Transparency Denial Standard v1.6

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Contents

General

Purpose

Applicability

Basic Concepts

Detail

Implementation Considerations

General

Senders

Receivers

History

Appendix A

 

General

The UHIN Transparency Denial Standard version 1.6 is compatible with state requirements set forth in Utah Code 31A-2-216(2).

Purpose

To establish performance measures that report the number and cost of an insurer’s denied health claims and to provide guidance pertaining to the reporting method and timeline to the Utah Insurance Department. Information derived from the data will be shared as public record for display on the Utah Insurance Department’s websites (insurance.utah.gov and healthrates.utah.gov).

Applicability

This standard applies to all health benefit plans issued or renewed on or after January 1, 2015 or otherwise defined by Utah Administrative Insurance Rule R590-271 (Data Reporting for Consumer Quality Comparison), which can be found at https://rules.utah.gov/publicat/code/r590/r590-271.htm.

This standard or rule may not apply to ERISA-governed plans or self-insured plans as defined by the Utah Insurance Department rule. Please consult with your legal department and the Utah Insurance Department for applicability.

Basic Concepts

  • Claim: An invoice or bill submitted to a payer for one or more medical services.
  • Claims Paid: Claims reported in a Remittance Advice.
  • Denial: A reportable status of claim/service that has been accepted for processing and is not paid. This includes paper and electronic claims.
  • Member Responsibility: The amount that the member is responsible to pay for the services that were rendered.
  • Provider Responsibility: The amount that the provider is required to write off and may or may not bill the member.
  • Reject: An electronic claim that is not accepted by a payer for processing due to data errors.
  • Reporting Period: Yearly for regular submissions of all claims adjudicated as of the end of the calendar year.
  • Service Line: The line item detail charge that makes up a claim. This is the unit of measurement for reporting the information.
  • SFTP: Secure File Transfer Protocol

Detail

This standard includes the following:

  • The format in which a payer will provide the data to the Utah Insurance Department will be in a report form. Please see the Transparency Standards Reporting Worksheet for Denials.
  • A list of Claim Adjustment Reason Codes (CARCs) which identify the denied services to be reported. See Appendix A.
  • As an exception, when claims are adjudicated at a claim level, they should be reported at a claim level (e.g. Per Diem, DRG).
  • Reporting is not required on claims where the carrier is not the primary payer.
  • Performance Measure for the reporting period (percentage and cost of claims denied[1]):
    • Member
      • Total count of denied services to member
      • Total cost of denied services to member
      • Member’s percentage of denied services and associated average cost can be calculated using the following formula: Total denied services to member divided by total billed services
    • Provider
      • Total count of denied services to provider
      • Total cost of denied services to provider
      • Provider’s percentage of denied services and associated average cost can be calculated using the following formula: Total denied services to provider divided by total billed services
    • Totals
      • Total count of denied services
      • Total count of billed services
      • Total cost of denied services
      • Total cost of billed services
      • Total percentage of denied services and associated average cost can be calculated using the following formula: Total denied services divided by total billed services
    • Reporting timelines and submission times:
      • Annual submissions are due to the Utah Insurance Department on or before April 1 of the succeeding calendar year. All received will be posted to the Utah Insurance Department website (https://healthrates.utah.gov) on April 1st.
      • Reported totals will be based on a full year’s data, January 1 – December 31st.
      • Report the claims based on paid (remittance) date.
      • All data is reported at the company level for Utah business.
    • Always report the final status of any claim that is adjusted. Do not report all the iterations of adjustments.
    • Denied services where a contract does not exist between a health plan and a provider are reported as a member denied services.
    • Denied services where a contract does exist between a health plan and a provider are reported as a provider denied service.
    • The primary denial reason is used for reporting purposes when there are multiple denial reasons on the same line. This may require payers to develop a hierarchy/prioritization for reporting purposes to determine the primary denial.

The report excludes all claims that are rejected before entering your adjudication system. For example:

  • Billing Errors
  • Duplicate Claim
  • Eligibility
  • Incorrect payer
  • Invalid Provider ID
  • Non-compliant HIPAA Transactions
  • Secondary Insurance

The report includes major medical policies which may cover certain dental, pharmacy, and vision services. The report excludes dental, pharmacy, vision only policies and government program claims (i.e. Medicare, Medicare Advantage Plan, Medicare Part D, CHIP and Medicaid).

