september 2017 pre meeting - wpc-edi.com · september 2017 meeting pittsburgh pa | sunday |...

SEPTEMBER 2017 MEETING PITTSBURGH PA | SUNDAY | SEPTEMBER 24 2017

SEPTEMBER 24, 2017 1

September 2017 Meeting Announcement

The September 2017 Code Maintenance Committee meeting will be held in

Pittsburgh, PA on Sunday, September 24 at The Westin Convention Center.

This is the same hotel where the ASC X12 Standing Meeting is held. Please

see http://www.x12.org for meeting information.

The Code Committee meets from 1:00 pm until 3:30 pm - usually in the same

room as the Medicare Caucus. To request a new code, change or deletion, use

the Request Form. Post to the September 2017 Agenda entry to reflect your

topics for discussion, or reply to individual posting when new codes are listed.

The agenda for the meeting will close on Friday, August 25, 2017. A virtual

preliminary screening meeting will be scheduled to review requests. That

meeting will be announced via the "Meeting Announcements" Online

Conference. No voting will be held on that session, but requests will be

screened to determine if additional outreach is needed. This timing permits

groups to conduct conference calls prior to the Code Maintenance Committee

meeting.

Each October the committee will hold elections for the Chair and Vice-Chair

position of the committee. In the even year (e.g. 2016, 2018) the Vice-Chair

position election is held. In the odd year (2017, 2019) the Chair position

election is held.

Old Business

Tabled items from June 2017

8

Claim Status Code Set Updates

Name: Mike Denison

Company: Change Healthcare

Phone: 615-932-3382

Email: MDenison@ChangeHealthcare

Request Type: Revision

List Name Health Care Claim Status



Value: Description Field

Description: There are several (consistent) modifications within the March 2017

Claim Status table update Description field that outline the required

"Usage:" of an entity code when utilizing certain status codes.

For example from the March published Status.csv file update: Current

description (message) as outlined in the published March 2017

Description field (which I believe is in error):

Status code 16

Description Field Claim/encounter has been forwarded to entity.

Note: This code requires use of an Entity Code. This change effective

September 1, 2017: Claim/encounter has been forwarded to entity.

Usage This code requires use of an Entity Code.

I believe the intent of the workgroup was to modify effective Sept. 1,

2017 as simply: Status code 16

Description Field Claim/encounter has been forwarded to entity.

Usage: This code requires use of an Entity Code. With the only

intended change being the modification of the word "Note" to "Usage".

There are 133 modifications similar to the above in the published

March update.

As often the contents of the Description field are

communicated/presented verbatim within provider facing solutions, the

descriptive "message" associated with the code will go from a simple

message to a duplicative, wordy, confusing, and time bound message

losing value and effectiveness.



Explanation: If the desire is to communicate advance notice of an upcoming Claim

Status change (which is great), it would be more appropriate to

communicate in the Note field similar to: March publication:

Code 16

Description Claim/encounter has been forwarded to entity. Note:

This code requires use of an Entity Code.

Effective Date 1/1/1995

Deactivation Date

Last Modified Date 3/1/2017

Note Description change effective September 1, 2017: Claim/encounter

has been forwarded to entity. Usage: This code requires use of an

Entity Code.

September publication:

Code 16

Description Claim/encounter has been forwarded to entity. Usage:

This code requires use of an Entity Code.

Effective Date 1/1/1995

Deactivation Date

Last Modified Date 9/1/2017

Note Description change effective September 1, 2017: Claim/encounter

has been forwarded to entity. Usage: This code requires use of an

Entity Code.

Commenter:

Comment:

Motioner:

Seconder:



Discussion Pre-Meeting May 15, 2017

Mike – shouldn’t it be in the note column instead of the description

column.

Merri-Lee – that is the process

Deb – this hasn’t changed in 20 years.

Mike – seems ridiculous how it is published.

Pete – what if we used the effective date and deactive date separately.

Mike thinks that would be a good idea.

Deb – we have to be careful, the entire industry has been doing this for

20 years with no problems.

Mike – he thinks that the industry has been tolerant and adapted to the

bad way it has been done. It seems ridiculous.

Margaret – Deb has a point. Anything we do to change how it is done

today will be impacting the entire industry.

Mike – these descriptions do change but when the change is dramatic

and the description goes to a duplicative description with repetitive

wording

June 4, 2017 Standing Meeting

Deb McCachern – issue arrived out of the March publishing of the

codes. Since the only change was from note to usage putting this in

the description field, it was confusing to providers. They received

questions from providers. The request is to not put this in the

description field, but in the Note field.

Discussion:

Pete – agree that there is a problem with the veracity. It would be good

to have two entries for the code.

Gail – concerned that this is an underlying data base issue and we

can’t discuss that here. She doesn’t think we can take action. It needs

to go to the publisher.

Margaret – the publisher is aware of this request. As mentioned in the

pre-meeting this will be a system change to everyone.

Does it stay as is or do we look for some alternative. Question, do we

want to make a change or not.

Pat W. – she believes it would be good to take a look to see if there is

a different way it could be done. She will be glad to assist in the work.

Volunteers – Pat, Deb McCachern, Pete, Deb S. Tina, Sam

Doreen – if a practice management vendor displays only part, does not

provide entire description. It is really up to the entity that displays the

data. Is this a good use of our time?

Pat W.- need to keep in mind CAQH CORE looks at this code list so

we will need to coordinate with them.



Qu

VOTE RESULTS - NUMBER OF: YES_______ NO ____ ABSTAIN____

Passed:

Failed:

Tabled: X

Assigned Code:

Definition:

10

New code for coinsurance

Name: Meg Kutz

Company: Anthem, Inc

Phone: 518 817 7724

Email: [email protected]

Request Type: New


Value:

Description: Coinsurance Status Code

Explanation: there are two other similar codes 98 and 753 for cost share. One for

deductible and the other for Co-pay but there is not a status for

Coinsurance. For consistence and to promote clarity on the 277 please

create a new code for coinsurance.

Commenter:

Comment:

Motioner:

Seconder:



Discussion Pre-Meeting May 15, 2017

Meg – nothing out there for co-insurance.

Margaret – comments? None

June 4 ,2017 Standing Meeting

Durwin– motion to approve

Karen S. – second

Karen S – WG5 agrees but believes it should be amended to “charges

apply to co-insurance” Betsy – does not believe that makes sense.

Sam – the entire claim would be all charges to apply to the deductible.

Wouldn’t this be the status as paid? Meg – she doesn’t know.

Suggests that this should be tabled until we can obtain the answer.

Durwin makes motion to table request. Karen seconds

Motion made by Durwin to table. Karen Second

NUMBER OF: YES 15 NO 0 ABSTAIN 0

Motion carries.

Pre-Meeting August 31, 2017

Meg – withdraws

September 24, 2017

Margaret – Meg confirmed that it is withdrawn.

