CurrentModa HealthPolicy N/A

Claim Adjustment Reason Codes (CARCs) and Explanation Codes (EXCD) — Remittance & Adjudication Guidance

Defines Health Care Claim Adjustment Reason Codes (CARCs), associated explanation codes (EXCD), and descriptions used by Moda Health for adjudication and remittance advice; applies to providers submitting claims to Moda Health.

Policy Summary

PayerModa Health

PolicyClaim Adjustment Reason Codes (CARCs) and Explanation Codes (EXCD) — Remittance & Adjudication Guidance

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJan 1, 1995

Next Review DateN/A

Key ActionIf a required modifier is missing or invalid for a billed procedure, correct and resubmit the claim with the proper modifier(s) (telemedicine claims require POS 02 plus telemedicine modifier).

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

~120Distinct EXCD entries shown

20+Distinct CARC sections

ModifiersModifier/procedure conflicts

EligibilityEligibility/coverage-not-in-effect codes

IncludesMedicare/Medicaid-specific notes

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Coverage rules, edits, and adjudication criteria

inv-01: Coverage edits and restrictions

Age, gender, diagnosis, procedure, place-of-service, and provider-type edits affect coverage/allowance as indicated by EXCD codes.

The procedure or revenue code must be consistent with the member's age; services may be not covered or restricted for specific age ranges (examples: not covered for members under age 3, under age 16, covered only under age 19).

See EXCD series 9E3–9E8, DP0, N15, N16, S8 for age-based restrictions.

The procedure code must be consistent with the member's gender; gender conflicts or sex-designated procedure mismatches will be disallowed.

See EXCD entries describing gender conflicts (w83, y30, z13).

Place of service (POS), procedure code and/or modifier must be appropriate and consistent; invalid or inappropriate POS will cause denial or require resubmission (telemedicine requires proper POS/modifier).

See EXCD place-of-service inconsistency and invalid POS entries (z64, XI7, XH0–XH3).

Provider type and provider participation affect coverage; services performed by non-covered provider types or outside participating programs may be denied or require rebilling to another payer.

See EXCD provider-type/provider specialty restrictions (31M, 62M, 7A5, 98M, u08).

Diagnosis/procedure pairing and specificity requirements must be met; missing or invalid diagnosis codes may trigger edits requiring corrected resubmission.

See EXCD diagnosis-related edits (n90, w87–w92).

inv-02: Claim edit remediation guidance

Common claim-edit conditions and required actions include:

NDC issues: missing, invalid, deactivated, or mismatched NDCs will require resubmission with a valid NDC and proper units/quantity.

See EXCD examples for NDC edits (112, 114, 583, 584).

Procedure/CPT/HCPCS issues: missing, invalid, deleted, or codes not valid for the plan require corrected resubmission with an appropriate procedure code.

See EXCD examples for invalid procedure codes (XA1, XA2, z11, z12).

Diagnosis edits: missing, incomplete, invalid, or unacceptable principal/secondary diagnosis codes must be corrected and resubmitted.

See EXCD diagnosis edits (n90, w87, w89–w92).

Patient demographic or claim-format errors (missing gender, DOB, account ID, invalid date spans) require correction and resubmission.

See EXCD patient data/form edits (w97, w98, y01, y03, t53).

inv-03: Coverage stance by code

Examples of coverage/coordination and non-coverage conditions indicated by codes in this segment:

Work/Third-party liability: Work-related injuries/illnesses or services payable by third-party liability are not covered by the plan; submit to Workers' Compensation, auto carrier, or other primary payer as applicable.

See EXCDs 67M, 6M7, 07M, 153, 154, 155, z74.

Coordination of Benefits: Primary carrier information or primary EOB is required for COB adjudication; claims will be held/adjusted until primary payer information is received.

See EXCDs 57M, 73P, 74M, CBI, CBN.

Provider enrollment/acceptance: Payment may be reduced or disallowed when the provider is not enrolled, does not accept assignment, or is not participating (may limit payment to emergent/urgent care only).

See EXCDs 57N, 57O, 57U, 528, 529, 5M4.

inv-04: Claim adjustment and payment rationale entries

Explanations indicating reasons for claim adjustment, denial, or payment limits include:

Coverage based on Medicare allowed amount or contractual pricing adjustments may reduce provider payment (provider discount applied; charges exceed allowed/contracted amount).

See EXCDs 526, 9A6, 9A8, PAA/PAP, PFU/PFV/PFW.

When timely filing or billing deadlines are not met, claims may be adjusted or denied for late submission.

See EXCD TF1 (timely filing).

Where no APC/Fee schedule rate or pricing information exists, the claim may be unpriced or require alternate pricing submission (may result in hold or denial).

See EXCD PAG/PAH/PAG/783 (unable to price/APC rules).

Certain services are non-covered for the diagnosis or considered excluded by Medicare/statute; prior member notification/documentation may be required before billing the member.

See EXCDs 563, 9F3, 999.

inv-05: PPO/network payment messages

Claim adjustment messaging indicating payment handled per PPO/network contracts

Claims priced or paid according to negotiated PPO/network contracts will include EXCD entries indicating the applicable network; payment and patient responsibility may be determined by that contract.

See EXCD W3C–W96 series (e.g., W3C, W3D, W92, W87) and contact for contract disputes (866.295.0770).

inv-06: Adjudication stance by reason code

Statements in this excerpt identify services that are non-covered or reduced based on reason codes and edits.

Services not meeting medical necessity criteria will be denied (CARC 50 series; EXCD facets indicate consultant review or medical necessity not established).

See CARC 50 and EXCD facets 05M/05R/0M2 and 73K/73L.

Experimental or investigational services are not covered; claims are denied to provider and member should not be billed.

See CARC 55 and EXCD facets N10, Z01, z80.

Assistant/co-surgeon/team modifiers and related reductions require documentation or may trigger payment reduction per Medicare guidance.

See EXCD z65 and CARC 45/54 guidance.

Invalid or inappropriate place of service will result in denial or request to resubmit with correct POS/diagnosis.

See CARC 58 and EXCD XH0–XH3, 992.

inv-07: Coverage examples and non-coverage reasons

Select non-coverage and coverage-limit examples from CARC/EXCD explanations

Experimental/investigational services: not covered and denied; do not bill the patient.

See EXCD 9I1 and related 55-series entries.

Services not proven effective per payer or failing consultant review are non-covered; consult 835 Service Payment Information REF if present.

See CARC 56 and EXCD 814/73K/73L.

Dental frequency and benefit limits: examples include fluoride once every six months through age 18, prophylaxis and bitewing x-rays limited to specific intervals, and complete series x-rays limited to multi-year intervals.

