EDI 835 HEALTH CARE CLAIM PAYMENT/ADVICE

Transcription

1 EDI 835 HEALTH CARE CLAIM PAYMENT/ADVICE IMPROVING THE UNDERSTANDING OF CLAIM PAYMENTS FOR INSURANCE CARRIERS PUBLISHED 2014 SoftCare HealthCare Solutions SoftCare ( ) 1

2 INTRODUCTION Imagine that you are an Insurance Carrier who is using a large group of client services representatives to handle claims inquiry phone calls from providers. You have thousands of inquiries on outstanding claims and you need to provide details on when the provider will get paid, which claim that they are being paid for and why some claims aren t being paid in full. Today, the process is a nightmare with constant turnover and more and more calls from providers wanting to reduce their AR cycles. Wouldn t it be great if this information could automatically flow from your systems to the providers without manual intervention and phone calls? The implementation of a fully integrated EDI 835 Health Care Claim Payment/Advice into your applications allows this to become reality. Let s discuss what this miracle document is and what is can do for both you the Insurance Carrier and the Providers: The HIPAA Implementation Guide for the EDI 835 Health Care Claim Payment/Advice Transaction describes the transaction s business use and definition in the following way: The 835 is intended to meet the particular needs of the health care industry for the payment of claims and transfer of remittance information. The 835 can be used to make a payment, send an Explanation of Benefits (EOB) remittance advice, or make a payment and send an EOB remittance advice from a health care payer to a health care provider, either directly or through a DFI [Depository Financial Institution]. The 835 Transaction (sometimes called the Claims Remittance Advice or Claims RA Transaction) is a claims payment reporting transaction. It tells claim submitters the results of payer adjudication at the claim and service line levels. The 835 Claim Remittance Advice does not report on claims that have not yet been processed or have been pended by the payer in their claims adjudication process. In the HIPAA environment, providers can obtain the statuses of all claims by the use of the EDI Health Care Claim Status Request (276) and Notification (277). These EDI documents include information on claims which have finalized, pended, rejected, paid or not completed adjudication. The 835 RA Transactions and 837 EDI Health Claim Transactions are closely linked. Although data on 835 Transactions comes from the payers claim adjudication database and their financial system, much of it is derived from information on incoming 837s and paper claims, with the addition of Payment Amounts, Adjustment Reason Codes, and Remark Codes generated by the adjudication process. Any change from a billed amount to a paid amount at a claim or service line level is called an adjustment in HIPAA nomenclature and is reported on the 835 with an Adjustment Reason Code and an Adjustment Amount. Adjustment Reason Codes occur at institutional and professional claim service line levels. In addition, the 835 Transaction supports HIPAA compliant Remark Codes at both levels. Remarks Codes are not directly associated with changes from billed to payment amounts but are used to provide additional information about claim and service line errors SoftCare Solutions Inc. 2

