                                                          must send and the
                                                                                          provider should refer to
                                                                                          the 835 Healthcare
                                                                                          Policy Identification
                                                                                          Segment (loop 2110
                                                                                          Service Payment
                                                                                          information REF). To
                                                                                          be used for Workers‟
                                                                                          Compensation only.
1.0 California DWC Bill Adjustment Reason Code / CARC / RARC Matrix Crosswalk
   DWC Bill             Issue              DWC Explanatory               CA Payer     CARC     Claims Adjustment          RARC   Remittance Advice Remark
  Adjustment                                  Message                  Instructions               Reason Code                    Code Descriptions (RARC)
 Reason Code                                                                                  Descriptions (CARC)
MISC.
M2             Appeal /Reconsideration No additional                                     193 Original payment
                                       reimbursement allowed                                 decision is being
                                       after review of                                       maintained. Upon
                                       appeal/reconsideration.                               review, it was
                                                                                             determined that this
                                                                                             claim was processed
                                                                                             properly.



M3             Third Party Subrogation Reduction/denial based                            215 Based on subrogation
                                       on subrogation of a third                             of a third party
                                       party settlement.                                     settlement.


M4             Claim is under           Extent of injury not finally                     221 Workers‟
               investigation            adjudicated. Claim is                                Compensation claim is
                                        under investigation.                                 under investigation.
                                                                                             Note: If adjustment is
                                                                                             at the Claim Level, the
                                                                                             payer must send and
                                                                                             the provider should
                                                                                             refer to the 835
                                                                                             Insurance Policy
                                                                                             Number Segment
                                                                                             (Loop 2100 Other
                                                                                             Claim Related
                                                                                             Information REF
                                                                                             qualifier „IG‟) for the
                                                                                             jurisdictional regulation.
                                                                                             If adjustment is at the
                                                                                             Line Level, the payer
                                                                                             must send and the
                                                                                             provider should refer to
                                                                                             the 835 Healthcare
                                                                                             Policy Identification
                                                                                             Segment (loop 2110
                                                                                             Service Payment
                                                                                             information REF).
1.0 California DWC Bill Adjustment Reason Code / CARC / RARC Matrix Crosswalk
   DWC Bill             Issue               DWC Explanatory            CA Payer     CARC     Claims Adjustment       RARC     Remittance Advice Remark
  Adjustment                                   Message               Instructions               Reason Code                   Code Descriptions (RARC)
 Reason Code                                                                                Descriptions (CARC)
MISC.
M5             Medical Necessity         Medical Necessity Denial.                      50 These are non-covered
               Denial. You may submit    You may submit a                                  services because this
               a request for an          request for an                                    is not deemed a
               appeal/reconsideration.   appeal/reconsideration.                           'medical necessity' by
                                                                                           the payer.

M6             Appeal/                                                                  50 These are non-covered N10        Payment based on the findings of
               Reconsideration denied                                                      services because this            a review organization/professional
               based on medical                                                            is not deemed a                  consult/manual
               necessity.                                                                  'medical necessity' by           adjudication/medical or dental
                                                                                           the payer.                       advisor.



M7             This claim is the                                                       109 Claim not covered by
               responsibility of the                                                       this payer/ contractor.
               employer. Please submit                                                     You must send the
               directly to employer.                                                       claim to the correct
                                                                                           payer/ contractor.
                                                                                           (CARC) 109 is to be
                                                                                           used with qualifier PR
                                                                                           in NM1 to indicate the
                                                                                           employer entity.
2.0 Matrix List in CARC Order
   DWC Bill
  Adjustment   CARC        RARC
 Reason Code
     G59         4
    G63          8
    PM1          8
    G55          11
    G72          15        N175
    G73          15
     G9          16        N350
    G10          16        N29
    G11          16        M30
    G12          16        N236
    G13          16        N240
    G14          16        M31
    G15          16        N451
    G16          16        N452
    G17          16        M118
    G18          16        N456
    G19          16        N455
    G20          16        N497
    G21          16        N498
    G22          16        N499
    G23          16        N500
    G24          16        N501
    G25          16        N502
    G26          16        N503
    G27          16        N504
    G28          16        N453
    G29          16        N454
    G30          16        N26
    G31          16        N455
    G32          16        N456
    G33          16        N394
    G34          16        N393
    G35          16        N396
    G36          16        N395
    G37          16        N458
    G38          16        N457
    G39          16        N460
    G40          16        N459
2.0 Matrix List in CARC Order
   DWC Bill
  Adjustment   CARC        RARC
 Reason Code
     G41         16        N462
    G42          16        N461
    G43          16        N464
    G44          16        N463
    G45          16        N466
    G46          16        N465
    G47          16        N468
    G48          16        N467
    G49          16        N493
    G50          16        N494
    G51          16        N495
    G52          16        N496
    G66          16        N443
    PM2          16        N435
     S8          16        M29
     S9          16        N233
     A2          16        N463
     A3          16        N464
     A4          16        N203
                           N439
     A6          16
                           N440
    G56          18
    G75          31
    G69          38
    G70          39        N175
    G62          40
     A5          40
     F2          40
     G4          45
    G76          50
     M5          50
     M6          50        N10
    S11          54        N130
    PM8          59
    PM9          59        N130
     S1          59
     S4          59        N130
    G65          89        N130
2.0 Matrix List in CARC Order
   DWC Bill
  Adjustment   CARC        RARC
 Reason Code
      P2         91
    EM1          95        M15
    SS3          96        N390
     G7          97
     G8          97        M15
    G58          97        N390
     S2          97
     S3          97        M144
     A1          97        N130
    CL1          97        M15
    PM4         107        N122
    DME1        108        N446
    DME2        108        N445
    DME3        108
    G77         109
     M7         109
    G61         112
    G79         119        N436
    G80         119        N437
    PM3         119        N362
    PM5         119        N130
    PM6         119        N362
    G67         131
    G64         134
    G54         150        N22
    EM2         150        N130
    G78         151
    PM7         151        N362
    EM3         152
     G5         162        M118
    PM11        170
     G53        175        N378
                           N388
                176        N349
                           N389
                           M123
    G60         191
     M2         193
2.0 Matrix List in CARC Order
   DWC Bill
  Adjustment   CARC        RARC
 Reason Code
     G57        197
     F1         197
    G68         198        N435
    PM12        198
     M1         214
     M3         215
    G71         216
     G3         220
     M4         221
    G81         225
    G74         226        N66
    SS1          B7        N450
     G1         W1
     G2         W1         N448
     G6         W1         N130
    PM10        W1         N435
     S5         W1         N22
     S6         W1         N130
     S7         W1         N130
    S10         W1         N514
     P1         W1         N447
    DME4        W1
    SS2         W1         N390
    SS4         W1         N441
     F3         W1         N442
     F4         W1         130
     F5         W1         M20
     F6         W1         N444

				
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