See EXCDs 809, 810, 811 and related dental frequency facets.

inv-08: Coverage determinations and billing rules (excerpt)

Explanations indicating coverage determinations or exclusions for specific services and situations.

Certain dental services are explicitly excluded or limited (examples: implants/implant-related services not covered or limited; sealant repairs not covered; full mouth debridement not covered within 24 months of prophylaxis).

See EXCDs indicating implant and exclusion rules (various 9J*/809/83D/85A/85B).

Some services are included in other payments or considered bundled/incidental and are not separately reimbursable (e.g., biopsy with surgery, tooth preparation and temporary treatment included in restoration payment).

See EXCDs 2M0, 503, 512, 707, 709, 820, 821, 837, 997.

Coverage exclusions or limits may be plan- or county‑specific (examples: services not covered under Lane County contract; primary care dentist requirement).

See EXCD 80P and related contract-specific facets.

inv-09: Dental billing/edit criteria

Common coverage/billing criteria and edits in this section:

Bundling/inclusion: many services and miscellaneous charges are included in base or related service payments and are not eligible for separate reimbursement.

See EXCDs 707, 709, 71D, 71E, 71F, 997 and related entries.

Timing and replacement limits: repairs, replacements, retreatments and follow-up care commonly limited to defined time windows (examples: within 6, 12, 24 months; some items limited to once every 2 years or per lifetime).

See EXCDs 9H0, 9G2, 9G6, 9JJ and replacement frequency guidance.

Same-day and component restrictions: services performed on the same day as related procedures may be considered part of the primary procedure and not separately billable.

See EXCDs 70R, 70S, 71D, 71E and global package guidance.

Imaging and diagnostic inclusions: capture and reading of imaging and certain diagnostic aids are included in imaging fees; specific x-ray series rules apply (e.g., 60-day complete series logic).

See EXCD imaging inclusions and x-ray series rules (82T, 9F9).

inv-10: Bundling, global period, frequency, and duplicate billing rules

Rules indicating when a service is considered part of another service and therefore not separately reimbursable or limited by frequency/timeframe.

Included-in-primary: services identified as part of another procedure on the same date are bundled into the primary procedure's payment and are not separately payable unless qualifying modifier/documentation is present.

See EXCDs t11, n44, 9I8, 9I9, D0B–D0D.

Frequency limits: certain services are limited by specific timeframes (examples: implant cleaning limited to once every 2 years; periodontal scaling within 24 months considered part of initial treatment; deep cleaning of an implant allowed only once same day).

See EXCDs 9JJ, 9JE–9JH, D0J and related frequency facets.

Global periods: E/M services and other codes billed during a surgical global postoperative period (0, 10, 90 days) by the same provider are generally included in the global fee and not separately reimbursable without appropriate modifiers and documentation.

See EXCDs WGC, WHB, XB4 and global packaging remarks.

Duplicate billing: duplicate or multiple submissions for the same procedure/date may be denied or combined into a single allowed amount.

inv-11: Claim adjudication and bundling/denial criteria

Adjudication rules and common denial/bundling reasons reflected as EXCD facets:

Global period edits: surgical codes submitted within the global period by the same provider will be disallowed unless a qualifying modifier and supporting documentation justify separate payment.

See EXCD n37, n45, n41 and related global-period facets.

Component bundling: procedures identified as components of another procedure on the same date are bundled; separate payment is not allowed unless a qualifying NCCI modifier is present.

See EXCD n44, n46, n64, t11, t14.

Unbundling/NCCI: procedure codes unbundled per Medicare/Medicaid NCCI edits are disallowed unless policy allows separate payment.

See EXCD n51, n52, n58 and references to NCCI guidance.

Add-on code requirements: add-on or secondary codes require the primary code to be billed on the same date; missing primary code will result in add-on code violation and denial.

See EXCD guidance for add-on/qualifying primary code (107 series; example CPT add-on 33225).

inv-12: EXCD-based coverage limits and billing instructions

Selected examples of coverage limits and conditions from EXCD codes:

Service frequency limits: items limited to one per specified time period (examples: removable partial dentures once in five years; dentures once in ten years; certain restorations limited to 36 months).

See EXCDs 80O, 8B5, 8B3, 822 and related facets.

Per-tooth and lifetime limits: services may be limited per tooth or per lifetime (examples: limited to once per lifetime per tooth space; implant maximums tracked per lifetime).

See EXCDs 18D and implant maximum guidance (90D/971 examples).

Service maximums per benefit period: therapy, hearing, home health, and other service maximums are represented by L-series EXCDs and indicate benefit exhausted for the period.

See EXCDs L46–L59 and associated L-series entries.

Billing/redirection instructions: certain services must be billed to alternate payers or contractors (e.g., VSP for routine vision, Original Medicare for hospice, GOBHI for behavioral health); rebilling to correct entity required.

inv-13: Adjudication code-to-action mappings

Common adjudication outcomes and the EXCD codes used to represent them:

Maximums met: when a service or benefit maximum for the benefit period or lifetime is reached, L-series EXCDs (e.g., L46–L59, L5A) indicate the maximum has been met and benefits are exhausted.

See EXCDs L46–L59, L5A.

Units exceeded/quantity limits: if billed units exceed allowed maximums per day or period, EXCDs such as 89A–89C and PS2 indicate units over the maximum and denied units.

See EXCDs 89A, 89B, 89C and 784/846/999 for unit/benefit limits.

Contract/pricing adjustments: claims priced under negotiated contracts reference EXCD codes (e.g., 7A6, EDM) and may change allowed amount and patient responsibility.

See EXCDs 7A6, EDM and W-series network codes.

Clinical/policy denial: when clinical review finds no standard of care or insufficient support, EXCDs like 9F3 or 999 indicate no benefit and denial.

See EXCDs 9F3, 999.

inv-14: Coverage Stance Extracted from Explanation Codes

Statements in this excerpt describing when payment is limited or denied include:

Denial for lack of prior therapy or clinical history: EXCD entries indicate benefit limited when nonsurgical therapy history is absent or clinical criteria not met.

See EXCD 846 and related clinical-limitation facets.

Units or quantity limits: EXCDs denote when daily or lifetime quantity limits have been exceeded and billed units are denied.

See EXCDs 89A/89C, 89B and quantity-limit examples (N29/WGW/WGX).

Provider or participation restrictions: payment may be denied or limited when services are performed by non-covered provider types or non-participating providers.

See EXCDs 31M, 62M, 7A5, 98M indicating provider restrictions.

Coding/format issues: invalid or unsupported procedure codes or modifiers will trigger resubmission instructions and denial until corrected.