Implementation Considerations

General

  • This information will be used by the public to compare Health Insurers and Health Benefit Plans.
  • All data is to be sent directly to the Utah Insurance Department via the UID secure upload site. Payers are encouraged to contact UID directly for connectivity methods. Contact Jeff Hawley at healthresearch@utah.gov, or 801-538-9684.
  • The Department recognizes that the Claim Adjustment Reason Codes are updated each trimester and may impact reporting. Payers should report the CARC codes that are valid as of the date of service being denied.
  • The CARC codes used in this Standard will be reviewed yearly in November for changes, additions, and deletions in the report. Adopted/Deleted CARCs are effective for data collection in the following calendar year.
  • A Frequently Asked Questions for Transparency Reporting document is available at https://uhin.org/knowledge-center/#/Standards/.

Senders

  • Senders should contact UHIN for questions and concerns with the Standards. Contact UHIN Customer Service at 1-877-693-3071 (toll free).
  • Senders should contact the Utah Insurance Department for questions and concerns regarding reporting submission, connectivity, and acceptance. Contact Jeff Hawley at healthresearch@utah.gov, or 801-538-9684.
  • If CARCs are kept outside of payers’ claim processing systems, a CARC crosswalk may be used for reporting purposes.

Receivers

  • The Utah Insurance Department is responsible for maintaining and receiving reports.

History

 

Original

V1.1

V1.2

ORIGINATION DATE

1/2010

1/11/2012

9/16/2014

APPROVAL DATE

5/18/2011

5/30/2012

5/6/2015

EFFECTIVE DATE

6/18/2011

6/30/2012

6/6/2015

 

 

V1.3

V1.4

V1.5

ORIGINATION DATE

11/30/2016

10/16/2017

11/26/2018

APPROVAL DATE

12/30/2016

2/7/2018

1/2/2019

EFFECTIVE DATE

2/28/2017

3/7/2018

2/2/2019

 

 

V1.6

 

 

ORIGINATION DATE

11/13/2019

 

 

APPROVAL DATE

12/18/2019

 

 

EFFECTIVE DATE

01/18/2020

 

 

 

 

Appendix A

2019 Reporting Claim Adjustment Reason Codes (CARC)

Included Code value

Description

Use Date

13

The date of death precedes the date of service.

Start: 01/01/1995

14

The date of birth follows the date of service.

Start: 01/01/1995

29

The time limit for filing has expired.

Start: 01/01/1995

39

Services denied at the time authorization/pre-certification was requested.

Start: 01/01/1995

40

Charges do not meet qualifications for emergent/urgent care. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

Start: 01/01/1995

49

This is a non-covered service because it is a routine/preventive exam or a diagnostic/screening procedure done in conjunction with a routine/preventive exam. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

Start: 01/01/1995

50

These are non-covered services because this is not deemed a 'medical necessity' by the payer. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

Start: 01/01/1995

51

These are non-covered services because this is a pre-existing condition. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

Start: 01/01/1995 

53

Services by an immediate relative or a member of the same household are not covered.

Start: 01/01/1995

54

Multiple physicians/assistants are not covered in this case. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

Start: 01/01/1995

55

Procedure/treatment/drug is deemed experimental/investigational by the payer. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

Start: 01/01/1995

56

Procedure/treatment has not been deemed 'proven to be effective' by the payer. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

Start: 01/01/1995

58

Treatment was deemed by the payer to have been rendered in an inappropriate or invalid place of service. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

Start: 01/01/1995

59

Processed based on multiple or concurrent procedure rules. (For example multiple surgery or diagnostic imaging, concurrent anesthesia.) Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

Start: 01/01/1995

60

Charges for outpatient services are not covered when performed within a period of time prior to or after inpatient services.

Start: 01/01/1995

61

Adjusted for failure to obtain second surgical opinion.
Notes: The description effective date was inadvertently published as 3/1/2016 on 7/1/2016. That has been corrected to 1/1/2017.

Start: 01/01/1995

95

Plan procedures not followed.

Start: 01/01/1995

96

Non-covered charge(s). 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.) Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

Start: 01/01/1995

108

Rent/purchase guidelines were not met. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

Start: 01/01/1995

111

Not covered unless the provider accepts assignment.

Start: 01/01/1995

112

Service not furnished directly to the patient and/or not documented.

Start: 01/01/1995

114

Procedure/product not approved by the Food and Drug Administration.

Start: 01/01/1995

115

Procedure postponed, canceled, or delayed.

Start: 01/01/1995

117

Transportation is only covered to the closest facility that can provide the necessary care.

Start: 01/01/1995

119

Benefit maximum for this time period or occurrence has been reached.