3 BALANCING FINANCIAL DATA Although the information in an EDI 835 Health Care Payment Advice can be provided at many levels, it is generally provided at the Claim Level and if the payers applications can provide it at the Service Line Level. Generally at the outpatient/professional service line level, balancing is between the amounts charged for the service, any line-level adjustment made to the charged amount, and the service line payment amount. The 835 translates these requirements into specific data elements that carry Charged Amounts, Adjustment Amounts, and Paid Amounts. Each Paid Amount must always be equal to the Charged Amount minus the Adjustment Amount. At the transaction level, the Total Payment Amounts for all claims in a transaction must equal the sum of all claim-level Payment Amounts plus or minus and Provider Level Adjustments for overpayments. For all levels of balancing, positive Adjustment Amounts are subtracted from amounts charged by the provider to create Payment Amounts. Negative Adjustment Amounts, should they occur, are negative to the payer and are added to the amounts charged by the provider. REMITTANCE TRACKING At the 835 can also be used for Remittance Tracking, The Trace Number and the Payer Identification Number in the 835 Transaction s Re-association Trace Number (TRN) Segment re-associate the remittance advice data in the 835 Transaction with the payment sent separately. For most payers the TRN02 element is the Payment Number of the check written for provider payment by the payers Financial System. Claims and Service Lines As used by most progressive payers, the structure of the 835 Transaction defines institutional and professional at the service line level. Each Claim Payment Segment on the 835 Transaction represents an adjudicated payment or denial. PRESENT AND FUTURE At present, the EDI 835 Health Care Payment/Advice is mandated in a number of states as required and by HIPAA as of January The reason for the mandate was to somewhat placate providers when states mandated the use of the EDI 837 Health Care Claim. The concept was that if the Insurance Carriers benefit most from the implementation of the Claim, the providers must also get an advantage so the mandate for the Payment/Advice. What would have been more logical was the mandate of the Health care Claim Status Notification (277) which reports on all claims and their status (not just finalized claims) but that said, the 835 is a valuable document if implemented correctly. The EDI 835 Health Care Payment/Advice transaction was adopted by HIPAA to be the standard communication tool for reporting payments, adjustments, and patient responsibility. Intuitively, one would expect that healthcare providers would be able to program their systems one time to process payments from all payers from whom they receive electronic files SoftCare Solutions Inc. 3

4 However, implementation of the ASC X transactions has been hampered by variations in the association of Claims Adjustment Reason Codes (CARCs For a full list of CARC codes and notes on the appropriate implementation see Appendix A of this document) and Claim Adjustment Group Codes (for a full list and implementation notes, see Appendix B of this document). Incorrect coding can lead to costly and unnecessary manual follow-up, faulty electronic secondary billing, inappropriate write-offs of billable charges, and incorrect billing of patients for co-pays and deductibles. The net effect can be reluctance on the part of providers to employ the 835, reducing ROI for payers and providers alike. Additional problems have been encountered when CARC s are deemed to be irrelevant or need to be split into additional codes. While the standards committee can eliminate a code, it is up to the individual payers to eliminate the codes and use the new codes when they are added. For the provider, this becomes an additional burden as they now have to be aware of every change and what it means. If we look at for example the CARC code 86 which is to mean a Statutory Adjustment. This code was supposed to be stopped in its usage on 10/16/2003 as it s a duplicate of code 45. What if the payer doesn t stop its usage or what if the payer is diligent and stops the use of the code and uses a 45 for a Statutory Adjustment? If the provider doesn t know or program the change, the effect is a slowdown in processing as a human must review this new code and determine what action it should take for its occurrence. Let s look at another real life example and how it can dramatically effect a providers bottom line. In this scenario, a payer has sent transactions with CARC=1 ("Deductible amount" matched with a Group Code of CO (Contractual Obligation) rather than the seemingly obvious PR (Patient Responsibility). To a provider, CO means "write this off" and PR means "bill the patient or secondary insurer." If the provider has relied only on the Group Code, it would be writing off cash receivables, which could ultimately result in increased charges. Examples of the opposite situation have also been seen. These are cases in which the payer has reported the CO (Contractual Obligation) as PR (Patient Responsibility). This scenario can result, and has resulted, in patients being billed for amounts that providers should have written off in accordance with their contract. Another real example of the difficulties that payers are having with implementing the standards is the case of a large payer who merged several entities into one organization but they had several different claims adjudication systems. 835 files sent from each group of this payer have different interpretations of how CARCs and Group Codes are matched. This results in providers having to program multiple times to process payments from one insurance company. Multiplied over the number of healthcare providers in the United States, this would cause severe inflation in healthcare costs from legislation that was designed to do just the opposite. Bottom Line is that the Electronic Remittance Advice (835) when implemented correctly provides a huge ROI to Insurance Carriers. To effectively implement it requires expertise and diligence but the savings on the bottom line can be dramatic for the entire HealthCare Business Chain (Insurance Carriers and Providers) SoftCare Solutions Inc. 4