See EXCDs XA1, XA2, t64, u14, y46 and coding issue facets.

inv-15: Non-covered examples and plan-specific exclusions

Examples of services/items explicitly identified as not covered or excluded under certain plans (Medicare/ODS Advantage references present):

Non-durable medical equipment and certain supplies are not covered under specific plan variants.

See CARC 204 and EXCD 516.

Cosmetic services and supplies are not covered; cosmetic procedures are excluded from benefits.

See CARC 204 and EXCD 518.

Certain preventive, telephone consultation, transportation (non-ambulance), fertility/infertility treatments, and other items are explicitly excluded under Medicare/ODS Advantage plan variants.

See CARC 204 facets 519, 553, 546 and related exclusions.

inv-16: Authorization/UM criteria

Authorization and utilization management-related coverage reductions or denials:

Absence of required precertification, referral, or authorization will result in denial or benefit reduction; claims may be denied and providers instructed not to bill the member.

See CARC 197 and facets 040, 532, 134, 135, 81H, UM0–UM3.

Units exceeding an authorization will be reduced or denied; EXCD facets indicate reduced allowable units, unit limits exceeded, or predetermination required for non-participating providers.

See EXCDs 81T, 7M0, 198 and UM1–UM3.

When predetermination/authorization records are missing or show no authorization on file, benefits will be reduced or not allowed and instructions may indicate 'do not bill member'.

See EXCD facets 532, 135, 708 and related 197-series entries.

Code mappings, EXCD/CARC examples, and coding guidance

Examples of copayment and modifier EXCDsmixed

004	Reduced copayment
005	Increased copayment
514	Modifier billed is invalid for the procedure

Age-based coverage EXCDsmixed

9E3	This service is not covered. Not covered for members under age 16.
9E4	Covered only for members under age 19.
9E5	This service is not covered. Not covered for members under age 3.

Submission/coding error EXCDsmixed

112	Missing/incomplete/invalid/deactivated/withdrawn National Drug Code (NDC).
114	A valid NDC code is required for physician administered drugs covered by the Oregon Health Plan
117	Please resubmit with a valid CPT/HCPCS code

Selected EXCD coding explanationsmixed

EXCD 112	Missing/incomplete/invalid/deactivated/withdrawn National Drug Code (NDC).
EXCD 114	A valid NDC code is required for physician administered drugs covered by the Oregon Health Plan.
EXCD 583	The NDC submitted does not match procedure code submitted. Unable to process.
EXCD 584	NDC lacks unit(s) of measure and/or quantity.
EXCD 117	Please resubmit with a valid CPT/HCPCS code.
EXCD 118	No CPT/HCPCS code billed; revenue code requires a CPT/HCPCS code.
EXCD 140	This code is not valid for commercial plans; code specific to Medicare or Medicaid.
EXCD 741	Units billed are invalid because they are not consistent with the procedure code definition.
EXCD 785	Unable to price this service; billing requirements for APC/OPPS reimbursement not met.

Claim/explanation codesmixed

z11	Procedure code has been deleted
z12	Procedure code is missing or invalid
z16	Patient date of birth missing, invalid, or after date of service
z17	Units do not match date span between begin/end dates of service
z29	Diagnosis code on the line is invalid
z30	No primary diagnosis code
z32	Diagnosis code requires additional digits (4th/5th)
z33	Inappropriate modifier combination
z51	Procedure code not valid for Medicare
Q1	Service is a duplicate of a previously processed service or is currently in process

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Example EXCD entries for pricing/discounts/filingmixed

9A6	The charge exceeds the Delta amount allowed.
9A8	The charge exceeds the amount allowed.
PAA	The charge exceeds the contracted amount for this service.
PAP	The charge exceeds the contracted rate for this service.
PDC	Provider discount has been applied.
TF1	Timely filing not met by the provider. Claim submitted after contract time limit.

EXCD (Explanation Code) mappingsmixed

W3C	Paid according to your PPO contract with Ohio Preferred Network
W3D	Paid according to your PPO contract with Intergroup
W92	Paid according to your PPO contract with MedCost Pros MMP/MCP (contract disputes call 866.295.0770)

Examples of codes and modifiers referencedCPT | HCPCS | Modifier

C9399	Drug received FDA approval but does not have a HCPCS assigned; triggers special edit
FX/FY	Modifier indicating X-Ray radiograph on film; may reduce payment

Surgical modifiersModifier

66	Modifier 66 for surgical team; payment reduction possible
CT	Modifier CT referenced for payment reduction

Select CARCs with descriptionsmixed

55	Service is considered experimental/investigational and not covered
56	Procedure/treatment not proven to be effective by payer
58	Rendered in inappropriate or invalid place of service
59	Processed based on multiple or concurrent procedure rules

Additional CARCs and plan rulesmixed

60	Outpatient services not covered when performed within a period prior to/after inpatient services
66	Blood deductible (first 3 pints not covered per plan year)
96	Miscellaneous non-covered or plan-specific reasons (many sub-facets described)

Selected EXCD entries (dental and utilization rules)mixed

EXCD=784	Exceeds the maximum number of units for this service
EXCD=78N	Observation services beyond 48 hours are denied
EXCD=9H9	Statutorily non-covered. Medicare does not pay for this item or service
EXCD=811	Payment provided for complete series x-rays once in a three year period
EXCD=810	Benefit provided for examination, bitewing x-rays and one prophylaxis in each six month period

Representative EXCD bundling and frequency codesmixedCovered

EXCD = 707	Benefits for miscellaneous charges are included in the payment for the base rate.
EXCD = 774	Service has been determined to be part of the Global Surgical Package. No separate reimbursement can be made.
EXCD = 820	A separate, additional payment is not provided for tooth preparation, temporary treatment, bases, impressions or local anesthesia.
EXCD = 82T	Full series x-rays and single x-rays billed within 60 days are considered a complete series.
EXCD = 837	Reline is included in the amount of payment provided for the complete replacement of a denture base.
EXCD = 993	A separate, additional payment is not provided for denture adjustment and post-op care done within six months after initial placement.
EXCD = 9JJ	Cleaning an implant is limited to one time every 2 years.

