The 5010 X12 guide appears to allow for the LQ Health Care Remark Code to be returned on its own, including supplemental RARCs, correct? We are doing post-payment reviews and would like to send an informational RARC code to provide information to the provider why the claim is being paid or less, e.g., Claim adjustment for Post Audit review of DRG and would return RARC code N647, “Adjusted based on the diagnosis-related group (DRG”, on the corrected claim segment. We feel this follows the TR3 Notes LQ Health Care Remark codes. Are we correct in our interpretation?
We feel this allows us to align with CAQH Core’s Operating Rules for Information Exchange (CORE) Payment & Remittance (835) Infrastructure Rule vPR.1.0 and helps mitigate:
• Unnecessary manual provider follow-up. The RARC is conveying information about claim processing.
And provide for:
• Less staff time spent on phone calls and websites. Reducing our Provider calls requesting why the claim was adjusted.
• More accurate and efficient remittance/claim information. RARC is providing a specific reason for the adjustment
The Health Care Claim Payment/Advice Technical Report Type 3 (005010X221A1) provides the following guidance on the use of LQ, MIA, and MOA segments.
If a service Remittance Advice Remark Code (RARC) is appropriate, it is reported in an LQ segment (applies to a specific line). If a claim RARC is appropriate, it is reported in an MIA or MOA segment for inpatient and outpatient claims, respectively. If the RARC is reported in the MIA or MOA it would apply to the entire claim.
The LQ per the TR3 notes states the RARCs are used to provide additional information. They have no direct ties to actual payment. Therefore sending a RARC as ‘informational’ in the LQ as noted in the example would be appropriate if applied to that given line. If your RARC applies to the entire claim, then the 2100 MIA or MOA would be more appropriate.
Please also refer to RFI# 1777 for additional information on LQ, MIA and MOA segment usage with or without a CAS.