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Routine: BARADJRF

BARADJRF.m

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BARADJRF  ;IHS/SD/POT - CREATE ENTRY IN A/R EDI STND CLAIM ADJ REASON ;

 ;;1.8;IHS ACCOUNTS RECEIVABLE;**28**;OCT 26, 2005;Build 92

 ;vc; Version BARADJR10.INT/BAR.1  Date 07-Mar-17  By User  Location BAR$M

 ;vc; Component name INT.BARADJR10  Routine name: BARADJR10

 ; IHS/DIT/CPC HEAT326081 - V1.8 P28 - updated SARs

 ; Continuation of BARADJRL

 ;

EN ; EP

 ; Update A/R EDI Stnd Adj Reason Descriptions

 S BARD=";;"

 S BARCNT=0

 D BMES^XPDUTL("A/R EDI STND CLAIM ADJ REASONS Phase 2...")

 F  D UPDSTND2 Q:BARVALUE="END"

 K DIC,DA,X,Y,DIE

 D ^BARVKL0

 Q

 ; ********************************************************************

UPDSTND2 ;

 S BARCNT=BARCNT+1

 S BARVALUE=$P($T(@1+BARCNT),BARD,2,6)

 Q:BARVALUE="END"

 K DIC,DA,X,Y,DIE

 S DA=0

 S DA=$O(^BARADJ("B",$P(BARVALUE,BARD),DA))

 Q:+DA<=0

 S DIE="^BARADJ("

 S DR=".02///^S X=$E($P(BARVALUE,BARD,2),1,80);101///^S X=$E($P(BARVALUE,BARD,5),1,200)"

 D ^DIE

 D MES^XPDUTL($P(BARVALUE,BARD)_$S($L($P(BARVALUE,BARD))=2:"   ",$L($P(BARVALUE,BARD))=1:"    ",1:"  ")_$E($P(BARVALUE,BARD,2),1,65))

 Q

 ; ********************************************************************

 ; STND CODE ;; SHORT DESC ;; RPMS CAT ;; RPMS TYP ;; LONG DESC

 ; ********************************************************************

1 ;;DIC="^BARADJ("

 ;;1;;Deductible Amount;;13;;29;;Deductible Amount

 ;;2;;Coinsurance Amount;;14;;602;;Coinsurance Amount

 ;;3;;Co-payment Amount;;14;;27;;Co-payment Amount

 ;;4;;Procedure code is inconsistent with modifier used or a req modifier is missing;;4;;604;;The procedure code is inconsistent with the modifier used or a required modifier is missing.

 ;;5;;Procedure code/type of bill is inconsistent with the place of service;;4;;605;;The procedure code/type of bill is inconsistent with the place of service. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

 ;;6;;The procedure/revenue code is not consistent with the patient's age;;4;;606;;The procedure/revenue code is inconsistent with the patient's age. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

 ;;7;;Procedure/revenue code is not consistent with the patient's gender;;4;;607;;The procedure/revenue code is inconsistent with the patient's gender. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

 ;;8;;Procedure code is not consistent with the provider type/specialty;;4;;608;;The procedure code is inconsistent with the provider type/specialty (taxonomy).

 ;;9;;Diagnosis inconsistent with patient's age;;4;;609;;The diagnosis is inconsistent with the patient's age. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

 ;;10;;Diagnosis inconsistent with patient's gender;;4;;610;;The diagnosis is inconsistent with the patient's gender. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

 ;;11;;Diagnosis inconsistent with procedure;;4;;611;;The diagnosis is inconsistent with the procedure. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

 ;;12;;Diagnosis inconsistent with provider type;;4;;612;;The diagnosis is inconsistent with the provider type. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

 ;;13;;The date of death precedes the date of service;;4;;613;;The date of death precedes the date of service.

 ;;14;;The date of birth follows the date of service;;4;;614;;The date of birth follows the date of service.

 ;;15;;Auth # missing, invalid, or does not apply to billed svc or prv;;4;;615;;The authorization number is missing, invalid, or does not apply to the billed services or provider.