Qu

VOTE RESULTS - NUMBER OF: YES____ NO __ ABSTAIN___

Passed:

Failed:

Tabled: WITHDRAWN

Assigned Code:

Definition:

New Business

New items since the last meeting.



Chair Election

Margaret Weiker – was originally elected to finish out Merri-Lee

Stine’s postion. Elections are as follows; odd years Chair and

even years Vice Chair. At this time there has been no changes

to the process. There could be changes once the ECO process

is incorporated.

Laurie Burckhardt – Nominates to re-elect Margaret Weiker.

Sherry Wilson – Seconded.

Merri-Lee Stine– Motion to close nominations.

Gail Kocher– Seconded.

Discussion: MaryKay McDaniel - can you technically run as

representative for NCPDP and chair? Margaret – according to the

MOU between NCPDP and X12, not allowed to hold leadership

positions. Before it was ok since this committee is not part of

X12. MaryKay – and it is still not. Margaret – if it goes forward,

we will address at that time.

Closing nominations – approve 16 opposed 0 abstain 0

Merri-Lee – Makes motion to elect Margaret by unanimous

consent.

Gail – Seconded.

Approve 15 opposed 0 abstain –

Motion carries.

1

would like to see new code for hearing aids

Name: Donna Reynolds

Company: Dr. Stephanie Herrera

Phone: 979-299-1520


Request Type: New

List Name Health Care Service Type

Value:

Description: Hearing Aids



Explanation: These are not included under DME - need new category

Commenter:

Comment:

Motioner:

Seconder:



Discussion Pre-Meeting August 31, 2017

WG1 – Bruce – for hearing aids, what is needed? Are they asking for a

service type?

Gail – hearing aid would not be a service type, it is a supply.

Merri-Lee – could request a service type code for

Traditionally broken out for carriers. They could ask specifically for

hearing aid and they could return that benefit.

Bruce – as a pre-cert or a referral. Could use as a service type for the

278 as well. He was looking for some more description.

Gail – why are we getting this now? If there is a gap today, why hasn’t

this come forward before now and by many others.

Merri-Lee – there is a gap now.

Gail – would expect there to be more context around this from a payer.

She is not having plans come to her and saying they can’t do this. The

description as it stands is not for a service type.

Gail – can you describe this better?

Merri-Lee – in an eligibility transaction makes sense to her.

Bruce – the request is not clear on what they are looking for.

Margaret – will send email to submitter and ask for further description

and what type of inquiry is it?

Email Response from Submitter:

We are an otolaryngologist office and we have 2 audiologists who sell

and service hearing aids. We are getting the audiologists credentialed

and on our insurance contracts so that we can file insurance for

hearing aids. I've discovered, as I verify benefits or request pre-

determination for them, there is not ANSI code for hearing aids. There

is no way to verify benefits for them through any insurance company

online portal due to this. I also cannot go through the automated benefit

verification process since hearing aids are not classified separately.

Therefore, I must wait to speak to a representative to verify benefits

properly. This is quite time consuming.

Thank you for your consideration.

September 24, 2017

Margaret emailed the submitter to get additional information. The

agenda has been posted and the email is in the agenda.

Discussion:

Gail – still doesn’t make sense. The request talks about credentialing

and then eligibility.

Margaret – they are credentialed. They get them in the plan but when

she does eligibility benefits for hearing aids, there is not a code to

convey.



Qu

VOTE RESULTS - NUMBER OF: YES__12__ NO _1_ ABSTAIN__1_

Passed: X – request is denied

Failed:

Tabled:

Assigned Code:

Definition:

2

New Status Code

Name: Cindy Bigenwalt

Company: Blue Cross and Blue Shield of Kansas

Phone: 785-291-8757


Request Type: New


Value:

Description: Procedure code and diagnosis code are not compatible

Explanation: When the procedure code and diagnosis are not compatible, we are unable to

complete the processing of the claim.

Commenter:

Comment:

Motioner:

Seconder:




Cindy – she is not sure she meant to send this request. It looks like it

was answered on the 26th and recommendations were given of what

could be used. She doesn’t recall sending a follow-up.

Margaret – there are two requests

Gail – what does she mean by someone responded? Cindy – noticed

that there was a comment from the RARC committee.

Merri-Lee – that is a different request. That was the RARC committee,

not this committee.

Margaret – what you read sounds like a response from the RARC

committee

Cindy – she guesses that they did submit a request for this committee.

Karen – looking at codes and if you are talking about 277

acknowledgements and front-end editing, you can use 254 with 454. If

talking 276/277 use 488 status code - pointing to the procedure code

you sent is not compatible with the diagnosis. They don’t have the

words “compatible” but those codes will work.

Karen – you can use multiple status codes so you could use a

combination that will convey the message. If you as a company are

only giving one, that could be causing issues. Maybe you should look

at your company’s process and see if codes need to be added for the

complete message.

Karen – it depends on which transaction you are talking about. You

are letting the claim come in and process, wouldn’t it go out on the

835? If that is the case, it wouldn’t be a status code.

Cindy – her company will give it a try.

Karen – if you are rejecting from the 835 that is one set of codes, if it is

before adjudication it would be status codes.

September 24, 2017

Withdrawn per email from Cindy Bigenwalt dated Sept. 21, 2017.


Passed:

Failed:

Tabled: WITHDRAWN

Assigned Code:

Definition:



3

add entity required to status code

Name: Kena H. Gwinn

Company: Anthem

Phone: 804.339.9317




Value: 403

Description: Entity referral notes/orders/prescription

Explanation: note needs added that entity code is required when sending this

status code

Commenter:

Comment:

Motioner:

Seconder:


Karen – she hasn’t gone over this with the wg yet, but she is thinking it

will be approved. This code is needed.

Sept 2017

Margaret – did group meet and what did they decide?

Karen – wg agreed that they should have and makes motion to approve

Laurie – seconded

Approved – 14 opposed 0 abstain 1

Effective date: Laurie –

Merri-Lee – new codes were effective upon publication. Modified codes was 6

months.

Pat – 6 months after publication


Passed: X – approved – effective 6 months after publication



Failed:

Tabled:

Assigned Code: 403

Definition: Entity referral notes/orders/prescription. Usage: This code requires use

of an entity.

4

Code List Change Request Form

Name: Harvey Mintz

Company: CSRA

Phone: (518)257-4844



List Name Claim Adjustment Reason Code

Value: 16

Description: Change Definition to:

Claim/service has submission/billing error(s) or lacks information which is

needed for adjudication. Usage: Do not use this code for claims

attachment(s)/other documentation. 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.) Refer to the 835

Healthcare Policy Identification Segment (loop 2110 Service Payment

Information REF), if present.

Or:

Claim/service lacks information has which is needed for adjudication or has

submission/billing error(s). Usage: Do not use this code for claims

attachment(s)/other documentation. 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.) Refer to the 835

Healthcare Policy Identification Segment (loop 2110 Service Payment

Information REF), if present.

