X12 Ingest & Denial Analytics

Not necessarily — $107.25 reported as patient responsibility

Not necessarily. The payer reported $107.25 as patient responsibility on this 835. The 835 reports $107.25 under group PR on this claim, which the payer adjudicated as a denial. It carries CARC 50 and claim-level RARC N115. CARC 50: These are non-covered services because this is not deemed a 'medical necessity' by the payer. RARC N115: This decision was based on a Local Coverage Determination (LCD). An LCD provides a guide to assist in determining whether a particular item or service is covered. The payer declined coverage because it did not consider the service medically necessary, and assigned the reported amount to patient responsibility. Compare the provider's itemised bill with the explanation of benefits; request the applicable coverage policy; ask the provider whether the clinical record supports reconsideration or appeal; and confirm any deadline and process with the plan. If a balance remains, ask the provider about payment or financial-assistance options. Medical necessity is a clinical judgement, so a reconsideration may be possible: ask the provider whether the record supports one, and confirm with the plan what evidence it would need.

From: 835 CAS adjustments under group PR on this claim, with the remark codes reported alongside them; the CARC and RARC reference lists for the code descriptions.

Limits: The 835 records the payer's adjudication. This application cannot determine whether the provider billed the amount, whether it is legally collectible, whether required prior notice was given, whether another payer is responsible, or whether an appeal would succeed.

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