5 HEALTH CARE CLAIM PAYMENT ADVICE THE SOFTCARE APPROACH SoftCare recognizes that for many organizations involved in the implementation of Health Care Claim Payment/ Advice be they Insurance Carriers, Providers, Provider Associations, IPA s, PPO s or third party billers there are just too many things to consider to develop an inter- organization solution. This is why SoftCare s Solution group was established to provide the appropriate mix of software and services to create the appropriate solutions. They walk an organization through the selection of an appropriate solution. This process includes: Determination of what type of information be received and sent? For the payer, will they support Line Item Adjustments, Adjustment Reason Codes and Group Adjustment Codes? Will the codes sent follow the intent of the standard or be customized? For providers, what information will be received and what of this information is important to your business processes? What information should be targeted to provide the biggest bang for the bucks for all involved? What would be the appropriate standards for the payment advice to allow software providers the ability to interface to the appropriate formats? We strongly believe in the concept of a standardized XML Interface layer to capture Payment information. This layer is used to interface with a providers or payers claims management and financial applications. This allows for the most flexibility while ensuring that the application is abstracted from the requirements of the various payers/carriers and providers. What level information (claim and/or line item) should be provided in provider centric reports and/or electronic files on claims status provided? What time frame should responses be provided (typically provided in near- real time)? All of these variables create an implementation roadmap. Once the implementation roadmap is completed, the next step is to implement the solution using the OpenEC TradeLink EDI Management System. This step involves working with the organization to configure TradeLink to meet their business processes. Once completed, the Solutions Group will test with a company s trading partners and train internal staff on how to implement future members. The key to SoftCare s Solutions group is to provide the software and services required to implement Electronic Health Care Claim Payment /Advices quickly and efficiently. Implementations are measured in weeks not years SoftCare Solutions Inc. 5

6 APPENDIX A CLAIM ADJUSTMENT REASON CODES Claim adjustment reason codes communicate an adjustment, meaning that they must communicate why a claim or service line was paid differently than it was billed. If there is no adjustment to a claim/line, then there is no adjustment reason code. 1 - Deductible Amount 2 - Coinsurance Amount 3 - Co-payment Amount 4 - The procedure code is inconsistent with the modifier used or a required modifier is missing. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. 5 - The procedure code/bill type is inconsistent with the place of service. Note: Refer to the The procedure/revenue code is inconsistent with the patient's age. Note: Refer to the The procedure/revenue code is inconsistent with the patient's gender. Note: refer to the The procedure code is inconsistent with the provider type/specialty (taxonomy). Note: Refer to the The diagnosis is inconsistent with the patient's age. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present The diagnosis is inconsistent with the patient's gender. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present The diagnosis is inconsistent with the procedure. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present The diagnosis is inconsistent with the provider type. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present The date of death precedes the date of service The date of birth follows the date of service The authorization number is missing, invalid, or does not apply to the billed services or provider Claim/service lacks information which is needed for adjudication. 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.) 2013 SoftCare Solutions Inc. 6

7 17 - Requested information was not provided or was insufficient/incomplete. At least one Remark Code must be provided (may be comprised of either the Remittance Advice Remark Code or NCPDP Reject Reason Code.) 18 - Duplicate claim/service This is a work-related injury/illness and thus the liability of the Worker's Compensation Carrier This injury/illness is covered by the liability carrier This injury/illness is the liability of the no-fault carrier This care may be covered by another payer per coordination of benefits The impact of prior payer(s) adjudication including payments and/or adjustments Charges are covered under a capitation agreement/managed care plan Payment denied. Your Stop loss deductible has not been met Expenses incurred prior to coverage Expenses incurred after coverage terminated Coverage not in effect at the time the service was provided The time limit for filing has expired Payment adjusted because the patient has not met the required eligibility, spend down, waiting, or residency requirements Patient cannot be identified as our insured Our records indicate that this dependent is not an eligible dependent as defined Insured has no dependent coverage Insured has no coverage for newborns Lifetime benefit maximum has been reached Balance does not exceed co-payment amount Balance does not exceed deductible Services not provided or authorized by designated (network/primary care) providers Services denied at the time authorization/pre-certification was requested 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 SoftCare Solutions Inc. 7