EXCD/bundling code groupsmixed

9JA-9JR,9JS-9JZ,9K0-9K7,9L3-9L9,9M0-9M9	EXCD series describing services that are part of another procedure, limited frequency, or included in global fees (dental-focused examples)
N01-N05,N25,N31-N32,N50-N59	EXCD entries indicating charges considered part of a more comprehensive procedure, redundant, secondary, or combined into primary procedure
WGA-WGV,WHA-WHG,WHF	EXCD entries describing global surgical/obstetric packaging and inclusion in other payments

Add-on codes requiring primary codeCPTCovered

33225

HCPCS add-on code referenced as lacking required primary code

Examples of EXCD facet codes with limitsmixedCovered

90D	Benefits for Implants are allowed a maximum of 4 per lifetime
971	Emergency services performed by an out of network provider are limited to a $100.00 maximum benefit

Benefit maximum status codesmixed

L14	Vision service maximum has been met for this benefit period
L1A	The yearly stoploss has been met. Benefits will be paid at 100% for the remainder of this calendar/plan year

EXCD mappings for service maximumsmixedCovered

L46	Physical, Speech, Occupational Therapy service maximum has been met for this benefit period.
L50	Family Planning service maximum has been met for this benefit period.
L5A	Prescription self-injectables annual maximum has been met.

Contract/negotiated rate EXCDsmixed

7A6	Paid according to your PPO contract with PHS. For contact disputes please call 866.295.0770.
EDM	Processed with Moda Health contract #111.

Denial/unit-limit EXCDsmixedNot Covered

89A	Units billed exceed the maximum units allowed per day for this drug/medication. The units over the maximum have been denied.
999	Not Covered. No indication of failed reline or clinical stating reline would not be sufficient.

Examples of invalid/unsupported procedure codes and modifiersmixedNot Covered

XA1	Inactive or deleted CPT/HCPCS code
XA2	Invalid CPT/HCPCS code
t64	Procedure code not accepted for this plan/line of business
u14	Procedure code not accepted for this type of plan/line of business
u89	Procedure modifier invalid on date of service
y46	Modifier not in list of valid OPPS modifiers
z34	Modifier on the line is invalid

Revenue/Procedure code editsmixedCovered

199	Revenue code and Procedure code do not match; rebill with appropriate revenue code
w15	Whole blood revenue codes can only be used when billing for whole blood
y70	Observation revenue code used with HCPCS that does not represent observation service

Non-covered / excluded itemsmixedNot Covered

204	This service/expense is not covered (used for many specific exclusions and non-covered items)

inv-40: Resubmission required when — missing/invalid CPT/HCPCS or NDC codes or required documentation.

When resubmission is requiredMissing, incomplete, invalid, deactivated, or withdrawn NDC; missing or invalid CPT/HCPCS or revenue code requiring CPT/HCPCS; invalid or incomplete diagnosis (resubmit with valid primary diagnosis); lab pathology or other documentation requested; incorrect/incomplete modifiers or provider specialty information

Action to take

Required provider actions, documentation, and billing instructions

Documentation Required

Information request / resubmission actions

Claims may be returned for missing or invalid information. Common requests include: description of service/supply, valid diagnosis code, valid NDC (with unit of measure/quantity when applicable), CPT/HCPCS procedure codes, ADA codes or itemized invoices. Follow the remittance instructions and resubmit corrected claims with the requested details.

If NDC issues (EXCD 112, 583, 584) — include valid NDC, unit(s) of measure, and quantity on resubmission.
If diagnosis missing or insufficient (EXCD 109, 57I, 85M) — provide specific, valid ICD-10 code(s).
If CPT/HCPCS missing or invalid (EXCD 117/118/586/800) — resubmit with correct procedure codes or revenue/CPT pairing.
When an invoice or itemization is requested (EXCD 918) — attach invoice and any clinical documentation that supports medical necessity.

Key terms and code definitions

inv-87: Explanation Code — EXCD definition.

EXCD (Explanation Code)A short keyed code (facet) mapped to a plain‑language explanation used on remittance advices to describe the reason a claim line was adjusted, denied, or requires action

UsageEXCD facets accompany CARC entries to provide granular, human‑readable adjudication reasons and required next steps (e.g., resubmit with valid code, provide documentation)

ReferenceRefer to 835 Service Payment Information REF when present for policy or documentation linkage

inv-88: CARC — Health Care Claim Adjustment Reason Code definition.

CARC definitionHealth Care Claim Adjustment Reason Code (CARC) — numeric/group code indicating the primary reason a claim line was adjusted, denied, or reduced (examples include codes for coordination of benefits, payment limits, and denials)

Interaction with EXCD

Policy Summary

PayerModa Health

PolicyClaim Adjustment Reason Codes (CARCs) and Explanation Codes (EXCD) — Remittance & Adjudication Guidance

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJan 1, 1995

Next Review DateN/A

SourceLink

On This Page

Modifier and combination errors (invalid or missing required modifiers) require corrected claim submission with valid modifiers; some modifiers trigger documentation requirements.

See EXCD modifier/PMI guidance (PMI, 514, z33, z34).

Pre-authorization/denial:

Services denied when pre-authorization/precertification is not on file or when pre-auth requests were denied.

See EXCD 043 and related 197 series facets for absent/denied authorizations.

See EXCD duplicate/possible duplicate codes (Q1–Q3, z15, n40, x86).

See EXCD billing directives and contact info (VSP contact 1-844-693-8863; rebill examples).

Resubmit corrected claim with valid CPT/HCPCS or NDC, include requested documentation (e.g., lab/pathology, operative report), and supply valid primary diagnosis or modifier as noted

Supporting noteAt least one remark code must be provided when claim/service lacks information; refer to 835 Service Payment Information REF when present

inv-41: Per Diem / Per Case indications (PAL/PAC).

Per Diem indication (PAL)EXCD PAL = 'This is your Per Diem payment' — use when payment is per diem

Per Case indication (PAC)EXCD PAC = 'This is your Per Case rate' — use when payment is per case

Contract/pricing contextPer-case or per-diem EXCDs are used alongside contract/DRG/APC messages when claims are priced to negotiated rates or facility packages

inv-42: Token charge threshold example ($1.01).

Token charge thresholdCharge exceeds token charge ($1.01) — EXCD w18 indicates token charge exceeded

Adjudication implicationCharges above the token threshold may trigger reduced payment or additional review

Provider actionReview and correct billing to reflect nominal/zero charge when appropriate or provide justification for amounts above $1.01

inv-43: Multiple procedure reduction example — 50% reduction example.

Typical reduction amountMultiple procedure reduction examples include a 50% reduction of the allowed amount for specified multiple procedure scenarios (EXCD t19/t21/t19 series)

Applicable scenariosMultiple surgery, multiple endoscopy, multiple imaging or concurrent procedures where Medicare/CMS guidelines require reduction

Documentation requirementOperative report or supporting documentation may be required when more than 5 procedures performed or to substantiate reductions

inv-44: Dental frequency limits — fluoride, bitewing, prophylaxis frequency examples.