Explanation: The problem with the current definition of CARC 16 is the clause "errors which

is needed", for two reasons; because it is "information", not "errors" that

adjudication requires, and because of > the plural-singular conflict.

Commenter:

Comment:

Motioner:

Seconder:




Pat W. – WG3 reviewed and they are in agreement with it. They will

suggest a small wording change, but they will move this forward.

Gail – can we have the proposed wording?

Pat – “Claim/service lacks information or has submission/billing

error(s)”

Karen – Can we say – “Claim/Service lacks information which is

needed for adjudication”

Pat W. – will take that back to the WG and have a response in Sept.

September 24, 2017

Pat – makes motion to approve with a variation in description on first

16 Claim/Service has submission(s)/ or lacks information.

Seconded – Sherry Wilson

Discussion – none

Approve 16 opposed 0 abstain 0

Pat – makes motion to make effective immediately

Seconded – Sherry Wilson

Discussion:

Pat – it isn’t substantive it is just clean up.

Merri-Lee – disagrees because databases have to update.

Gail – making it effective immediately is so we can have it now

otherwise we are pushing something off that needs to be done.

Laurie – is a little concerned with making it immediate because they

have to have the language on the EOB in WI and it makes it a tight

line.

Gail – lets do 3 months, just seems ridiculous to hold off for 6 months

when it should be just a change in a table.

Gail – requests that motion be modified to make effective 3 months

after publication.

Pat – her thought was making it effective in 3 months.

Effective Feb. 1, 2018.

Donna – can we put together a table that shows the publication dates

and possible effective dates? Margaret has taken as an action item.



VOTE RESULTS - NUMBER OF: YES_12_ NO _1_ ABSTAIN_1_

Passed: X – effective 3 months after publication (February 1, 2018)

Failed:

Tabled:

Assigned Code: Revise 16

Definition: Claim/service has submission/billing error(s) or lacks information. Usage: Do

not use this code for claims attachment(s)/other documentation. 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.) Refer to the 835 Healthcare Policy Identification Segment (loop 2110

Service Payment Information REF), if present.

5

Code List Change Request Form

Name: Harvey Mintz

Company: CSRA

Phone: (518)257-4844




Value: B12

Description: Change definition from "Services not documented in patients' medical

records." to "Services not documented in patient's medical records."

Explanation: Correct plural to singular.

Commenter:

Comment:

Motioner:

Seconder:




Pat W. – this is just changing to “patient’s”. 835 WG agrees.

September 24, 2017

Margaret – read description of the request.

Pat – makes motion to approve revised wording as submitted

LuAnn – seconded

Discussion: None

Approve 16 opposed 0 abstain 0

Pat – motion to make effective immediately

Sherry – seconded

Discussion:

Gail – isn’t it the same discussion we just had. If we are doing non-

substantive on this one too, we should just say these are effective 3

months after publication date.

No objections to amending motion

VOTE RESULTS - NUMBER OF: YES__16__ NO _0__ ABSTAIN_1__

Passed: X – effective 3 months from publication (February 1, 2018)

Failed:

Tabled:

Assigned Code: Revise B12

Definition: Services not documented in patient's medical records.

6

Code to show a PR of Spenddown

Name: Vicky Pierce

Company: Utah State Medicaid

Phone: 801-884-3902


Request Type: New




Value:

Description: Spenddown Amount

Explanation: New CARC for Spenddown Amount. Medicaid makes the patient responsible

for a portion of a claim when a claim is used to meet their Spenddown. This is

different than a Copay, Coinsurance or Deductible. Need new value to report

PR of Spenddown.

Commenter:

Comment:

Motioner:

Seconder:


Pat W. – there was a lot of conversation about this in the 835 WG call.

There was not enough Medicaid experience on the call. There were a

number of people that were going to reach out and see if they can get

more information on it. Hoping that Vickie could help out with how UT

handles it. They know there is a CARC 178, but they feel this could be

a little different.

Gail – spenddown is a little different for Medicaid

September 24, 2017

Pat – discussed in WG3 would like to table to next meeting – motion

made

Gail – seconded

Discussion:

Sue – the code committee of the NMEH is inactive.

VOTE RESULTS - NUMBER OF: YES__15__ NO _0_ ABSTAIN_1_

Passed:

Failed:

Tabled: X

Assigned Code:

Definition:

7



New Code for PR or Cost or Care

Name: Vicky Pierce

Company: Utah State Medicaid

Phone: 801-884-3902


Request Type: New


Value:

Description: Cost of Care Amount

Explanation: New CARC for Cost of Care Amount. Medicaid makes the patient responsible

for a portion of Nursing Home Charges in order for a member to be eligible for

Medicaid. This is also known as Patient Liability. This is different than a

Copay, Coinsurance or Deductible. Need new value to report PR of Cost of

Care. Currently it is being reported in Copay but is causing confusion for

providers as this amount is not a copay.

Commenter:

Comment:

Motioner:

Seconder:


Pat W. – same kind of issue. There is a CARC that could work. Still

need further information to adjudicate.

Margaret – she doesn’t think this is just for UT.

Gail – we need to loop in our committee Medicaid representative to

make sure we don’t do something for one state and it causes a

problem for others.

Laurie B. – agrees we really need someone with a strong Medicaid

background.

September 24, 2017

Pat – motion to deny. Discussed with Vicky and she agreed to use

code 162

Sherry – seconded




Passed: X – Motion passed. Request denied.

Failed:

Tabled:

Assigned Code:

Definition:

8

New Status Code

Name: Cindy Bigenwalt

Company: Blue Cross and Blue Shield of Kansas

Phone: 785-291-8757


Request Type: New


Value:

Description: Qualifier/date combination missing/incomplete/invalid for box 14/15

Explanation: Box 14 & 15 require a qualifier if a date is submitted and vice versa.

Commenter:

Comment:

Motioner:

Seconder:




Cindy – it may not need to be this specific. Box 14 and 15 has the new

qualifier codes. They are seeing providers sending qualifiers and no

date or date and no codes.

Gail – this sounds like you are rejecting a claim because of this and if

that is the case a CARC would be the appropriate code to use.

Pat – they will circle back. Off the top of her head, she doesn’t know

what the 14 and 15 are.

Karen – from a status perspective there is a date for all status codes.

From this perspective you could reject because something is wrong

with this information.

Laurie – when she did the research on this she didn’t find a CARC.

She also wasn’t too clear about the business workflow so she couldn’t

go any further.

Gail – would like to talk with the State of Kansas to see if she, in

representing BCBS plans, can help Cindy. She would like to connect

with her offline and make sure we have all the information. There is 20

minutes left to get through the rest of the agenda.

September 24, 2017

Withdrawn per email from Cindy Bigenwalt dated Sept. 21, 2017.