8 41 - Discount agreed to in Preferred Provider contract Charges exceed our fee schedule or maximum allowable amount. (Use CARC 45) 43 - Gramm-Rudman reduction Prompt-pay discount Charge exceeds fee schedule/maximum allowable or contracted/legislated fee arrangement. (Use Group Codes PR or CO depending upon liability) This (these) service(s) is (are) not covered This (these) diagnosis(es) is (are) not covered, missing, or are invalid This (these) procedure(s) is (are) not covered These are non-covered services because this is a routine exam or screening procedure done in conjunction with a routine exam. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present These are non-covered services because this is not deemed a 'medical necessity' by the payer. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present These are non-covered services because this is a pre-existing condition. Note: Refer to the The referring/prescribing/rendering provider is not eligible to refer / prescribe / order / perform the service billed Services by an immediate relative or a member of the same household are not covered Multiple physicians/assistants are not covered in this case. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present Procedure/treatment is deemed experimental/investigational by the payer. Note: Refer to the Procedure/treatment has not been deemed 'proven to be effective' by the payer. Note: Refer to the Payment denied/reduced because the payer deems the information submitted does not support this level of service, this many services, this length of service, this dosage, or this day's supply. Note as of 06/30/2007 this code was split into codes 150, 151, 152, 153 and Treatment was deemed by the payer to have been rendered in an inappropriate or invalid place of service. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present SoftCare Solutions Inc. 8

9 59 - Processed based on multiple or concurrent procedure rules. (For example multiple surgery or diagnostic imaging, concurrent anesthesia.) Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present Charges for outpatient services are not covered when performed within a period of time prior to or after inpatient services Penalty for failure to obtain second surgical opinion. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present Payment denied/reduced for absence of, or exceeded, pre-certification/authorization Correction to a prior claim Denial reversed per Medical Review Procedure code was incorrect. This payment reflects the correct code Blood Deductible Lifetime reserve days. (Handled in QTY, QTY01=LA) 68 - DRG weight. (Handled in CLP12) 69 - Day outlier amount Cost outlier - Adjustment to compensate for additional costs Primary Payer amount. This code was supposed to be stopped on 06/30/2000 and now use code Coinsurance day. (Handled in QTY, QTY01=CD) 73 - Administrative days Indirect Medical Education Adjustment Direct Medical Education Adjustment Disproportionate Share Adjustment Covered days. (Handled in QTY, QTY01=CA) 78 - Non-Covered days/room charge adjustment Cost Report days. (Handled in MIA15) 80 - Outlier days. (Handled in QTY, QTY01=OU) 81 - Discharges PIP days SoftCare Solutions Inc. 9

10 83 - Total visits Capital Adjustment. (Handled in MIA) 85 - Patient Interest Adjustment (Use Only Group code PR) - Notes: Only use when the payment of interest is the responsibility of the patient Statutory Adjustment. This code was supposed to be stopped in its usage on 10/16/2003 as it s a duplicate of code Transfer amount Adjustment amount represents collection against receivable created in prior overpayment Professional fees removed from charges Ingredient cost adjustment. Note: To be used for pharmaceuticals only Dispensing fee adjustment Claim Paid in full No Claim level Adjustments Processed in Excess of charges Plan procedures not followed Non-covered charge(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.) Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present 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 The hospital must file the Medicare claim for this inpatient non-physician service Medicare Secondary Payer Adjustment Amount. 100 Payment made to patient/insured/responsible party/employer. 101 Predetermination: anticipated payment upon completion of services or claim adjudication. 102 Major Medical Adjustment. 103 Provider promotional discount (e.g., Senior citizen discount). 104 Managed care withholding. 105 Tax withholding SoftCare Solutions Inc. 10