Fluoride frequencyBenefit provided for topical fluoride once every six months through age 18 (EXCD 809)

Bitewing x‑rays / prophylaxisBenefit provided for examination, bitewing x‑rays and one prophylaxis (including scaling and curettage) in each six‑month period (EXCD 810)

Complete series x‑raysPayment provided for complete series x‑rays (including panoramic) once in a three‑year period (EXCD 811)

inv-45: Frequency limits / units — many EXCDs denote exceeded units or frequency per time span.

Units/frequency exceededEXCDs indicate units billed exceed allowed units or frequency limits (e.g., Medically Unlikely Edits — EXCD w37/w93; Clinical daily maximum exceeded — EXCD N29)

Units per day exampleUnits billed exceed maximum units allowed per day for a drug/medication — EXCD 89A/89C denote units over maximum denied

Too many proceduresEXCDs XC0/XF5/WGX/WGW indicate total billed units or procedures exceed lifetime or medically unlikely maximums

inv-46: Replacement frequency limits — common time windows (6,12,24 months, 2 years).

Common replacement windowsReplacement/recementation limits commonly set to 6 months, 12 months, 24 months (2 years) depending on procedure (examples: recementation within 6 months considered part of initial placement — EXCD 853/156; replacement limited to 24 months — EXCD 851)

Specific examplesReplacement of crown not covered if performed within 24 months of 1st placement (EXCD 8A1); replacement of fillings not covered within 12 months (EXCD 8B1)

Reline/repair timingReline or repair within specified months after initial placement may be included in initial service and not separately payable (EXCD 837/993/8A8)

inv-47: Frequency / global period thresholds — examples of time-based thresholds.

Global period examplesE/M services billed within surgical global periods (0, 10, 90 days) are included in the global fee and not separately reimbursable (EXCD XB4/XB6/XB3) — adjust or append qualifying modifiers and documentation if separate payment claimed

Service inclusion timeframesServices performed within 6 months or 1 year after seating an implant/crown may be considered included in the initial placement (EXCD 9JN/9JO)

Periodontal thresholdPeriodontal scaling/root planing within 24 months of initial treatment is considered part of initial treatment (EXCD D0J)

inv-48: Global period/component bundling rules — Medicare/NCCI-based component rules and disallowance unless modifier documented.

Medicare/NCCI component rulesProcedures identified as components of another procedure on the same date are bundled and disallowed unless a qualifying NCCI or other modifier is present (EXCD n44/n46/y43/y44) — follow Medicare/NCCI guidance

Global package bundlingServices included in the global surgical package are not separately reimbursable (EXCD WGD/WGC/WGE) unless policy/modifier allows separate payment

Modifier documentationWhen modifier 59 or other modifier is used to report separate service, documentation is required to support medical necessity for separate payment (see provider action notes)

inv-49: Frequency and lifetime limits (examples) — once per lifetime/tooth, limits per year/benefit period.

Once-per-lifetime examplesSome services limited to once in a lifetime (EXCD 952 indicates 'Benefit limited to once in a lifetime')

Per-tooth or per-year limitsServices limited to once per tooth in five years or per specified intervals (EXCD 8C2, 977); implants limited to maximum of 4 per lifetime (EXCD 90D) or tracked per benefit year (EXCD 955)

Limits per benefit periodTherapy/service annual or benefit‑period maximums use EXCD mappings L46–L56 and L60–L69 to indicate maximums met

inv-50: units-per-day maximum — referenced denial when units exceed maximum (EXCD 89A/89C).

Units-per-day maximum denialEXCD 89A/89C indicate units billed exceed the maximum units allowed per day for this drug/medication; units over the maximum have been denied

Clinical daily maximumEXCD N29 indicates clinical daily maximum exceeded; may trigger denial or reduced payment

Lifetime and medically unlikely editsEXCDs WGW/WGX/XC0/XF5 denote lifetime maximums or medically unlikely total billed units leading to denial or request for review

inv-51: Maximum units/day or lifetime — claims may be denied when billed units exceed allowed maxima (EXCD examples).

Maximum units/day or lifetime policyClaims may be denied when billed units exceed maximum allowed per day or lifetime for medications/procedures (EXCD 89A/89B/89C; lifetime exceed indications WGW/WGX)

Examples of EXCDs usedEXCD 89A = units exceed daily maximum; EXCD 89B = patient reached maximum units for condition; EXCD WGW/WGX = billed units exceed lifetime maximum or medically unlikely totals

Provider actionIf flagged, provide authorization/clinical justification or adjust billed units to allowed maximum; rebill if appropriate

inv-52: Length of service consistency — example of ventilation hours inconsistent with span.

Length-of-service consistency exampleVentilation code 5A1955Z indicating >96 consecutive hours is inconsistent with billed discharge span of <96 hours — EXCD notes length of service not supported

Adjudication implicationIf length of service on claim does not match procedure code expectations or discharge span, claim may be adjusted or denied pending documentation

Provider actionProvide supporting medical record or correct date/span to align with procedure's required duration

Billing Rule

Requests for alternative pricing submission

Some claims must be submitted to an alternate pricing/address as directed. If the remittance indicates a third-party pricing address, follow those instructions for corrected billing.

Use the exact address shown on the remark when instructed to submit for pricing.
Do not rebill Moda when the remark directs another entity; follow the alternative payer submission instructions.

Prior Authorization

Provider registration requirement (DMAP)

DMAP registration is required for payment for certain services. Providers who receive this facet must complete the application before resubmitting claims.

Follow the URL provided on the remittance to apply (e.g., https://www.eocco.com/providers/becomeaprovider as referenced).
Claims from unregistered providers will be denied until registration is complete.

Prior Authorization

Pre-authorization denial

Claims for services without an approved pre-authorization/precertification will be denied. Do not bill the member when denial is due to lack of authorization.

EXCD 197/81H/81T: No authorization on file or units exceed authorized amount — claim denied.
EXCD 197/134/135: No record of pre-authorization from Moda Behavioral / no prior authorization — no benefits allowed; do not bill member.
When predetermination is required (EXCD 893/81D) follow the predetermination process before rendering service.

Note

EXCD code descriptions (examples)

Explanation code (EXCD) entries map to specific human-readable claim actions or limitations. Use EXCD values on remittances to identify required next steps.

EXCD W3C–W96: Paid according to specific PPO contract — contact for contract disputes if needed.
EXCD L46–L5E: Service maximums met for therapy, hearing, home health, etc. — no further benefit for period.
EXCD L12/L30/L31: Lifetime maximums reached — no further benefits available.

Note

Contract dispute contact

For contractual payment or network disputes contact the number provided on remittance. Moda references a contract-dispute contact for PPO-related payment issues.

