8/1/2025
•
Posted by Provider Relations
Fidelis Care would like to announce a new Explanation of Benefit (EOB) adjustment reason code that will be applied to claims where Fidelis Care has received a primary carrier payment.
New EOB Reason Code Details:
- CARC Code: 216 – Based on the findings of a review, organization or the payer’s findings.
- RARC Code: N199 – Additional payment/recoupment approved based on payer-initiated review/audit.
- These are internal adjustments that reflect the primary carrier’s payment. They do not impact the provider’s Remittance Advice financially and are not considered recoupments.
Primary Carrier Billing and Payments:
Medicaid is the payer of last resort and should always be billed after all other insurance carriers. Fidelis Care partners with vendors, such as HMS, to identify previously paid claims that were the responsibility of another carrier.
- When it is identified that Fidelis Care Medicaid paid out of order, the vendor outreaches and obtains payments directly from the appropriate carrier.
- The payments from the appropriate carrier are then posted to the claim in the Fidelis Care system as an internal adjustment.
- There is no impact to the provider’s payment from Fidelis Care.
- The CARC/RARC codes identified above will show on the EOB when this process occurs.
If you have any questions, please contact your Fidelis Care Provider Relations Specialist. To find your designated representative, please visit Contact Your Designated Provider Relations Specialist.