11 106 Patient payment option/election not in effect. 107 The related or qualifying claim/service was not identified on this claim. Note: Refer to the Rent/purchase guidelines were not met. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. 109 Claim not covered by this payer/contractor. You must send the claim to the correct payer/contractor. 110 Billing date predates service date. 111 Not covered unless the provider accepts assignment. 112 Service not furnished directly to the patient and/or not documented. 113 Payment denied because service/procedure was provided outside the United States or as a result of war. The use of this code was supposed to be stopped as of 06/30/2007, use codes 157, 158 or Procedure/product not approved by the Food and Drug Administration. 115 Procedure postponed, cancelled, or delayed. 116 The advance indemnification notice signed by the patient did not comply with requirements. 117 Transportation is only covered to the closest facility that can provide the necessary care. 118 ESRD network support adjustment. 119 Benefit maximum for this time period or occurrence has been reached. 120 Patient is covered by a managed care plan. This code was to be stopped as of 06/30/2007 and you are supposed to use code Indemnification adjustment - compensation for outstanding member responsibility. 122 Psychiatric reduction. 123 Payer refund due to overpayment. - Notes: Refer to the payers/hipaa implementation guide for proper handling of reversals. 124 Payer refund amount - not our patient. - Notes: Refer to payer/hipaa implementation guide for proper handling of reversals. 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.) 126 Deductible -- Major Medical - Notes: Use Group Code PR and code Coinsurance -- Major Medical - Notes: Use Group Code PR and code SoftCare Solutions Inc. 11

12 128 Newborn's services are covered in the mother's Allowance. 129 Prior processing information appears incorrect. This change to be effective : Prior processing information appears incorrect. 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.) 130 Claim submission fee. 131 Claim specific negotiated discount. 132 Prearranged demonstration project adjustment. 133 The disposition of this claim/service is pending further review. 134 Technical fees removed from charges. 135 Interim bills cannot be processed. 136 Failure to follow prior payer's coverage rules. (Use Group Code OA). 137 Regulatory Surcharges, Assessments, Allowances or Health Related Taxes. 138 Appeal procedures not followed or time limits not met. 139 Contracted funding agreement - Subscriber is employed by the provider of services. 140 Patient/Insured health identification number and name do not match. 141 Claim spans eligible and ineligible periods of coverage. 142 Monthly Medicaid patient liability amount. 143 Portion of payment deferred. 144 Incentive adjustment, e.g. preferred product/service. 145 Premium payment withholding. This code is supposed to be stopped as of 04/01/2008 and use Group Code CO and code Diagnosis was invalid for the date(s) of service reported. 147 Provider contracted/negotiated rate expired or not on file. 148 Information from another 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.) 149 Lifetime benefit maximum has been reached for this service/benefit category. 150 Payer deems the information submitted does not support this level of service SoftCare Solutions Inc. 12

13 151 Payment adjusted because the payer deems the information submitted does not support this many/frequency of services. 152 Payer deems the information submitted does not support this length of service. Note: Refer to the Payer deems the information submitted does not support this dosage. 154 Payer deems the information submitted does not support this day's supply. 155 Patient refused the service/procedure. 156 Flexible spending account payments. Note: Use code Service/procedure was provided as a result of an act of war. 158 Service/procedure was provided outside of the United States. 159 Service/procedure was provided as a result of terrorism. 160 Injury/illness was the result of an activity that is a benefit exclusion. 161 Provider performance bonus 162 State-mandated Requirement for Property and Casualty, see Claim Payment Remarks Code for specific explanation. 163 Attachment referenced on the claim was not received. 164 Attachment referenced on the claim was not received in a timely fashion. 165 Referral absent or exceeded. 166 These services were submitted after this payers responsibility for processing claims under this plan ended. 167 This (these) diagnosis(es) is (are) not covered. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. 168 Service(s) have been considered under the patient's medical plan. Benefits are not available under this dental plan. 169 Alternate benefit has been provided. 170 Payment is denied when performed/billed by this type of provider. Note: Refer to the 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 SoftCare Solutions Inc. 13