Have claim details and remittance information available when calling.
Use the contact for PPO contract payment disputes only as indicated on the remittance.

Documentation Required

Documentation requirements for surgeon modifiers

When surgeon or global-period related modifiers are used (including modifier 59 and other significant modifiers), supporting documentation is required. Medicare guidance applies to modifier documentation and certain claims will be pended or denied without adequate justification.

If modifier 59 is billed (EXCD z14) — include documentation explaining distinct procedural service.
If services occur within a global surgical period (EXCD n37/n41/n20) — submit supporting notes, dates, and rationale; E/M services during global period require modifier and documentation.
When multiple procedures raise surgical/global edits (EXCD n15) — operative reports may be requested when >5 procedures performed on DOS.

Denial Risk

Not proven/effective

Some procedures or treatments are classified as not proven or not effective and are not covered. Check the remittance/835 policy reference segment for details and do not bill the member.

When EXCD 56 is present, refer to the 835 Healthcare Policy Identification Segment for specific policy references.
Experimental/investigational denials (EXCD 55 variants) are not payable and members must not be billed.

Billing Rule

Outpatient/inpatient timing exclusion

Outpatient services billed within restricted windows around inpatient admissions may be excluded. Verify service dates against inpatient admission/discharge to avoid denials.

If remittance references EXCD 60 or related facets, review inpatient dates and rebill with appropriate place/type of service or attach supporting documentation if outpatient services were appropriately separate.
APC/OPPS billing requirements may apply when level of care is questioned — follow rebill instructions if level of service unsupported (EXCD 150/774/776).

Billing Rule

Professional/technical component billing notes

Professional (modifier 26) and technical component billing must follow the payer rules. Claims with modifier 26 or split billing may be adjusted or denied if paired with global or mutually exclusive services.

Do not bill modifier 26 when service is not payable as a separate professional component (EXCD XJ3/XJ6/XJ7).
When professional and technical components are billed, ensure the global service rules and modifiers are correct to avoid adjustments.

Billing Rule

Plan-specific coverage limitations

Plan-specific coverage limits and noncoverage scenarios are enforced (frequency limits, provider participation, and service-specific exclusions). Review the relevant EXCD and plan guidance before rebilling.

Frequency limits (e.g., full mouth debridement, fluoride, x-ray frequency) — resubmit only if outside restricted windows.
Provider participation: Some services payable only when performed by participating or specific program providers (EXCD 122, 928).
Cosmetic exclusions: e.g., Invisalign labeled cosmetic — limited benefit (EXCD 956/958).

Documentation Required

Advance notice / member agreement (GA/GX)

Modifiers GA and GX indicate the member was notified in advance and signed an agreement to pay for noncovered services. Claims with these modifiers reflect advance notice and member agreement.

If GA/GX is present, the provider documented advance notice and member financial responsibility.
Ensure accompanying documentation of the signed agreement is retained in patient records in case of audit.

Note

Predetermination and claim review notes

Predeterminations and claim reviews carry specific caveats (timing relative to treatment, service combinations, readmission/DRG edits). Follow predetermination guidance and rebilling instructions when review results change the allowed benefit.

Predetermination valid only under specified conditions (e.g., EXCD 905: denture placed within 6 months of extraction).
If claim review changes DRG or level of care (EXCD 150/770/776), rebill per instructions; additional explanation may follow.
Services considered part of another procedure or included in an allowance should not be billed separately (EXCD N01–N05, N25, N31–N32).

Billing Rule

Adjudication actions for bundled/combined services

When multiple services are bundled or considered components of a primary procedure, payment may be reduced or combined into the primary procedure. Separate payment is not allowed for bundled components without appropriate modifiers and documentation.

Apply multiple procedure reductions where indicated (EXCD 59 series); follow ASC/Medicare guidelines for percentage reductions.
If a procedure is identified as a component of another (EXCD t11, n46, y43–y45), do not expect separate payment unless a supported modifier and documentation justify separation.
When bilateral or professional/technical reductions apply, ensure correct modifiers and documentation (EXCD WGR, n50).

Billing Rule

Redirect claims to correct payer/contractor

If remittance indicates the claim/service should be billed to a different payer, follow the redirect instructions and resubmit to the correct contractor. Do not rebill Moda when services are delegated.

EXCD 054/108: Services denied due to delegation — submit to the delegated entity or new carrier as specified.
EXCD 40E/70G/70I/70P: Mental/behavioral health claims may be paid by other vendors (e.g., ValueOptions, GOBHI); rebill to those entities.
EXCD y87: Item can only be billed to the DME Regional Carrier (status indicator Y).

Billing Rule

DME carrier billing restriction

Certain DME items are payable only through the DME regional carrier. If remittance indicates a DME-only billing restriction, rebill to the DME Regional Carrier per guidance.

Do not bill the plan when EXCD y87 appears — submit to the DME Regional Carrier.
Check HCPCS status indicators when billing DME items to ensure correct payer routing.

Note

Report service maximums reached

When service maximums for therapy, nursing, prescriptions, or other benefits have been met, claims will be denied or reduced. EXCD L-series codes identify specific service maximums reached.

EXCD L46–L49: Therapy service maximums met for benefit period — no further therapy benefit until reset.
EXCD L5A/L5B/L5D/L5E: Prescription self-injectables annual max, ambulance, skilled nursing, acupuncture/naturopath/massage maximums reached.
When maximum is reached, advise the member and do not bill the plan for additional units beyond the allowed maximum.

Note

Out-of-pocket and lifetime maximum indicators

Out-of-pocket, network, and lifetime maximums are represented by EXCD codes. When these limits are reached, no further benefits are available for the specified categories.

EXCD L2B: Lifetime major medical out-of-network maximum met — no further out-of-network benefits.
EXCD L30/L31: Dental lifetime maximum met — no further dental benefits available.
EXCD L33/L34/L35: Periodontal, TMJ, orthodontic lifetime maximums reached.

Denial Risk

Denial and unit-limit indicators

Denials and unit-limit edits use specific EXCD codes to indicate the reason (units exceeded, benefit limited, not covered, medication units over maximum). Review EXCDs and rebill with corrected units or clinical justification if appropriate.

EXCD 89A/89B/89C: Units billed exceed maximum allowed — units over max denied.
EXCD 784/150: Exceeds maximum number of units for this service — reduce units and resubmit if appropriate.
EXCD 999/9F3: Not covered or no indication that criteria met — clinical justification required for reconsideration.

Billing Rule

Rebill required for unsupported inpatient billing

If the claim's inpatient status or level of service is unsupported by submitted documentation, rebilling is required. An explanation letter or corrected claim will be requested when review finds outpatient/inpatient mismatches or unsupported inpatient billing.

