Section title: Requests for Interpretation
States we service are requiring a list of CARC Codes and/or CAGC Codes that are considered 'true denials'

Does X12 have any suggestions on how to apply a disposition to each CARC Code? Several States are now asking Health Plans to provide a sort of crosswalk which identifies what they call 'true denials' and/or CAGC's that we see as denials. We have reached out to CAQH and were told that our understanding of using the CARC/RARC combinations as both adjustments and/or denials is correct so we are reaching out to see if there is any other feedback you can provide.


From one of our State Requests: The Division is creating a comprehensive database of CAS Codes as a result we are asking for you to provide us with a listing of the claim adjustment group code and claim adjustment reason code that you consider the combination to be a true denial on medical encounters.

RFI Response

The CARC/RARC combinations can be used as both partial adjustments and full adjustment of the billed charge. It is dependent on the payer’s business rules/contract. A business contract can be between the provider and the payer or the member and the payer.


It is not within X12’s purview to comment on the usage of a CARC or RARC code. X12 cannot comment on a payer’s policy/contracts or procedure for denying claims and the usage of adjustment codes.