14 172 Payment is adjusted when performed/billed by a provider of this specialty. Note: Refer to the Service was not prescribed by a physician. 174 Service was not prescribed prior to delivery. 175 Prescription is incomplete. 176 Prescription is not current. 177 Patient has not met the required eligibility requirements. 178 Patient has not met the required spend down requirements. 179 Patient has not met the required waiting requirements. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. 180 Patient has not met the required residency requirements. 181 Procedure code was invalid on the date of service. 182 Procedure modifier was invalid on the date of service. 183 The referring provider is not eligible to refer the service billed. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. 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. 185 The rendering provider is not eligible to perform the service billed. Note: Refer to the Level of care change adjustment. 187 Consumer Spending Account payments (includes but is not limited to Flexible Spending Account, Health Savings Account, Health Reimbursement Account, etc.) 188 This product/procedure is only covered when used according to FDA recommendations. 189 'Not otherwise classified' or 'unlisted' procedure code (CPT/HCPCS) was billed when there is a specific procedure code for this procedure/service 190 Payment is included in the allowance for a Skilled Nursing Facility (SNF) qualified stay. 191 Not a work related injury/illness and thus not the liability of the workers' compensation carrier. 192 Non standard adjustment code from paper remittance. Note: This code is to be used by providers/payers providing Coordination of Benefits information to another payer in the 837 transaction 2013 SoftCare Solutions Inc. 14

15 only. This code is only used when the non-standard code cannot be reasonably mapped to an existing Claims Adjustment Reason Code, specifically Deductible, Coinsurance and Co-payment. 193 Original payment decision is being maintained. Upon review, it was determined that this claim was processed properly. 194 Anesthesia performed by the operating physician, the assistant surgeon or the attending physician. 195 Refund issued to an erroneous priority payer for this claim/service. 196 Claim/service denied based on prior payer's coverage determination. This code was supposed to be stopped on 02/01/2007 and replaced with code Precertification/authorization/notification absent. 198 Precertification/authorization exceeded. 199 Revenue code and Procedure code do not match. 200 Expenses incurred during lapse in coverage 201 Workers Compensation case settled. Patient is responsible for amount of this claim/service through WC 'Medicare set aside arrangement' or other agreement. (Use group code PR). 202 Non-covered personal comfort or convenience services. 203 Discontinued or reduced service. 204 This service/equipment/drug is not covered under the patient's current benefit plan 205 Pharmacy discount card processing fee 206 National Provider Identifier - missing. 207 National Provider identifier - Invalid format 208 National Provider Identifier - Not matched. 209 Per regulatory or other agreement. The provider cannot collect this amount from the patient. However, this amount may be billed to subsequent payer. Refund to patient if collected. (Use Group code OA) 210 Payment adjusted because pre-certification/authorization not received in a timely fashion 211 National Drug Codes (NDC) not eligible for rebate, are not covered. 212 Administrative surcharges are not covered 213 Non-compliance with the physician self referral prohibition legislation or payer policy. 214-Workers' Compensation claim adjudicated as non-compensable. This Payer not liable for claim or service/treatment. (Note: To be used for Workers' Compensation only) 2013 SoftCare Solutions Inc. 15

