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CARC-NCPDPReject by cuiliqing

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									Pharmacy CARC Description                                                                       Electronic   Paper   Group   Situation                                            Associated NCPDP Fields       NCPDP Reject
  Y/N    Code                                                                                                        Code

   Y       3    Co-payment Amount                                                                   X         X       PR     Used when the adjustment process was to adjust Patient Pay Amount. (505-F5)
                                                                                                                             a patient pay amount that was paid on a claim.
                                                                                                                             The sum of all components of patient pay
                                                                                                                             amount are to be reported as using this CARC
                                                                                                                             Code.

   N       13   The date of death precedes the date of service.




   N       14   The date of birth follows the date of service.




   N       15   The authorization number is missing, invalid, or does not apply to the billed
                services or provider.



   Y       16   Claim/service lacks information which is needed for adjudication. At least          X         X      CO/PI   NCPDP recommends that rejects not be reported                                      See NCPDP
                one Remark Code must be provided (may be comprised of either the                                             on the 835 for electronically submitted claims. If                                 External Code List
                NCPDP Reject Reason Code, or Remittance Advice Remark Code that is                                           rejects are reported, the appropriate NCPDP
                not an ALERT.)                                                                                               reject code(s) as defined in the ECL must be
                                                                                                                             used.
   N       18   Duplicate claim/service.




   N       22   This care may be covered by another payer per coordination of benefits.


   Y       23   The impact of prior payer(s) adjudication including payments and/or                 X         X       OA     Used as an adjustment on an approved payable Other Payer Amount Recognized (566-
                adjustments.                                                                                                 and not as a reject. Valid only when amount not J5)
                                                                                                                             equal to zero (0).

   N       24   Charges are covered under a capitation agreement/managed care plan.




   N       26   Expenses incurred prior to coverage.




   N       27   Expenses incurred after coverage terminated.
N   29   The time limit for filing has expired.




N   31   Patient cannot be identified as our insured.




N   32   Our records indicate that this dependent is not an eligible dependent as
         defined.



N   33   Insured has no dependent coverage.




N   34   Insured has no coverage for newborns.




N   38   Services not provided or authorized by designated (network/primary care)
         providers.



N   39   Services denied at the time authorization/pre-certification was requested.




N   40   Charges do not meet qualifications for emergent/urgent care. Note: Refer to
         the 835 Healthcare Policy Identification Segment (loop 2110 Service
         Payment Information REF), if present.
Y   45   Charge exceeds fee schedule/maximum allowable or contracted/legislated        X   X    CO     Used when adjudicated amounts payable for            Compare Professional Service Fee
         fee arrangement. (Use Group Codes PR or CO depending upon liability).                         fields other than ingredient cost (see CARC 90),     Submitted (477-BE) to Professional
                                                                                                       dispensing fee (see CARC 91) and tax (see            Service Fee Paid (562-J1).
                                                                                                       CARC 105 & 137) are different than submitted on
                                                                                                       either electronic or paper claims. If the claim is   Compare Incentive Amount Submitted
                                                                                                       rejected CARC Code Value 16 must be used.            (438-E3) to Incentive Amount Paid (521-
                                                                                                                                                            FL).

                                                                                                                                                            Compare Other Amount Claimed
                                                                                                                                                            Submitted (480-H9) to Other Amount
                                                                                                                                                            Paid (565-J4).


Y   90   Ingredient cost adjustment. Note: To be used for pharmaceuticals only.        X   X   CO/PI   Used when the ingredient cost paid is other than Compare Ingredient Cost Submitted
                                                                                                       the submitted amount and not the result of       (409-D9) to
                                                                                                       determining amount paid from Usual and           Ingredient Cost Paid (506-F6)
                                                                                                       Customary (426-DQ).
Y   91    Dispensing fee adjustment.                                                      X   X   CO/PI   Used when the dispensing fee paid is other than Compare Dispensing Fee Submitted
                                                                                                          the submitted amount and not the result of      (412-DC) to Dispensing Fee Paid (507-
                                                                                                          determining amount paid from Usual and          F9)
                                                                                                          Customary (426-DQ).

N   97    The benefit for this service is included in the payment/allowance for another
          service/procedure that has already been adjudicated. Note: Refer to the
          835 Healthcare Policy Identification Segment (loop 2110 Service Payment
          Information REF), if present.

N   100   Payment made to patient/insured/responsible party/employer.




N   105   Tax withholding.

N   109   Claim not covered by this payer/contractor. You must send the claim to the
          correct payer/contractor.



N   110   Billing date predates service date.




Y   111   Not covered unless the provider accepts assignment.                             X   X   CO/PI   If submit claim was for Medicare Part B.