EXCD 776: Records review doesn't support inpatient level — rebill as outpatient if appropriate and include supporting documentation.
EXCD 784/783: Unable to price due to missing APC/OPPS billing requirements or unit maximums — correct and rebill.
When rebilling, follow the instructions on the remittance and include any requested clinical records or attachments.

Prior Authorization

Prior authorization / Utilization Management denials

Absence of precertification, authorization, notification, or predetermination is a common cause of denial. Claims disallowed by Utilization Management will reference UM-related EXCD values — do not bill the member when the denial is due to missing authorization.

EXCD 197/UM0/UM3: Services disallowed by Utilization Management due to no authorization on file — do not bill member.
EXCD 197/UM1/UM2/81T: Units exceed or were reduced by an authorization — adjust units billed to authorized amount.
EXCD 81D/893: Predetermination required for non-participating providers or specific services — obtain prior to service to avoid denial.

CARCs are used with EXCD facets to convey detailed explanation text on remittance advices (use with Group Code OA for prior payer impact)

ExamplesCARC entries include numeric ranges for deductible, coinsurance, non‑coverage, global package, lifetime maximums, and more

inv-89: Health Care Claim Adjustment Reason Code — explanatory definition for EXCD usage.

Purpose of CARC/EXCD pairingHealth Care Claim Adjustment Reason Code plus EXCD facet indicate when a claim/service lacks information, has submission/billing errors, or requires a specific corrective action (e.g., resubmit with valid CPT/HCPCS or NDC)

Common messagesExamples include requests to resubmit with valid diagnosis, CPT/HCPCS, or supporting lab/pathology reports

Operational noteDo not use CARC 16 solely for attachments; include at least one remark code when using CARC 16

inv-90: Explanation Code — descriptive text providing reason and required action.

Explanation Code (descriptive)Short descriptive text accompanying EXCD facet conveying the reason and any required action (e.g., 'Please resubmit with valid CPT/HCPCS code', 'Lab pathology report is required')

Provider instructionExplanation Code descriptions often specify required attachments or resubmission criteria to resolve claim issues

Reference guidanceWhere present, refer to 835 Service Payment Information REF for policy linkage and additional details

inv-91: Explanation Code (EXCD) used to convey specific reason for claim line disallowance or adjustment.

EXCD as facet for disallowance/adjustmentEXCD facets are used to convey a specific, short keyed reason for claim line disallowance or adjustment and are mapped to human‑readable explanations on remittance advices

ExamplesFacets like n37, t11, u31 indicate global period, bundling, or component relationships causing disallowance

Mapping notePayer maps EXCD facets to CARC entries to provide granular adjudication reasons

inv-92: CARC - general categories describing why claim lines are adjusted, denied, or reduced.

CARC categoriesCARCs describe general adjudication categories such as deductible, coinsurance, coordination of benefits, non‑coverage, global packaging, and lifetime maximums

Use with EXCDCARCs are supplemented by EXCD facets to provide more detailed messaging on remittance advice

Example CARC actionsApply contractual allowance, deny, request additional information, or indicate rebill/redirect to another payer

inv-93: GDM / GEM — processed with ODS contract notes.

GDM / GEM mappingProcessed with ODS contract indicators (GDM/GEM) — denotes processing under specific Moda/ODS contract numbers

Operational implicationIndicates claim was adjudicated per contract terms which may affect pricing or patient responsibility

Example contractsReferences include ODS contract #111 and #999 in EXCD descriptions

inv-94: PMI — Procedure modifier combination invalid or required modifier missing.

PMI definitionProcedure modifier combination invalid or a required modifier is missing — EXCD PMI indicates modifier issues that may disallow or reduce payment

Provider actionCorrect modifier combinations or supply required modifier on corrected/resubmitted claim

ExampleEXCD PMI used alongside CARC 45 to show modifier-related payment adjustments

inv-95: EXCD — Explanation Code (facet) used for human-readable reasons referencing payment per contract.

EXCD as human-readable facetEXCD facets provide short keyed, human‑readable reasons referencing payment per contract or specific adjudication behavior (e.g., 'Paid according to your PPO contract')

Mapping to remittanceThese facets appear on remittance advices to explain how payment was determined per contract or network

ExamplesW3C/W3D/W92 indicate payment per PPO contract with named networks

inv-96: Not medically necessary / Medical Necessity definition.

Not medically necessaryServices not deemed medically necessary by the payer are non‑covered; CARC 50 and facets (e.g., 05M, u36) indicate lack of medical necessity and denial

Required referenceRefer to 835 Healthcare Policy Identification Segment (loop 2110) when present for policy basis of medical necessity determinations

Provider actionSubmit supporting clinical documentation or appeal if clinical evidence supports medical necessity

inv-97: Experimental / Investigational — definition and billing implication (not covered, do not bill patient).

Experimental / investigational statusServices deemed experimental or investigational by the payer are not covered; EXCD facets (e.g., 517, 701, 9I1) denote experimental status — do not bill the patient

Adjudication outcomeSuch services are denied to provider and marked non‑covered on remittance advice

Provider actionDo not bill patient; consider prior authorization/policy review if service has conflicting evidence

inv-98: Assistant/Co/Team Surgeon modifier requirements — need supporting documentation per Medicare guidance.

Assistant/Co/Team Surgeon modifier requirementsAssistant, co‑surgeon, or team surgeon modifiers generally require supporting documentation; Medicare guidance may disallow reimbursement without documentation (EXCD n28/n54/n57/z43/z44 etc.)

Documentation requiredOperative reports or supporting clinical documentation should be submitted to validate assistant/co/team surgeon services

Adjudication effectAbsence of required documentation may result in disallowance or payment reduction per CMS rules

inv-99: Payer-specific facet/explanation code mapped to a CARC to provide granular adjudication reason (EXCD Facets).

Payer-specific EXCD facetsPayer-specific facet/explanation codes (EXCD facets) are mapped to CARCs to provide granular adjudication reasons on remittance advices

PurposeFacets allow the payer to express plan‑specific limitations, redirections, or contract processing (e.g., rebill to other contractor) while using standard CARC categories

ExamplesFacets include directives like 'This service needs to be billed to the Oregon Health Authority' (EXCD 73E) or rebill to GOBHI for mental health (EXCD GOB)

inv-100: Multiple procedure reduction — payment adjustment applied when multiple procedures performed.