Passed:

Failed:

Tabled: WITHDRAWN

Assigned Code:

Definition:

9

Add CLIA reference to status code

Name: Karen Shutt

Company: Highmark

Phone: 717-302-4905






Value: 544

Description: Add the acronym CLIA and also Number to Status Code 544 for

synchronization with the 837 data element.

Clinical Laboratory Improvement Amendment (CLIA) Number

Explanation: For consistency with the 837 data element/REF name and also easier

identification within the status code list, code 544 should be updated to include

CLIA and Number in the description.

Commenter:

Comment:

Motioner:

Seconder:


Karen – wants to add “(CLIA)” and Number because that is what is in

the guide. If they don’t search for CLIA, they won’t find it.

September 24, 2017

Karen – makes motion to approve this request adding CLIA to the

description for easier searching.

Sue – seconded

Effective date: 3 months after publication date. None opposing

VOTE RESULTS - NUMBER OF: YES__14_ NO _0_ ABSTAIN_1_

Passed: X - effective 3 months after publication (February 1, 2018)

Failed:

Tabled:

Assigned Code: 544

Definition: Clinical Laboratory Improvement Amendment (CLIA) Number

10

New CARC for Attending physician

Name: Meg Kutz




Phone: 518 817 7724


Request Type: New


Value:

Description: New CARC similar to Existing CARC's 183 and 184 but for Attending

Physician

Explanation: "Attending provider is not eligible to provide direction of care"

Commenter:

Comment:

Motioner:

Seconder:


Pat – WG3 thought it made sense to add. Appeared to be a gap.

Gail – is it the same verbiage format as the other?

Pat – we will make sure that it is.

September 24, 2017

Pat – makes motion to approve for new code as submitted

Seconded – Crystal

Discussion: None

Effective Date: immediately upon publication


Passed: X

Failed:

Tabled:

Assigned Code: 283

Definition: Attending provider is not eligible to provide direction of care

11



Add a code to indicte a Pended Precert Request is in process of being

reviewed. Primarily to be utilized by the Precert Inquiry Transaction

response (X215)

Name: Janice Bakos

Company: WEDI Prior Auth WorkGroup

Phone: 570 775-0229


Request Type: New

List Name Health Care Services Review Decision Reason

Value:

Description: Utilization Review currently in progress

Explanation: Providers wish to know their Pended request is actively being reviewed.

Commenter:

Comment:

Motioner:

Seconder:


Janice – would like to withdraw this one. They have submitted two

other specific codes.

Margaret – we will pull

Request withdrawn.


Passed:

Failed:

Tabled: WITHDRAWN

Assigned Code:

Definition:

12

New status code for same/similar procedure



Name: Meg Kutz


Phone: 518 817 7724


Request Type: New


Value:

Description: New status code "Same/similar service previously submitted for time

frame/session"

Explanation: There are no other status codes today that are applicable for this condition

where same or similar svs is billed within a set time frame not necessarily on

same date. (this status is similar to what would eventually go out on the 835

ERA as a denial under RARC M80 and M86. This is also NOT a duplicate

situation.

Commenter:

Comment:

Motioner:

Seconder:




Karen – she has not run it by the WG, but she didn’t see a problem.

She will present to the WG.

September 24, 2017

Karen – WG5 generally agreed on it but was not sure on the verbiage.

Karen – makes motion to approve request with modified language.

Laurie – Seconded

Discussion:

Karen – preferred language – take out the word “same” in the original

request.

Meg – the only thing she is concerned about with the word same, you

could have the same service within the same set timeframe. This is

not for duplicates. She looked at RARCs and there are

Gail – the way Meg just explained the situation is the verbiage we

should use. Can we just say you cannot do this twice in one

timeframe? Only one same/similar service can be submitted for the

same timeframe/session

Pete – “submitted service is similar to a service previously submitted

for this timeframe.”

Gigi – shouldn’t the word “same” be in there?

Donna – the key is that this is in the same timeframe.

Gail – issue is that similar does not mean exact. Can be same service

and submitted on day 2 and 3 but it is only allowed to be submitted

within 5 day period. It is more about a specified timeframe.

Verbiage now; “submitted service is similar/same to a service

previously submitted for this timeframe.”

Meg - recommends “Service submitted for the same/similar service

within a set timeframe.”

Nancy – is good with Meg’s recommendation

Effective immediately.

VOTE RESULTS - NUMBER OF: YES_15__ NO _0_ ABSTAIN_0_

Passed: X

Failed:



Tabled:

Assigned Code: 779

Definition: Service submitted for the same/similar service within a set

timeframe.

13

new code for lifetime max

Name: Meg Kutz


Phone: 518 817 7724


Request Type: New


Value:

Description: New status for lifetime max benefit has been met. "Lifetime benefit maximum"

Explanation: Currently only one code for benefit max (483) and no code for lifetime max.

They are two different denials. Sending 483 for lifetime max would not be

compliant or accurate. please approve new code for lifetime.

Commenter:

Comment:

Motioner:

Seconder:




Meg – there is one for benefit but not lifetime max.

Karen – will need to work it with the WG. She thinks this is going down

the path of creating a status code for the same thing that is in a CARC.

Meg – they have struggled with this for years. Trying to reduce their

calls.

September 24, 2017

Karen – motion to approve request

Sherry – seconded

Discussion:

Gail – is the motion to approve exactly the way the request was

submitted?

Margaret – the request is to add “Lifetime Benefit Maximum”

Motion carries.



Passed: X

Failed:

Tabled:

Assigned Code: 780

Definition: Lifetime Benefit Maximum

14

New status for readmission denial

Name: Meg Kutz


Phone: 518 817 7724


Request Type: New


Value:

Description: new status code for denial "Claim has been identified as a readmission"



Explanation: When claim received that is within 24 hours of discharge the claim must be

denied and provider must send an adjustment to the original admission. there

is not good status code to state denied for readmission. We are currently

using Status 735 right now but that is not an accurate code.

Commenter:

Comment:

Motioner:

Seconder:


Karen – WG has not talked about it yet.

September 24, 2017

Karen – makes motion to approve request.

Sherry – seconded

Discussion: None



Passed: X

Failed:

Tabled:

Assigned Code: 781

Definition: Claim has been identified as a readmission

15

Revise CARC 5 description

Name: Patricia Wijtyk

Company: TMG Health

Phone: 6102029565




Value: 5



Description: The procedure code/type of bill is inconsistent with the place of service.

Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110

Service Payment Information REF), if present.

Explanation: Revise term: type of bill to be consistent

Commenter: Patricia Wijtyk

Comment: There are multiple ways to report a missing or exceeded authorization. Add a

note: To report missing authorization, use CARC 197 or CARC 16 and RARC

M62.

Motioner:

Seconder:


Pat – the comment belongs with the next entry. Because they are

deactivating the next one. Syncing up the wording of “bill type” across

the industry.

