Provider FAQ: PES Claim Denial Logic

1. CARC code 226 – Information requested from the billing/rendering provider was not provided or was insufficient/incomplete.
2. RARC code N831 – You have responded to requests to revalidate your provider/supplier enrollment information.

No, CARC 226 is utilized for both educational and denial edits.

No claims are set to deny until the initial date of service.

1. Edit 341 - If a re-enrollment on a Billing Provider is not complete for a date of service on or after 1/1/23, the edit will set with a Deny status.
2. Edit 614 - If a re-enrollment on a Rendering Provider Identifier is not complete for a date of service on or after 1/1/23, the edit will set with a Deny status.
3. Edit 617 - If a re-enrollment on an Other Provider Identifier is not complete for a date of service on or after 1/1/23, the edit will set with a Deny status.
4. Edit 670 - If a re-enrollment on an Attending Provider Identifier is not complete for a date of service on or after 7/1/23, the edit will set with a Deny status.

Edits 341, 350, 614, 618, 619, & 670 are allowed to bypass the utilization of CARC 226 when the initial DOS is prior to 7/1/23.

If re-enrollment on a Pharmacy Number is not completed for a DOS on or after 7/1/23, the edit will be set with a deny status.

If re-enrollment on a Prescriber ID is not completed for a DOS on or after 7/1/23, the edit will be set with a deny status.

If re-enrollment on a Provider Identifier is not completed for a DOS on or after 7/1/23, the edit will be set with a deny status.

If re-enrollment on a Referring Provider Identifier is not completed for a DOS on or after 7/1/23, the edit will be set with a deny status.

If re-enrollment on an Ordering Provider Identifier is not completed for a DOS on or after 7/1/23, the edit will be set with a deny status.

If re-enrollment on a Attending Provider Identifier is not completed for a DOS on or after 7/1/23, the edit will be set with a deny status.

They are found in the Error Code Crosswalk located at https://www.lamedicaid.com/provweb1/forms/Error_Code/ERROR_CODE.pdf.

Yes, the memo is as follows: https://ldh.la.gov/assets/medicaid/PES/PES.ClaimDenialLogicMemo.pdf .