N   119   Benefit maximum for this time period or occurrence has been reached.




N   125   Submission/billing error(s). At least one 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.)


N   130   Claim submission fee.




Y   133   The disposition of this claim/service is pending further review.                X   X   CO/PI   To be used when claim submitted electronically
                                                                                                          is captured without pricing adjudication or paper
                                                                                                          claim is pended and provider cannot take action
                                                                                                          until claim is finalized by the payer.
Y   137   Regulatory Surcharges, Assessments, Allowances or Health Related            X   X   CO/PI   Used when the sales tax paid is other than the   Compare Flat Sales Tax Amount
          Taxes.                                                                                      submitted amount.                                Submitted (481-HA) to Flat Sales Tax
                                                                                                                                                       Amount Paid (558-AW)

                                                                                                                                                       Compare Percentage Sales Tax Amount
                                                                                                                                                       Submitted (482-GE) to Percentage
                                                                                                                                                       Sales Tax Amount Paid (559-AX)


Y   138   Appeal procedures not followed or time limits not met.                          X   CO/PI   paper claim only



Y   140   Patient/Insured health identification number and name do not match.             X   CO/PI   paper claim only                                                                           62



Y   144   Incentive adjustment, e.g. preferred product/service.                       X   X   CO/PI   Used when the incentive amount paid is other     Compare Incentive Amount Submitted
                                                                                                      than the submitted amount.                       (438-E3) to Incentive Amount Paid (521-
                                                                                                                                                       FL)
N   150   Payer deems the information submitted does not support this level of
          service.



N   153   Payer deems the information submitted does not support this dosage.




N   154   Payer deems the information submitted does not support this day's supply.




N   170   Payment is denied when performed/billed by this type of provider. Note:
          Refer to the 835 Healthcare Policy Identification Segment (loop 2110
          Service Payment Information REF), if present.

N   171   Payment is denied when performed/billed by this type of provider in this
          type of facility. Note: Refer to the 835 Healthcare Policy Identification
          Segment (loop 2110 Service Payment Information REF), if present.

N   175   Prescription is incomplete.




N   177   Patient has not met the required eligibility requirements.




N   178   Patient has not met the required spend down requirements.
N   181   Procedure code was invalid on the date of service.




N   182   Procedure modifier was invalid on the date of service.




N   184   The prescribing/ordering provider is not eligible to prescribe/order the
          service billed. Note: Refer to the 835 Healthcare Policy Identification
          Segment (loop 2110 Service Payment Information REF), if present.

N   185   The rendering provider is not eligible to perform the service billed. Note:
          Refer to the 835 Healthcare Policy Identification Segment (loop 2110
          Service Payment Information REF), if present.

N   187   Consumer Spending Account payments (includes but is not limited to
          Flexible Spending Account, Health Savings Account, Health
          Reimbursement Account, etc.)
N   189   'Not otherwise classified' or 'unlisted' procedure code (CPT/HCPCS) was
          billed when there is a specific procedure code for this procedure/service



N   197   Precertification/authorization/notification absent.




N   200   Expenses incurred during lapse in coverage




N   204   This service/equipment/drug is not covered under the patient's current
          benefit plan



N   206   National Provider Identifier - missing.




N   207   National Provider identifier - Invalid format




N   208   National Provider Identifier - Not matched.
N   226   Information requested from the Billing/Rendering Provider was not provided
          or was insufficient/incomplete. At least one 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.)

N   227   Information requested from the patient/insured/responsible party was not
          provided or was insufficient/incomplete. At least one 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.)

N   235   Sales Tax




N   A1    Claim/Service denied. At least one 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.)

N   B9    Patient is enrolled in a Hospice.
N   B13   Previously paid. Payment for this claim/service may have been provided in
          a previous payment.
N   D23   This dual eligible patient is covered by Medicare Part D per Medicare Retro-
          Eligibility. At least one 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.) Note: Stops 1/1/2012
Comment              X12
                     Comment

                                  NCPDP requires group code PI in addition to CO. The accepted
                                  payment of a pharmacy claim transactions do not imply a
                                  contract exists.



Use CARC Code 16
with appropriate
NCPDP Reject Code
value(s)
Use CARC Code 16
with appropriate
NCPDP Reject Code
value(s)
Use CARC Code 16
with appropriate
NCPDP Reject Code
value(s)
See NCPDP External   PR and OA Corrected
Code List            not
                     supported by
                     TR2


Use CARC Code 16
with appropriate
NCPDP Reject Code
value(s)
Use CARC Code 16
with appropriate
NCPDP Reject Code
                     TR3 requires Corrected
                     usage of OA.



