HBMA Attendees Share Their Biggest Challenges in Processing Claim Payments: Part I

On September 14-16, over 300 healthcare business management and billing professionals gathered at the HBMA Healthcare Revenue Cycle Conference in Phoenix, AZ. Zelis Payments used this opportunity to conduct an informal poll of attendees to learn about the biggest challenges in processing and management of claims and claim payments.

The poll identified three top challenges which we’ll address in a three-part series throughout the month of November.

Challenge number 1:
Many respondents indicated that codes in their remittance data lack sufficient detail to understand why a claim was denied. This can occur if remittance data omits specific core code combinations. Depending on what format remittance data takes (835 or EOP), certain code combinations may be omitted, which means there is less detail to accurately describe why an adjustment or denial occurred.

To illustrate an example of a denial scenario, the CARC descriptions depicted below for code 9 indicates that “the diagnosis is inconsistent with the patient’s age.” This code may apply to different scenarios. However, the RARC creates more clarity showing code M37 “not covered when the patient is under 35.” The RARC completes the picture of why the claim payment was denied.

In the CORE code combos, some CARC listings include a basic listing without a corresponding RARC or some codes do not have a corresponding RARC at all. There is a likelihood that code selection on the payer’s side may also contribute to the issue.

Omission of these codes may be due to:

  • OCR scanning errors at the lockbox or clearinghouse
  • Payers lacking detailed level reporting
  • Group medical EOPs lacking standard regulation – they may either include custom codes or lack significant detail
CARC Code CARC Description RARC RARC Descripion
 9 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. This change effective September 1, 2017: The diagnosis is inconsistent with the patient’s age. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
 9 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. This change effective September 1, 2017: The diagnosis is inconsistent with the patient’s age. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.  M37 Not covered when the patient is under age 35.
 9 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. This change effective September 1, 2017: The diagnosis is inconsistent with the patient’s age. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.  M82 Service is not covered when patient is under age 50.


How Zelis Adds Detail to Claim Data:

Zelis Payments has made investments in both technology and resources to produce balanced, detailed remittance data:

  • Proprietary integrations with leading core claims platforms enables us to extract remittance data – including all required CARCs, RARCs and CAGS directly from the payer’s claims system.
  • Incoming data is audited to verify that adjustment codes comply with CAQH CORE® standards.
  • A standardized format is applied to all payer data for ease of processing on the provider’s end.

Zelis Payments services are also backed with support from 835 specialists who can answer questions, as well as work with large providers to identify ways to apply rules-based modifications to 835s or NACHA files to address organizational needs such as payer splitting, file formatting or file extensions. This helps to fit remittance data files into the provider’s current workflow and eliminate expensive exception processing. Additionally, Zelis’ experts will work with the payer on your behalf which reduces the amount of time your staff needs to interact with payers over complex compliance issues.

In Part II of this three-part series, we’ll look at the second biggest challenge identified at HBMA, Maximizing Resources.