September 24 2017

Pat – makes motion to approve change to CARC 5 as submitted. “The

procedure code/type of bill is inconsistent with the place of service”

Gail – seconded

Motion carries – effective 3 months after publication



Failed:

Tabled:

Assigned Code: 5

Definition: The procedure code/type of bill is inconsistent with the place of

service. Usage: Refer to the 835 Healthcare Policy Identification

Segment (loop 2110 Service Payment Information REF), if present.

16

CARC 15 deactivate and add new


Company: TMG Health



Phone: 6102029565




Value: 15 and new

Description: Deactivate CARC 15

Add 1 new codes:

Authorization number may be valid but does not apply to the billed services

Explanation: Update to older code

Commenter:

Comment:

Motioner:

Seconder:


Pat – this is part of the cleanup that WG3 has taken up. There are

many codes that overlap. Deactivate 15 and add the above to 5 so

that there is one code.

September 24, 2017

Pat – makes motion to approve

Sue – seconded

Discussion: None

Immediate effective date for the new and 6 months after publication for

the deactivated code.

Meg – thought that deactivated codes were 1 year after publication. It

allows you to update databases, etc.

Gail – it would be more complicated because there is an operating rule

impacted. It has to allow the new one to be effective and she believes

that 6 months gives it enough time for the operating rule also.

Pat – read the rules again and it says 6 months for deactivated codes.

“Authorization number may be valid but does not apply to the billed

services.”



VOTE RESULTS - NUMBER OF: YES_16__ NO _0_ ABSTAIN_0_

Passed: X – code 284 effective immediately; deactivated code15 effective 6 months

after publication (May, 1, 2018)

Failed:

Tabled:

Assigned Code: 284

Definition: Authorization number may be valid but does not apply to the

billed services

17

Revise description for CARC32


Company: TMG Health

Phone: 6102029565




Value: 32

Description: Revise to: This dependent is not an eligible dependent.

Explanation: Update wording for older code

Commenter:

Comment:

Motioner:

Seconder:




Pat – cleaning up wording

September 24, 2017

Pat – makes motion to approve as revised. This is very old.

Sue – seconded

Discussion:

Karen – why does it have to be changed?

Pat – just reviewing and trying to clean up codes, it caught their eye.

Doreen – talking about a patient, would it be better to say the patient is

not the dependent?

Karen – agrees.

New proposed language – the “The patient is not an eligible

dependent”

Gail – it could cause more issues when it is a record issue. Feels

should read “Our records indicate the patient is not an eligible

dependent”

Laurie – thinks maybe WG3 should take it back looking at the

definitions.

Motion carries to “Our records indicate the patient is not an eligible

dependent”

Effective 3 months after publication.



Failed:

Tabled:

Assigned Code: 32

Definition: Our records indicate the patient is not an eligible dependent

18

CARC 138




Company: TMG Health

Phone: 6102029565




Value: 138 and new code

Description: Deactivate CARC 138

Add 2 new codes for:

Appeal procedures not followed - 285

and

Appeal time limits not met - 286

Explanation: Update to older code to help clarify the reason for the adjustment

Commenter:

Comment:

Motioner:

Seconder:


Pat – getting rid of 138 but split the description into 2 codes.

September 24, 2017

Pat – makes motion to approve deactivating 138 and replace with 2

new codes.

Sue – seconded

Discussion: None

Effective date of deactivated code 138 is 6 months (May 1, 2018).

New codes 285 & 286 effective immediately.


Passed: X – deactivate 138 effective 6 months after publication (May 1, 2018)

Failed:

Tabled:



Assigned Code: 285 and 286

Definition: 285 Appeal procedures not followed

286 Appeal time limits not met

19

CARC 139 description revision


Company: TMG Health

Phone: 6102029565




Value: 139

Description: Revise description to: Contracted funding agreement - Subscriber is employed

by the provider of services. Use only with Group Code CO.

Explanation: Adding the group code restriction will allow for better use of the code

Commenter:

Comment:

Motioner:

Seconder:




Pat – adding “Use Group Code OA only”

September 24, 2017

Pat – makes motion to revise CARC 139

Sherry – seconded

Discussion:

Gail – does that mean the notes from the pre-meeting is incorrect?

“Use only with Group Code CO” Pre-meeting notes were incorrect with

OA

Effective 6 months from publication because it is substantive.

Discussion:

Meg – this actually changes the usage and should be 6 months

because adding a group code.

Gail – agrees with 6 months

Margaret – is anyone opposed with 6 months?

Mike – can the committee consider being effective June 1 for coding?

Effective date: 6 months from publication


Passed: X – revision effective 6 months after publication (May 1, 2018)

Failed:

Tabled:

Assigned Code: Revise 139

Definition: Contracted funding agreement - Subscriber is employed by the provider

of services. Use only with Group Code CO

20

CARC 165


Company: TMG Health

Phone: 6102029565






Value: 165

Description: Deactivate 165

Add 1 new:

Referral exceeded

Explanation: Update to older code

Commenter: Patricia Wijtyk

Comment: Add a note to CAR 165: To report a missing referral, use CARC 16 and

RARCs N475, N476, N489 or N490 as appropriate.

Motioner:

Seconder:




Pat – same cleanup project.

Pat – when we say “add a note” we need to be careful because we

have a new attribute for notes. It is called Note, but not within the

description.

Karen – she thinks saying “in the notes section, add the following” is a

lot clearer. She feels we need to start making that distinction.

September 24, 2017

Pat – makes motion to deactivate 165. Add a note (other field) “To

report a missing referral, use CARC 16 and RARCs N475, N476, N489

or N490 as appropriate””

Sue – seconded

Discussion:

Donna – if it is deleted in a system, then there wouldn’t be a need for

the note.

Gail – if we are going to activate 165 why wouldn’t we create two new

codes instead of one and not to use 16 and add a bunch of RARCs.

Feels it will make it harder for the provider like it is.

Pat – there was a reason, it is all about missing information and how to

report it.

Gail – would like to know what the provider community says.

Pat – if we create a new CARC that says missing, direct them to 16

and the RARCs

Betsy – as a provider – looking at 16, it may not be that the claim is not

missing information but may be missing the referral.

Karen – recommends the note say CARC 16 or 250 to use.

Gail – that is the point it might not be an attachment. It may not be

something that was sent in with it.

Colleen from Aetna – the RARCs that are mentioned to use with 16 are

not in the CORE combinations.

Rachel – comment on the CORE code combinations. Just because

they are not in the combination now it does not mean that it won’t be

added when the work is published out of this meeting.

Gail – she understands what Rachel is saying but she does not feel

that X12 should post in our database until they are included.

Pete – starting to favor two new codes as well.

Doreen – the note about the RARCs is just instructional. Why can’t

that be used?

Margaret – the motion on the floor is to deactivate 165 and add notes




Passed: X – 165 deactivation effective 6 months after publication (May 1, 2018)

Failed:

Tabled:

Assigned Code: 287 and 288

Definition: 287

Referral Exceeded

288

Referral Absent

21

CARC 168


Company: TMG Health

Phone: 6102029565




Value: 168

Description: Deactivate 168,

Add new code:

Services considered under the dental and medical plans, benefits not

available.