Use CARC Code 16
with appropriate
NCPDP Reject Code
value(s)
Use CARC Code 16
with appropriate
NCPDP Reject Code
value(s)
Use CARC Code 16
with appropriate
NCPDP Reject Code
value(s)
Use CARC Code 16
with appropriate
NCPDP Reject Code
value(s)
Use CARC Code 16
with appropriate
NCPDP Reject Code
value(s)
Use CARC Code 16
with appropriate
NCPDP Reject Code
value(s)
Use CARC Code 16
with appropriate
NCPDP Reject Code
value(s)
Use CARC Code 16
with appropriate
NCPDP Reject Code
value(s)
Use CARC Code 16
with appropriate
NCPDP Reject Code
value(s)
Use CARC Code 16
with appropriate
NCPDP Reject Code
value(s)
Suggest that this is not
applicable to pharmacy

                           TR2 uses PR Corrected
                           and CO only




                           TR2 uses PR NCPDP requires group code PI in addition to CO. The accepted
                           and CO only payment of a pharmacy claim transactions do not imply a
                                       contract exists.
                            TR2 uses PR NCPDP requires group code PI in addition to CO. The accepted
                            and CO only payment of a pharmacy claim transactions do not imply a
                                        contract exists.


Use CARC Code 16
with appropriate
NCPDP Reject Code
value(s)

May be applied to report
adjustments after initial
provider payment; could
include patient / plan
paid amount changes
resulting in refund due
Use CARC Code value
of 137
Use CARC Code 16
with appropriate
NCPDP Reject Code
value(s)
Use CARC Code 16
with appropriate
NCPDP Reject Code
value(s)
                            TR2 uses PR NCPDP requires group code PI in addition to CO. The accepted
                            and CO only payment of a pharmacy claim transactions do not imply a
                                        contract exists.
Use CARC Code 3
since this is part of
patient co-pay amount.

Use CARC 16 and the
appropriate NCPDP
Reject based on fields
in error
To be used when the
claims submission fee
is included in the total
amount paid calculation.
                         TR2 uses PR NCPDP requires group code PI in addition to CO. The accepted
                         and CO only payment of a pharmacy claim transactions do not imply a
                                     contract exists.




                           TR2 uses NCPDP requires group code PI in addition to CO. The accepted
                          PR, CO, PI payment of a pharmacy claim transactions do not imply a
                            and OA   contract exists.
                          TR2 uses    NCPDP requires group code PI in addition to CO. The accepted
                          CO and PI   payment of a pharmacy claim transactions do not imply a
                            only.     contract exists.
                          TR2 uses    NCPDP requires group code PI in addition to CO. The accepted
                          CO only.    payment of a pharmacy claim transactions do not imply a
                                      contract exists.
Use CARC 16 and the
appropriate NCPDP
Reject based on fields
in error
Use CARC 16 and the
appropriate NCPDP
Reject based on fields
in error
Use CARC 16 and the
appropriate NCPDP
Reject based on fields
in error
Use CARC Code 16
with appropriate
NCPDP Reject Code
value(s)
Use CARC Code 16
with appropriate
NCPDP Reject Code
value(s)
Use CARC Code 16
with appropriate
NCPDP Reject Code
value(s)(s) based on
field(s) missing
Use CARC Code 16
with appropriate
NCPDP Reject Code
value(s)
Use CARC Code 16
with appropriate
NCPDP Reject Code
value(s)
Use CARC Code 16
with appropriate
NCPDP Reject Code
value(s)
Use CARC Code 16
with appropriate
NCPDP Reject Code
value(s)
Use CARC Code 16
with appropriate
NCPDP Reject Code
value(s)
Use CARC Code 16
with appropriate
NCPDP Reject Code
value(s)
Use CARC Code 3 to
report as part of copay
reduction.
Use CARC Code 16
with appropriate
NCPDP Reject Code
value(s)
Use CARC Code 16
with appropriate
NCPDP Reject Code
value(s)
Use CARC Code 16
with appropriate
NCPDP Reject Code
value(s)
Use CARC Code 16
with appropriate
NCPDP Reject Code
value(s)
Use CARC Code 16
with appropriate
NCPDP Reject Code
value(s)
Use CARC Code 16
with appropriate
NCPDP Reject Code
value(s)
Use CARC Code 16
with appropriate
NCPDP Reject Code
value(s)
use CARC 16 and the
appropriate NCPDP
Reject based on fields
that are missing

use CARC 16 and the
appropriate NCPDP
Reject based on fields
that are missing

Use CARC Code 137
for tax reporting.
Includes both D.0 and
paper claims.
Use CARC 16 and the
appropriate NCPDP
Reject based on fields
in error
Use CARC Code 45
Use CARC Code 18

Use only for 4010 -
Medicare recoupment.
Not mapped to 5010.

								
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