16 215 Based on subrogation of a third party settlement 216 Based on the findings of a review organization 217 Based on payer reasonable and customary fees. No maximum allowable defined by legislated fee arrangement. (Note: To be used for Workers' Compensation only) 218 Based on entitlement to benefits (Note: To be used for Workers' Compensation only) 219 Based on extent of injury (Note: To be used for Workers' Compensation only) 220 The applicable fee schedule does not contain the billed code. Please resubmit a bill with the appropriate fee schedule code(s) that best describe the service(s) provided and supporting documentation if required. (Note: To be used for Workers' Compensation only) 221 Workers' Compensation claim is under investigation. (Note: To be used for Workers' Compensation only. Claim pending final resolution) 222 Exceeds the contracted maximum number of hours/days/units by this provider for this period. This is not patient specific. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. 223 Adjustment code for mandated federal, state or local law/regulation that is not already covered by another code and is mandated before a new code can be created. 224 Patient identification compromised by identity theft. Identity verification required for processing this and future claims. 225 Penalty or Interest Payment by Payer (Only used for plan to plan encounter reporting within the 837) 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.) 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.) 228 Denied for failure of this provider, another provider or the subscriber to supply requested information to a previous payer for their adjudication 229 Partial charge amount not considered by Medicare due to the initial claim Type of Bill being 12X. Note: This code can only be used in the 837 transaction to convey Coordination of Benefits information when the secondary payer's cost avoidance policy allows providers to bypass claim submission to a prior payer. Use Group Code PR. 230 No available or correlating CPT/HCPCS code to describe this service. Note: Used only by Property and Casualty SoftCare Solutions Inc. 16

17 231Mutually exclusive procedures cannot be done in the same day/setting. Note: Refer to the Institutional Transfer Amount. Note - Applies to institutional claims only and explains the DRG amount difference when the patient care crosses multiple institutions. 233 Services/charges related to the treatment of a hospital-acquired condition or preventable medical error. 234 This procedure is not paid separately. 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.) 235 Sales Tax A0- Patient refund amount. 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.) A2- Contractual adjustment. This code was not to be used after 01/01/2008 and to use Code 45 with Group Code 'CO' or use another appropriate specific adjustment code. A3- Medicare Secondary Payer liability met. A4- Medicare Claim PPS Capital Day Outlier Amount. A5- Medicare Claim PPS Capital Cost Outlier Amount. A6- Prior hospitalization or 30 day transfer requirement not met. A7- Presumptive Payment Adjustment A8- Ungroupable DRG. B1- Non-covered visits. B2- Covered visits. B3- Covered charges. B4- Late filing penalty. B5- Coverage/program guidelines were not met or were exceeded. B6- his payment is adjusted when performed/billed by this type of provider, by this type of provider in this type of facility, or by a provider of this specialty. B7- This provider was not certified/eligible to be paid for this procedure/service on this date of service. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present SoftCare Solutions Inc. 17

18 B8- lternative services were available, and should have been utilized. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. B9- Patient is enrolled in a Hospice. B10 Allowed amount has been reduced because a component of the basic procedure/test was paid. The beneficiary is not liable for more than the charge limit for the basic procedure/test. B11 The claim/service has been transferred to the proper payer/processor for processing. Claim/service not covered by this payer/processor. B12 Services not documented in patients' medical records. B13 Previously paid. Payment for this claim/service may have been provided in a previous payment. B14 Only one visit or consultation per physician per day is covered. B15 This service/procedure requires that a qualifying service/procedure be received and covered. The qualifying other service/procedure has not been received/adjudicated. Note: Refer to the 835 B16 'New Patient' qualifications were not met. B17 Payment adjusted because this service was not prescribed by a physician, not prescribed prior to delivery, the prescription is incomplete, or the prescription is not current. B18 This procedure code and modifier were invalid on the date of service. B19 Claim/service adjusted because of the finding of a Review Organization. B20 Procedure/service was partially or fully furnished by another provider. B21 The charges were reduced because the service/care was partially furnished by another physician. B22 This payment is adjusted based on the diagnosis. B23 Procedure billed is not authorized per your Clinical Laboratory Improvement Amendment (CLIA) proficiency test. D1- Claim/service denied. Level of subluxation is missing or inadequate. This code was supposed to be stopped as of 10/16/2003 and use code 16 and remark codes if necessary. D2- Claim lacks the name, strength, or dosage of the drug furnished. - This code was supposed to be stopped as of 10/16/2003 and use code 16 and remark codes if necessary. D3- Claim/service denied because information to indicate if the patient owns the equipment that requires the part or supply was missing. This code was supposed to be stopped as of 10/16/2003 and use code 16 and remark codes if necessary SoftCare Solutions Inc. 18