Add to note section, not note in description: Also see See CARCs 254 and

270, 280

Explanation: This will fill the gap for the other codes

Commenter:

Comment:

Motioner:

Seconder:




Pat – same cleanup project. In the way it is worded there were gaps

between the messages and this is trying to fill in some of those gaps.

September 24, 2017

Pat – makes motion to deactivate 168 and add a new code as

submitted with a note referring to the other codes.

Sue – seconded

Discussion: None

New code 289 effective immediately and deactivated 168 will be in 6

months after publication.


Passed: X – 168 deactivation effective 6 months after publication (May 1, 2018)

Failed:

Tabled:

Assigned Code: 289

Definition: Services considered under the dental and medical plans, benefits

not available.

22

CARC 197, 198, new code


Company: TMG Health

Phone: 6102029565




Value: 197, 198

Description: Deactivate 97

Add new code for: Precertification/Notification/Authorization number may be

valid but does not apply to the billed services.

Change CARC 198 to: Precertification/authorization/notification exceeded

Explanation: To have consisten descritpon across precerts, autha and notifications



Commenter:

Comment:

Motioner:

Seconder:




Pat – same cleanup project.

September 24, 2017

Deactivate 197 (description above is incorrect) and modify 198

Pat – makes motion to deactivate 197, create a new code and modify

198 with new verbiage.

Sue – seconded

Discussion:

Laurie – on the description for 198

precertification/notification/authorization to be consistent with new code

request.

Pete – if 197 is deactivated it says that it is absent and we are not

replacing with anything that says absent, how are we accommodating

that? Gail same question.

Pat – have 15 says authorization 165 says referral. They found other

codes that had absent.

Gail – we just approved deactivating 15 so that is off the table. We

need to keep 197 and ok with changing 198.

Peggy – in dental they don’t use precertification or notification they use

prior authorization and pretreatment. Margaret – will be the equivalent

of a prior auth, right? Peggy – yes.

Kellene Parthemore – request #16 to create 284 says the same thing

as these requests.

Pat – as part of this motion can we go back to 284 and add

precertification/notification/authorization? Adding the new and putting it

in 284. Not deactivate 197,

Pat – would like to withdraw her motion.

Pat – makes new motion to revise 284 to read

“precertification/notification/authorization” change 198 and not

deactivate 197.

Gail – seconded

Discussion:

Kathy – had the comment on dental.

Margaret – do you oppose adding “pretreatment” and “prior

authorization”. Laurie recommends the prior authorization. Pre-

treatment she doesn’t know.

Gail – agrees with Laurie. Suggests to go ahead and add

“pretreatment” we just want to make sure we are using the same

sequence. Recommends “precertification/notification/authorization

/pretreatment” does not care the order just as long as they are




Passed: X – 197 and 198 effective 6 months from publication (May 1, 2017)

Failed:

Tabled:

Assigned Code: Revise 197; Revise 198; Revise New 284

Definition: 197 Precertification/authorization/notification/pre-treatment absent. 198 Precertification/notification/authorization/pre-treatment exceeded 284 Precertification/authorization/notification/pre-treatment number may be valid but does not apply to the billed services.

23

New Code


Company: TMG Health

Phone: 6102029565


Request Type: New


Value:

Description: Claim received by the dental plan, but benefits not available under this plan.

Claim has been forwarded to the patient's medical plan for further

consideration.

NOTE column: Refer to CARC 254. Report 19, 20, or 21 in CLP02.

Explanation: This supplements CARC 254

Commenter:

Comment:

Motioner:

Seconder:




Pat – filling in a gap received by dental. This is slightly different. Want

to make sure that CLP02 is still used.

September 24, 2017

Pat – makes motion to approve new code as submitted along with a

note that refers to CARC 254. Report Claim Status Codes 19, 20 or 21

in CLP02

Sue – seconded

Discussion:

Laurie – doesn’t understand what the column note means. She feels

the note is confusing.

Margaret – how would you modify the note?

Laurie – doesn’t think that 254 should be referred to.

Pat – because the reference is

Karen – what about adding “if not forwarded”

Margaret: should read CARC 254 if the claim was not forwarded.

Report Claim Status Codes 10, 20, 21 in CLP02.

Pete – should we modify 254 and add a note that says if forwarded, do

this…?

Margaret – suggestion is now to modify 254 with the new note Pete

mentioned.

Merri-Lee – understands what we are trying to do but is concerned that

we are trying to put information in codes that are currently in the TR3s.

Feels that we are getting too far in the details.

Laurie – question – is this process really different when the claim is

forwarded to a different payer. Wouldn’t it be similar to the RARCs that

are used when you are forwarding to an outside payer? The CARC

should say what is done and then refer to the other codes for details?

Pat – approached it as saying “we the payer” and thinking outside of

the box. Thought as making two codes it was a clearer picture.

Margaret – does anyone oppose moving the claim status code to the

note?

Betsy – has looked at codes and doesn’t see anything that is just a

simple forward.

Gail – would like to stick with the new code with a note to use CARC

254 if the claim is not forwarded.

New CARC 290 – effective immediately

Pat – Makes motion to make a note column to 254 to use 290 if the

claim was forwarded.

Gail – seconded





Failed:

Tabled:

Assigned Code: New code 290; Revise 254

Definition: 290

Claim received by the dental plan, but benefits not available under this

plan. Claim has been forwarded to the patient’s medical plan for further

consideration.

254

Add note column: Use CARC 290 if the claim was forwarded.

24

New Code


Company: TMG Health

Phone: 6102029565


Request Type: New


Value:

Description: Claim received by the medical plan, but benefits not available under this plan.

Claim has been forwarded to the patient's dental plan for further consideration.

NOTE attribute: Refer to CARC 270. Report 19, 20, or 21 in CLP02.

Explanation: This supplements CARC 270

Commenter:

Comment:

Motioner:

Seconder:



Discussion

Pre-Meeting August 31, 2017

Pat – same as item #23

September 24, 2017

Pat – makes motion to add new code as use code 270 if the claim was

not forwarded and on 270 add note to use new code if the claim was

forwarded.

Gail – seconded

Discussion:

None

Approved 14 opposed 0 abstain 1

Motion passes

New code 291 effective immediately

Revised code will be effective 3 months after publication. (also item

above)

VOTE RESULTS - NUMBER OF: YES 14 NO 0 ABSTAIN 1

Passed: X – revision effective 3 months from publication (February 1, 2018)

Failed:

Tabled:

Assigned Code: New code 291; Revise Code 280

Definition: 291

Claim received by the medical plan, but benefits not available

under this plan. Claim has been forwarded to the patient's dental

plan for further consideration.

NOTE attribute: Use CARC 280 if the claim was not forwarded

Revise 280

NOTE attribute: Use CARC 292 if the claim was forwarded.

