5/2/2024
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Posted by Provider Relations
Fidelis Care would like to inform providers about upcoming changes to our remittance advice. Effective May 12, 2024, the Fidelis Care remittance advice will include Claim Adjustment Reason Codes (CARC) and Remittance Advice Remark Codes (RARC), along with a description of the codes.
CARCs describe why a claim or service line was paid differently than it was billed and RARCs provider additional explanation for an adjustment already described by a CARC or convey information about remittance advice.
There are two types of RARCs, supplemental and informational. The majority of RARCs are supplemental; these are generally referred to as RARCs without further distinction. Supplemental RARCs provide additional explanation for an adjustment already described by the CARC. The second type of RARC is informational; these RARCs are all prefaced with “Alert”. Alerts are used to convey information about remittance processing and are never related to a specific adjustment or CARC.
Sample of Applicable CARC and RAC Codes found on a Remittance Advice:
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Explanation
Code
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CARC/RARC Code
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Description
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K09
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97/ N70
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CARC: The benefit for this service is included in the payment/allowance for another service/procedure that has already been adjudicated.
RARC: Consolidated billing and payment applies.
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K03
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97
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CARC: The benefit for this service is included in the payment/allowance for another service/procedure that has already been adjudicated.
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Z03
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23/N377
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CARC: The impact of prior payer(s) adjudication including payments and/or adjustments. (Use only with Group Code OA)
RARC: Payment based on a processed replacement claim.
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BHX
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45/ N860
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CARC: Charge exceeds fee schedule/maximum allowable or contracted/legislated fee arrangement.
RARC: Alert: The Federal No Surprise Billing Act Qualified Payment Amount (QPA) was used to calculate the member cost share(s).
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B95
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226/ M143
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CARC: Information requested from the Billing/Rendering Provider was not provided or not provided timely 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.)
RARC: The provider must update license information with the payer.
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i19
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252/ N350
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CARC: An attachment/other documentation is required to adjudicate this claim/service. 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).
RARC: Missing/incomplete/invalid description of service for a Not Otherwise Classified (NOC) code or for an Unlisted/By Report procedure.
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If you have any questions, please contact your Fidelis Care Provider Relations Specialist. To find your designated representative, please click here.