Multiple procedure reduction definitionPayment adjustment applied when multiple procedures (surgery, imaging, endoscopy) are performed — examples show reductions per Medicare/CMS including 50% reductions for certain scenarios (EXCD t19/t21/t19 series)

Applicable rulesMultiple surgery, endoscopy, imaging reductions and bilateral adjustments follow Medicare guidelines and may require operative report review

EXCD examplesEXCDs such as 056, 761, 9C9, WGQ, WGR denote allowance reduced based on multiple surgery or bilateral rules

inv-101: Bundled service — service/supply considered bundled or incidental, not eligible for separate payment.

Bundled service definitionService or supply considered bundled/incidental and not eligible for separate payment; often 'included in payment for another service' (EXCD 707/512/503/2M0)

ImplicationWhen an EXCD indicates inclusion, no separate reimbursement is available and charges are combined into primary procedure payment

ExamplesEXCD 707: miscellaneous charges included in base rate; EXCD 512/503: Medicare bundled/excluded codes

inv-102: Component of a global service — definition and implication for separate reporting.

Component of global serviceA service that is a component of a more comprehensive/global service should not be reported separately and is included in the global payment (EXCD 709/70R/70S)

Global package implicationGlobal surgical/obstetric packaging means certain visits, E/M or related services are included in the global fee and not separately payable (EXCD WGD/WGC/WGE)

Provider actionIf billing separately during global period, include qualifying modifier and supporting documentation to justify separate payment

inv-103: EXCD — adjudication text describing bundled/limited/excluded/included services.

EXCD adjudication text roleEXCD entries describe why a service is bundled, limited, excluded, or included in another payment; they provide plain‑language adjudication text on remittances

Examples of usesUsed to indicate time‑window inclusions (e.g., reline included in replacement), global package inclusion, and frequency limits

Operational noteEXCD facets should be read with the CARC to determine required provider action (deny, resubmit, document)

inv-104: Global surgical package — definition.

Global surgical package definitionGlobal surgical package: grouping of services/visits included in a single global fee for the surgical episode (includes pre‑op, intra‑op, post‑op as defined by 0/10/90 day packages)

Payment implicationServices within the global package are not separately reimbursable; EXCD facets (WGD/WGC/WGF/XB4 etc.) denote these rules

Billing guidanceE/M services billed during global period by same provider are disallowed unless appropriate modifier and supporting documentation justify separate payment

inv-105: Bundled/incidental service — definition reiterating non-separate payment status.

Bundled/incidental service definitionA service or supply included in payment for another procedure and not separately payable to the provider or patient (EXCD examples 71D, 9JV, 9JL)

Frequency/timeframe examplesCleaning an implant limited to one time every 2 years (EXCD 9JJ); many services limited by timeframes and included in initial placement for set months

Provider actionDo not bill separately when EXCD indicates included; if clinically necessary beyond limits, submit documentation for review

inv-106: Explanation Code (Facet) — short keyed reason for disallowance/bundling/review (example codes).

EXCD Facet (short keyed reason)A concise code (EXCD facet) used to indicate why a claim line was disallowed, bundled, or requires review (examples include n37, t11, u31) — shown on remittance advices

FunctionProvides quick, machine‑readable reason that maps to plain‑language explanation for providers and downstream systems

Example usagen37 indicates surgical code within global period; t11 indicates components bundled into same procedure

inv-107: Standard numeric CARC examples used for claim adjudication reasons (e.g., payment made to patient, not covered).

Standard numeric CARC examplesNumeric CARCs indicate primary adjudication reasons (examples: 100 Payment made to patient; 97 Bundled/service included; 109 Not covered by this payer — rebill to correct payer)

UsageCARCs are used on remittance advices to categorize actions such as denial, reduction, coordination of benefits, and redirection to other payers

Reference datesCARC entries include start and last modified dates to indicate effective policy timeframe

inv-108: EXCD facet code — EXCD example entry.

EXCD facet exampleEXCD facet entries provide brief keyed reasons such as 89A (units exceed daily maximum), 999 (not covered — no failed reline), 707 (misc charges included in base rate)

Remittance displayThese short EXCD facet codes appear on remittance advices mapped to readable explanations for provider action

Operational useSystems and staff should parse EXCD facets to determine whether to deny, request documentation, rebill, or redirect

inv-111: Lifetime benefit maximum — definition.

Lifetime benefit maximum — definitionA limit on the total benefits payable for a particular service or benefit category for the lifetime of the member (EXCD/L‑series and CARC descriptors indicate lifetime maximums met)

EXCD indicatorsEXCDs such as WGW/WGX or L‑series facets (L4B, L6A, L8A) indicate lifetime maximums have been met

ImplicationWhen lifetime maximum met, benefits are exhausted and claims are denied or paid as zero per plan rules

inv-112: Facets EXCD code used to map explanation code variants.

EXCD facet mapping roleFacets are used to map explanation code variants to more granular reasons for an adjustment or denial (e.g., multiple facet values under CARC 197 for authorization absence)

Operational noteFacets enable plan‑specific messaging while using standardized CARC categories on remittance advices

ExampleCARC 197 facets include 040 (Valid Referral/Pre‑auth not obtained) and UM0/UM1 indicating UM authorization issues

inv-113: Standard CARC entries with associated explanation descriptions and effective/modified dates.

Standard CARC entries with datesCARC entries include start and last‑modified dates alongside facets and explanation text to show policy effective/modified timing (several entries show Start: 01/01/1995; Last Modified examples)

PurposeDates indicate when a CARC/EXCD description became active or was last updated for adjudication reference

Example metadataMultiple CARC entries display 'Start: 01/01/1995 | Last Modified: 07/01/2017' in the document

inv-114: Explanation code facet used to provide more granular reason detail for a claim adjustment reason code.

Facet as granular reasonExplanation code facets provide granular detail for a CARC (e.g., 197 with facets 016, 018, 040 indicate various authorization-related outcomes) — used to guide provider action

Example mappingCARC 197 + EXCD 040 = Valid referral/pre‑authorization not obtained; CARC 197 + UM0 = Services disallowed by UM due to no authorization on file

Provider actionWhen facet indicates missing authorization/referral, do not bill member and seek required prior authorization or rebill as directed

inv-115: Numeric code indicating the primary reason a claim line was adjusted or denied (e.g., 197, 204).

Numeric CARC primary reasonNumeric CARCs (e.g., 197, 204) indicate the primary adjudication category such as absence of precert/authorization (197) or service not covered (204)

ExamplesCARC 197 used for 'Precertification/authorization/notification absent' with multiple EXCD facets; CARC 204 used for many explicit non‑covered items (cosmetic, non‑durable supplies, etc.)

Action guidanceRead CARC and associated EXCD facets together to determine whether to document, resubmit, redirect, or deny