25

New Code




Company: TMG Health

Phone: 6102029565


Request Type: New


Value:

Description: Claim received by the medical plan, but benefits not available under this plan.

Claim has been forwarded to the patient's Pharmacy plan for further

consideration.

NOTE attribute: Refer to CARC 280. Report 19, 20, or 21 in CLP02.

Explanation: Supplements CARC 280

Commenter:

Comment:

Motioner:

Seconder:


Pat – same thing as above #23

September 24, 2017

Gail – makes a motion to approve the new code with the note on the

new code and the revised code to be created the same as the item

before (#24).

Pat – seconded

Discussion: none

Approved 14 opposed 0 abstentions 1

Motion carries

New code 292 effective immediately

Revised effective 3 months from publication.

VOTE RESULTS - NUMBER OF: YES 14 NO 0 ABSTAIN 1

Passed: X – revised code effective 3 months from publication (February 1, 2018)

Failed:



Tabled:

Assigned Code: New code 292; Revised code 270

Definition: 292

Claim received by the medical plan, but benefits not available

under this plan. Claim has been forwarded to the patient's

pharmacy plan for further consideration.

NOTE attribute: Use CARC 270 if the claim was not forwarded

270

NOTE attribute: Use CARC 292 if the claim was forwarded

26

New code to indicate a prior auth request is in Initial review.

Name: Janice Bakos


Phone: 570 775-0229


Request Type: New


Value:

Description: Initial Utilization Review In Progress

Explanation: For use in the Precert Inquiry transaction. A value to indicate a Prior Auth

request is actively being worked by the initial reviewer. Kindly ignore prior

request of "Utilization Review in progress". This will offer additional details by

the inclusion of the word 'Initial'.

Commenter:

Comment:

Motioner:

Seconder:




Janice – submitting this on behalf of the WEDI prior auth wg. Request

is to add information where a precert may belong in the review

process. They have requested two new codes.

Bruce – they talked about it in WG10 and they support both this

request and #27.

September 24, 2017

Bruce – makes motion to approve two new codes - items #26 and #27

LuAnn – seconded

Discussion: none


New codes: 30 and 31 were adjudicated together

VOTE RESULTS - NUMBER OF: YES__16___ NO _0__ ABSTAIN_0_

Passed: X

Failed:

Tabled:

Assigned Code: 30

Definition: Initial Utilization Review In Progress

27

Decision Reason code to be used in the Precert Inquiry (X215)

tranasaction to indicate that a precert request is currently in review and

has been escalated to a higher level to complete that review.

Name: Janice Bakos


Phone: 570 775-0229


Request Type: New


Value:

Description: Escalated Utilization Review in Progress.



Explanation: A new code to be used in the X215 inquiry transaction to indicate that not only

is a Pended precert request in active review, but that it has been escalated to

a higher level for review. This request is to be considered instead of the

previously submitted request of "Utilization Review in progress". Request is for

two codes, one for Initial and another for Escalated Utilization Review in

Progress.

Commenter:

Comment:

Motioner:

Seconder:


Janice – submitting this on behalf of the WEDI prior auth wg. To add

information where a precert may belong in the review process. They

have requested two new codes.

Bruce – they talked about it in WG10 and they support both this

request and #26.

September 24, 2017

This item was adjudicated with Item #26.

This is new code 31.

VOTE RESULTS - NUMBER OF: YES__16__ NO _0__ ABSTAIN__0__

Passed: X

Failed:

Tabled:

Assigned Code: 31

Definition: Escalated Utilization Review in Progress.

Meeting adjorned at 3:30 There is a need to have the remainder of the agenda adjudicated before the next standing meeting. Margaret will schedule an interim call to complete.

Follow up call October 25, 2017 Quorum was met with 15 voting members.



28

CARC P21 - Modify description to insert "and/".

Name: Tina Greene

Company: Mitchell

Phone: 858 368 7104




Value: P21

Description: Deactivate:

Modify P21 description to:

Payment denied based on the Medical Payments Coverage (MPC) or

Personal Injury Protection (PIP) Benefits jurisdictional regulations and/or

payment policies.

Explanation: Modify P21 description to insert "and/".

Commenter:

Comment:

Motioner:

Seconder:


Tina – we will take offline and discuss

October 25, 2017

Insert comma after regulations

Motion to approve – LuAnn

Gail seconded

Approved opposed 0 abstain 0

Effective date – 3 months from publication

VOTE RESULTS - NUMBER OF: YES__15_____ NO _00___ ABSTAIN__0__

Passed: X – modify P21 description



Failed:

Tabled:

Assigned Code: Revise P21

Definition: Payment denied based on the Medical Payments Coverage (MPC) and/or

Personal Injury Protection (PIP) Benefits jurisdictional regulations, or payment

policies. Usage: 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') if the jurisdictional

regulation applies. 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) if the regulations apply. To be

used for Property and Casualty Auto only.

29

CARC P22 - Modify description to insert "and/".

Name: Tina Greene

Company: Mitchell

Phone: 858 368 7104




Value: P22

Description: Deactivate:

Modify P22 description to:

Payment adjusted based on the Medical Payments Coverage (MPC) and/or

Personal Injury Protection (PIP) Benefits jurisdictional regulations or payment

policies.

Explanation: Modify P22 description to insert "and/".

Commenter:

Comment:

Motioner:

Seconder:




Tina – will discuss offline and bring to Sept.

Discussed with auto and P22 should be modified the same as P21.

October 25, 2017

Insert comma after regulations

Motion to approve – Lu

Gail seconded

Approved opposed 0 abstain 0

Effective date – 3 months from publication

VOTE RESULTS - NUMBER OF: YES__15_____ NO _00___ ABSTAIN____

Passed: X – modify P22 description

Failed:

Tabled:

Assigned Code: Revise P22

Definition: Payment adjusted based on the Medical Payments Coverage (MPC)

and/or Personal Injury Protection (PIP) Benefits jurisdictional

regulations, or payment policies. Usage: 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') if the jurisdictional regulation applies. 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) if the regulations apply. To be

used for Property and Casualty Auto only.

30

CARC 100 - Modify description to insert "/attorney".

Name: Tina Greene

Company: Mitchell

Phone: 858 368 7104




Value: 100



Description: Revise to: Payment made to patient/insured/responsible

party/employer/attorney.

Explanation: Modify CARC 100 description to insert "/attorney".

Commenter:

Comment:

Motioner:

Seconder:

Discussion October 25, 2017

Motion to approve – LuAnn

Gail - seconded

Deb –thinks that this code should be split out. So that when the provider has

to go chase, they will know which entity.

Payment made to patient/insured/responsible party.

Payment made to employer.

Payment made to attorney.

LuAnn – withdraws motion

Gail – ok with withdraw

LuAnn – new motion to remove employer from 100 and create two new codes

for employer and attorney

Deb – should these be P codes? Gail suggests that they are not since there

could be use outside of P&C.


