Provider FAQ: PES Claim Denial Logic

Which Claims Adjustment Reason Codes (CARC) and Remittance Advice Reason Codes (RARC) will be utilized for 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.

Is CARC 226 used for just the denial edits?

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

CARC 226 is assigned to educational PES edits. When are claims set to deny?

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

How does utilizing CARC 226 for denial logic on or after January 1, 2023 effect Edits 341, 614, 617, & 670?

  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.

Which edits are allowed to bypass the utilization of CARC 226 when the initial date of service (DOS) is prior to 7/1/23?

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.

What are the specifics of the CARC 226 bypass for Edit 341 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.

What are the specifics of the CARC 226 bypass for Edit 350 when the initial DOS is prior to 7/1/23?

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.

What are the specifics of the CARC 226 bypass for Edit 614 when the initial DOS is prior to 7/1/23?

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.

What are the specifics of the CARC 226 bypass for Edit 618 when the initial DOS is prior to 7/1/23?

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.

What are the specifics of the CARC 226 bypass for Edit 619 when the initial DOS is prior to 7/1/23?

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.

What are the specifics of the CARC 226 bypass for Edit 670 when the initial DOS is prior to 7/1/23?

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.

Where can I find the implemented CARC & RARC codes and corresponding PECI edits?

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

Is there an updated PES Claim Denial Logic Memorandum with this information?

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