Start: 01/01/1995

128

Newborn's services are covered in the mother's Allowance.

Start: 02/28/1997

129

Prior processing information appears incorrect. 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.)

Start: 02/28/1997

136

Failure to follow prior payer's coverage rules. (Use only with Group Code OA)

Start: 10/31/1998

139

Contracted funding agreement - Subscriber is employed by the provider of services. Use only with Group Code CO.

Start: 06/30/1999

140

Patient/Insured health identification number and name do not match.

Start: 06/30/1999

148

Information from another provider was not provided or was insufficient/incomplete. 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.)

Start: 06/30/2002

150

Payer deems the information submitted does not support this level of service.

Start: 10/31/2002

151

Payment adjusted because the payer deems the information submitted does not support this many/frequency of services.

Start: 10/31/2002

152

Payer deems the information submitted does not support this length of service. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

Start: 10/31/2002

153

Payer deems the information submitted does not support this dosage.

Start: 10/31/2002

154

Payer deems the information submitted does not support this day's supply.

Start: 10/31/2002

155

Patient refused the service/procedure.

Start: 06/30/2003

157

Service/procedure was provided as a result of an act of war.

Start: 09/30/2003

158

Service/procedure was provided outside of the United States.

Start: 09/30/2003

159

Service/procedure was provided as a result of terrorism.

Start: 09/30/2003

160

Injury/illness was the result of an activity that is a benefit exclusion.

Start: 09/30/2003

163

Attachment/other documentation referenced on the claim was not received.

Start: 06/30/2004

164

Attachment/other documentation referenced on the claim was not received in a timely fashion.

Start: 06/30/2004 

167

This (these) diagnosis(es) is (are) not covered. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

Start: 06/30/2005

170

Payment is denied when performed/billed by this type of provider. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

Start: 06/30/2005

171

Payment is denied when performed/billed by this type of provider in this type of facility. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

Start: 06/30/2005

173

Service/equipment was not prescribed by a physician.

Start: 06/30/2005

174

Service was not prescribed prior to delivery.

Start: 06/30/2005

175

Prescription is incomplete.

Start: 06/30/2005 

176

Prescription is not current.

Start: 06/30/2005 

177

Patient has not met the required eligibility requirements.

Start: 06/30/2005

178

Patient has not met the required spend down requirements.

Start: 06/30/2005

179

Patient has not met the required waiting requirements. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

Start: 06/30/2005

180

Patient has not met the required residency requirements.

Start: 06/30/2005

181

Procedure code was invalid on the date of service.

Start: 06/30/2005

182

Procedure modifier was invalid on the date of service.

Start: 06/30/2005

183

The referring provider is not eligible to refer the service billed. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

Start: 06/30/2005 

184

The prescribing/ordering provider is not eligible to prescribe/order the service billed. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

Start: 06/30/2005

185

The rendering provider is not eligible to perform the service billed. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

Start: 06/30/2005

188

This product/procedure is only covered when used according to FDA recommendations.

Start: 06/30/2005

189

'Not otherwise classified' or 'unlisted' procedure code (CPT/HCPCS) was billed when there is a specific procedure code for this procedure/service

Start: 06/30/2005

190

Payment is included in the allowance for a Skilled Nursing Facility (SNF) qualified stay.

Start: 10/31/2005

192

Non standard adjustment code from paper remittance. Usage: This code is to be used by providers/payers providing Coordination of Benefits information to another payer in the 837 transaction only. This code is only used when the non-standard code cannot be reasonably mapped to an existing Claims Adjustment Reason Code, specifically Deductible, Coinsurance and Co-payment.

Start: 10/31/2005

193

Original payment decision is being maintained. Upon review, it was determined that this claim was processed properly.

Start: 02/28/2006

194

Anesthesia performed by the operating physician, the assistant surgeon or the attending physician.

Start: 02/28/2006 

197

Precertification/authorization/notification/pre-treatment absent.

Start: 10/31/2006

198

Precertification/notification/authorization/pre-treatment exceeded.

Start: 10/31/2006

199

Revenue code and Procedure code do not match.

Start: 10/31/2006

200

Expenses incurred during lapse in coverage

Start: 10/31/2006

201

Patient is responsible for amount of this claim/service through 'set aside arrangement' or other agreement. (Use only with Group Code PR) 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.)
Notes: Not for use by Workers' Compensation payers; use code P3 instead.

Start: 10/31/2006

202

Non-covered personal comfort or convenience services.

Start: 02/28/2007

203

Discontinued or reduced service.