New codes will be 293 and revised code 100 – effective in 6 months.

New code 294 (attorney) effective immediately.

Payment made to patient/insured/responsible party. New 100 Effective 6

months from publication

Payment made to employer. Will be CARC 293. Effective 6 months from

publication.

Payment made to attorney. Will be CARC 294. Effective immediately.

VOTE RESULTS - NUMBER OF: YES___15____ NO __0__ ABSTAIN_0___

Passed: X

Failed:

Tabled:



Assigned Code: Revised 100, New 293, New 294

Definition: 100: Payment made to patient/insured/responsible party.

293: Payment made to employer.

294: Payment made to attorney.

31

New Code

Name: Tina Greene

Company: Mitchell

Phone: 858 368 7104


Request Type: New


Value:

Description: Payment adjusted based on PPO/MPN/VPN.

Group Code CO

Explanation: CARC P12 is specific to fee schedule adjustment only. There needs to be

more specificity regarding any PPO used. Fee schedule and PPO adjustments

are different. There is a need in the P&C industry to specify the difference. All

stakeholders (Providers, Payers and States) are in agreement.

Commenter: Tina Greene

Comment: We would like to spell out PPO, MPN and VPN.

Preferred Provider Organization (PPO)/Medical Provider Network

(MPN)/Virtual Private Network (VPN).

Commenter: Tina Greene

Comment: VPN - Voluntary Provider Network

Motioner:

Seconder:




Karen – class of contract code should refer to the network.

Pat – “to be used for Property & Casualty only”

Karen – suggests breaking them out.

Pat – and as long as they all say “to be used for Property & Casualty only” it

would be fine.

October 25, 2017

Payment adjusted based on PPO. Add usage and group code CO.

Payment adjusted based on MPN. Add usage and group code CO..

Payment adjusted based on Voluntary Provider Network (VPN). Add

usage and group code CO

Motion to approve with updates – Pat

Seconded – Deb


To be effective immediately

VOTE RESULTS - NUMBER OF: YES__13_____ NO _0___ ABSTAIN__2__

Passed: X

Failed:

Tabled:

Assigned Code: P24, P25, P26 (effective immediately)



Definition: P24 Payment adjusted based on PPO. Usage: 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) if the regulations apply. To be used for Property and Casualty

only. (Use only with Group Code CO).

P25 Payment adjusted based on MPN. Usage: 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) if the regulations apply. To be used for Property and Casualty

only. (Use only with Group Code CO).

P26 Payment adjusted based on Voluntary Provider Network (VPN).

Usage: 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) if the

regulations apply. To be used for Property and Casualty only. (Use

only with Group Code CO).

32

New Code

Name: Tina Greene

Company: Mitchell

Phone: 858 368 7104


Request Type: New


Value:

Description: Payment denied based on the Liability Coverage Benefits jurisdictional

regulations and/or payment policies.



Explanation: Auto industry is in need of a code to specify Third Party (Liability Coverage

Benefits). This different than the MPC and PIP coverage/benefits identified in

existing P codes.

Commenter:

Comment:

Motioner:

Seconder:


Call ended.

October 25, 2017

Add usage to new code.

Motion to approve as amended with usage – Pat

Seconded – Deb

Approved Opposed Abstain 1


VOTE RESULTS - NUMBER OF: YES__14_ NO _0__ ABSTAIN_1__

Passed: X

Failed:

Tabled:

Assigned Code: P27

Definition: Payment denied based on the Liability Coverage Benefits jurisdictional

regulations and/or payment policies. Usage: If adjustment is at the Claim




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) if the regulations apply. To be used for Property

and Casualty Auto only.

33

New Code

Name: Tina Greene



Company: Mitchell

Phone: 858 368 7104


Request Type: New


Value:

Description: Payment adjusted based on the Liability Coverage Benefits jurisdictional

regulations and/or payment policies.


Benefits). This is different than the MPC and PIP coverage/benefits identified

in existing P codes.

Commenter:

Comment:

Motioner:

Seconder:


Pat - Motion to approve new code as written on Go To Meeting.

(includes Usage and To be used for Property and Casualty Auto only)

Deb - seconded

New code P28 effective immediately.

VOTE RESULTS - NUMBER OF: YES_13___ NO _0__ ABSTAIN_2__

Passed: X

Failed:

Tabled:

Assigned Code: P28



Definition: Payment adjusted based on the Liability Coverage Benefits jurisdictional

regulations and/or payment policies. Usage: If adjustment is at the Claim




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) if the regulations apply. To be used for Property

and Casualty Auto only.

34

Tina Greene

Name: Mitchell

Company: 858 368 7104

Phone: [email protected]

Email: New

Request Type: Claim Adjustment Reason Code

List Name Tina Greene

Value:

Description: Liability Benefits jurisdictional fee schedule adjustment.


Benefits). This is different than the MPC and PIP coverage/benefits identified

in existing P codes.

Commenter:

Comment:

Motioner:

Seconder:




Usage: 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) if the regulations apply, To be used for Property and

Casualty Auto only.

Pat - Motion to approve with the addition of Usage.

Deb - Seconded



VOTE RESULTS - NUMBER OF: YES_13__ NO _0__ ABSTAIN_2__

Passed: X

Failed:

Tabled:

Assigned Code: P29

Definition: Liability Benefits jurisdictional fee schedule adjustment. Usage: 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) if the

regulations apply. To be used for Property and Casualty Auto only.

January 2018 Request

01

Delete Duplicate Code

Name: Margaret Weiker

Company: NCPDP

Phone: 480-477-1000



List Name Health Care Service Type



Value:

Description: Delete Duplicate Code

Explanation: Code E24 and 88 are duplicates. E24 needs to be deleted from

the list.

Commenter:

Comment:

Motioner:

Seconder:


Margaret – with this request it will require a deletion of a duplicate code. If we

should wait until the January meeting, that is fine.

Gail – which one should stay and which one deleted? Margaret – 88 is the

code that should be deleted because it is the one that is being used currently.

Gail – doesn’t think E24 is in the standard. Not until 7030.

Bruce – everyone agreed that E24 would be deleted.

Margaret – they went over these codes extensively with 270/271 wg.

Bruce - they had a separate meeting for reviewing the spreadsheet.

Pete – he sees “retail pharmacy prescription drug” Margaret – and that does

not exist.

Gail – why do we still have others that have “drug” in i?. Some other

inconsistencies that we may need to look at.

Gail is comfortable with taking it out, but is 270/271 ok with it?

WG 1’s representatives are ok with deleting E24.

Motion to approve – Kath Jonzzon

Seconded – LuAnn



VOTE RESULTS - NUMBER OF: YES_15_ NO 0_ ABSTAIN_0_

Passed: X – delete E24 effective immediately

Failed:

Tabled:

Assigned Code:



Definition:

september 2017 pre meeting - wpc-edi.com · september 2017 meeting pittsburgh pa | sunday |...

Documents