19 D4- Claim/service does not indicate the period of time for which this will be needed. This code was supposed to be stopped as of 10/16/2003 and use code 16 and remark codes if necessary. D5- Claim/service denied. Claim lacks individual lab codes included in the test. This code was supposed to be stopped as of 10/16/2003 and use code 16 and remark codes if necessary. D6- Claim/service denied. Claim did not include patient's medical record for the service. This code was supposed to be stopped as of 10/16/2003 and use code 16 and remark codes if necessary. D7Claim/service denied. Claim lacks date of patient's most recent physician visit. This code was supposed to be stopped as of 10/16/2003 and use code 16 and remark codes if necessary. D8Claim/service denied. Claim lacks indicator that 'x-ray is available for review.' This code was supposed to be stopped as of 10/16/2003 and use code 16 and remark codes if necessary. D9- Claim/service denied. Claim lacks invoice or statement certifying the actual cost of the lens, less discounts or the type of intraocular lens used. This code was supposed to be stopped as of 10/16/2003 and use code 16 and remark codes if necessary. D10- Claim/service denied. Completed physician financial relationship form not on file. This code was supposed to be stopped as of 10/16/2003 and use code 17 and remark codes if necessary. D11Claim lacks completed pacemaker registration form. This code was supposed to be stopped as of 10/16/2003 and use code 17 and remark codes if necessary D12Claim/service denied. Claim does not identify who performed the purchased diagnostic test or the amount you were charged for the test. This code was supposed to be stopped as of 10/16/2003 and use code 17 and remark codes if necessary D13Claim/service denied. Performed by a facility/supplier in which the ordering/referring physician has a financial interest. This code was supposed to be stopped as of 10/16/2003 and use code 17 and remark codes if necessary D14Claim lacks indication that plan of treatment is on file. This code was supposed to be stopped as of 10/16/2003 and use code 17 and remark codes if necessary. D15Claim lacks indication that service was supervised or evaluated by a physician. This code was supposed to be stopped as of 10/16/2003 and use code 17 and remark codes if necessary D16 Claim lacks prior payer payment information. - This code was supposed to be stopped as of 10/16/2003 and use code 16 and remark codes if necessary D17 Claim/Service has invalid non-covered days. - This code was supposed to be stopped as of 06/30/2007 and use code 16 and remark codes if necessary D18 Claim/Service has missing diagnosis information. This code was supposed to be stopped as of 06/30/2007 and use code 16 and remark codes if necessary 2013 SoftCare Solutions Inc. 19

20 D19Claim/Service lacks Physician/Operative or other supporting documentation - This code was supposed to be stopped as of 06/30/2007 and use code 16 and remark codes if necessary D20 Claim/Service missing service/product information. - This code was supposed to be stopped as of 06/30/2007 and use code 16 and remark codes if necessary D21 This (these) diagnosis(es) is (are) missing or are invalid D22 Reimbursement was adjusted for the reasons to be provided in separate correspondence. (Note: To be used for Workers' Compensation only) - Temporary code to be added for timeframe only until 01/01/2009. Another code to be established and/or for 06/2008 meeting for a revised code to replace or strategy to use another existing code 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.) W1 Workers Compensation State Fee Schedule Adjustment Payer Responsibility Sequence Number Code. APPENDIX B CLAIM ADJUSTMENT GROUP CODES CO CR OA PI PR Contractual Obligations - Use this code when a joint payer/payee contractual agreement or a regulatory requirement resulted in an adjustment. Correction and Reversals - Use this code for corrections and reversals to prior. Use when CLP02=22, Reversal of Previous Payment. Other adjustments Payer Initiated Reductions - Use this code when, in the opinion of the payer, the adjustment is not the responsibility of the patient, but there is no supporting contract between the provider and the payer (i.e., medical review or professional review organization adjustments). Patient Responsibility 2013 SoftCare Solutions Inc. 20