Claims Processing Edit Updates Effective May 12, 2014

4/17/2014 12:15:51 PM

We would like to inform you of changes to our PacificSource Community Solutions’ claims processing edits that will take effect May 12, 2014.

We are currently updating our claims system to utilize Medicaid NCCI edits for our Community Solutions claims. These edits will be applied to ALL claims received on or after May 12, 2014.

Examples of edits include but are not limited to:

  • Medically Unlikely Edits (MUE) will prompt a:
    • Claims adjustment reasoning code (CARC) of 50 with a message: "Non-covered srvcs as not deemed a med necessity"
    • Remittance advice remark code (RARC) of N362 with a message: "The # of days/units exceeds our maximum"
  • Procedure To Procedure (PTP) edits will prompt a 236 CARC with a message: "PTP NCCI EDIT"

If you receive one of these edits on a remit, please review the coding and/or the Medicaid.gov website for the most recent NCCI edits before appealing the denial. The files can be found at http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Data-and-Systems/National-Correct-Coding-Initiative.html.


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