Start: 02/28/2007

204

This service/equipment/drug is not covered under the patient’s current benefit plan

Start: 02/28/2007

210

Payment adjusted because pre-certification/authorization not received in a timely fashion

Start: 07/09/2007

212

Administrative surcharges are not covered

Start: 11/05/2007

213

Non-compliance with the physician self referral prohibition legislation or payer policy.

Start: 01/27/2008

215

Based on subrogation of a third party settlement

Start: 01/27/2008

216

Based on the findings of a review organization

Start: 01/27/2008

226

Information requested from the Billing/Rendering Provider was not provided or not provided timely or was insufficient/incomplete. 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.)

Start: 09/21/2008

227

Information requested from the patient/insured/responsible party was not provided or was insufficient/incomplete. 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.)

Start: 09/21/2008

228

Denied for failure of this provider, another provider or the subscriber to supply requested information to a previous payer for their adjudication

Start: 09/21/2008

231

Mutually exclusive procedures cannot be done in the same day/setting. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

Start: 07/01/2009

233

Services/charges related to the treatment of a hospital-acquired condition or preventable medical error.

Start: 01/24/2010

236

This procedure or procedure/modifier combination is not compatible with another procedure or procedure/modifier combination provided on the same day according to the National Correct Coding Initiative or workers compensation state regulations/ fee schedule requirements.

Start: 01/30/2011

238

Claim spans eligible and ineligible periods of coverage, this is the reduction for the ineligible period. (Use only with Group Code PR)

Start: 03/01/2012

240

The diagnosis is inconsistent with the patient's birth weight. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

Start: 06/03/2012

242

Services not provided by network/primary care providers.
Notes: This code replaces deactivated code 38

Start: 06/03/2012

243

Services not authorized by network/primary care providers.
Notes: This code replaces deactivated code 38

Start: 06/03/2012

250

The attachment/other documentation that was received was the incorrect attachment/document. The expected attachment/document is still missing. 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).

Start: 09/30/2012

251

The attachment/other documentation that was received was incomplete or deficient. The necessary information is still needed to process the claim. 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).

Start: 09/30/2012

252

An attachment/other documentation is required to adjudicate this claim/service. 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).

Start: 09/30/2012

256

Service not payable per managed care contract.

Start: 06/02/2013

257

The disposition of the claim/service is undetermined during the premium payment grace period, per Health Insurance Exchange requirements. This claim/service will be reversed and corrected when the grace period ends (due to premium payment or lack of premium payment). (Use only with Group Code OA).
Notes: To be used after the first month of the grace period.

Start: 11/01/2013

258

Claim/service not covered when patient is in custody/incarcerated. Applicable federal, state or local authority may cover the claim/service.

Start: 11/01/2013

261

The procedure or service is inconsistent with the patient's history.

Start: 06/01/2014

269

Anesthesia not covered for this service/procedure. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

Start: 03/01/2015  

272

Coverage/program guidelines were not met.

Start: 11/01/2015

273

Coverage/program guidelines were exceeded.

Start: 11/01/2015

296

Precertification/authorization/notification/pre-treatment number may be valid but does not apply to the provider.

Start: 07/01/2018

299

The billing provider is not eligible to receive payment for the service billed.

Start: 07/01/2019

A1

Claim/Service denied. 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.)

 Start:

1/1/1995

A6

Prior hospitalization or 30 day transfer requirement not met.

 Start:

1/1/1995

A8

Ungroupable DRG.

 Start:

1/1/1995

B1

Non-covered visits.

 Start:

1/1/1995

B7

This provider was not certified/eligible to be paid for this procedure/service on this date of service. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

Start: 01/01/1995  

B8

Alternative services were available, and should have been utilized. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

Start: 01/01/1995  

B11

The claim/service has been transferred to the proper payer/processor for processing. Claim/service not covered by this payer/processor.

Start: 01/01/1995

B12

Services not documented in patient's medical records.

Start: 01/01/1995  

B14

Only one visit or consultation per physician per day is covered.

Start: 01/01/1995  

B16

'New Patient' qualifications were not met.

Start: 01/01/1995  

B20

Procedure/service was partially or fully furnished by another provider.

Start: 01/01/1995  

B23

Procedure billed is not authorized per your Clinical Laboratory Improvement Amendment (CLIA) proficiency test.

Start: 01/01/1995  

 

*Note: Group Codes “CO”, “OA” and “PI” should be reported as provider responsibility in this report.

 

[1] Denial percentages are based on submitted billed charges to the payer. Member percentage and provider percentage should equal 100 percent of denied services.

 

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