 ;;16;;Claim/service lacks information/has submission/billing error(s).;;4;;616;;Claim/service lacks information or has submission/billing error(s).

 ;;17;;Requested info not provided or insufficient/incomplete;;4;;617;;Requested information was not provided or was insufficient/incomplete. At least one Remark Code must be provided.

 ;;18;;Duplicate claim/service;;3;;135;;Exact duplicate claim/service (Use only with Group Code OA except where state workers' compensation regulations requires CO)

 ;;19;;Work related injury/illness-liability of Work Comp Carrier;;4;;619;;This is a work-related injury/illness and thus the liability of the Worker's Compensation Carrier.

 ;;20;;Injury/illness is covered by the liability carrier;;4;;620;;This injury/illness is covered by the liability carrier.

 ;;21;;Injury/illness is the liability of the no-fault carrier;;4;;621;;This injury/illness is the liability of the no-fault carrier.

 ;;22;;Care may be covered by another payer per coord of benefits;;4;;622;;This care may be covered by another payer per coordination of benefits.

 ;;23;;The impact of prior payer(s) adjudication including payments and/or adjustments;;4;;623;;The impact of prior payer(s) adjudication including payments and/or adjustments. (Use only with Group Code OA)

 ;;24;;Charges covered under cap agreemnt/managed care;;4;;624;;Charges are covered under a capitation agreement/managed care plan.

 ;;25;;Payment denied. Stop loss deductible has not been met;;4;;625;;Payment denied. Your Stop loss deductible has not been met.

 ;;26;;Expenses incurred prior to coverage;;4;;626;;Expenses incurred prior to coverage.

 ;;27;;Expenses incurred after coverage terminated;;4;;627;;Expenses incurred after coverage terminated.

 ;;28;;Coverage not in effect at the time the service was provided;;4;;628;;Coverage not in effect at the time the service was provided. Notes: Redundant to codes 26 & 27

 ;;29;;The time limit for filing has expired;;4;;134;;The time limit for filing has expired.

 ;;30;;Payment adjusted-patient not met required elig, spend down, wait, or res reqmnts;;4;;630;;Payment adjusted because the patient has not met the required eligibility, spend down, waiting, or residency requirements.

 ;;31;;Patient cannot be identified as insured;;4;;166;;Patient cannot be identified as our insured.

 ;;32;;Our records indicate patient is not an eligible dependent;;4;;632;;Our records indicate the patient is not an eligible dependent.

 ;;33;;Insured has no dependent coverage;;4;;633;;Insured has no dependent coverage.

 ;;34;;Insured has no coverage for newborns;;4;;17;;Insured has no coverage for newborns.

 ;;35;;Lifetime benefit maximum has been reached;;4;;167;;Lifetime benefit maximum has been reached.

 ;;36;;Balance does not exceed co-payment amount;;4;;636;;Balance does not exceed co-payment amount.

 ;;37;;Balance does not exceed deductible;;4;;637;;Balance does not exceed deductible.

 ;;38;;Services not provided or authorized by designated (network) providers;;4;;638;;Services not provided or authorized by designated (network/primary care) providers.

 ;;39;;Services denied at the time authorization/pre-certification was requested;;4;;639;;Services denied at the time authorization/pre-certification was requested.

 ;;40;;Charges do not meet qualifications for emergent/urgent care;;4;;640;;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.

 ;;41;;Discount agreed to in Preferred Provider contract;;4;;168;;Discount agreed to in Preferred Provider contract.

 ;;42;;Charges exceed our fee schedule or maximum allowable amount;;4;;21;;Charges exceed our fee schedule or maximum allowable amount. (Use CARC 45)

 ;;43;;Gramm-Rudman reduction;;4;;643;;Gramm-Rudman reduction.

 ;;44;;Prompt-pay discount;;4;;644;;Prompt-pay discount.

 ;;45;;Charges exceed fee schedule/max allow or contracted/legislated fee arrangement;;4;;645;;Charge exceeds fee schedule/maximum allowable or contracted/legislated fee arrangement.

 ;;46;;This (these) service(s) is (are) not covered;;4;;122;;This (these) service(s) is (are) not covered. Notes: Use code 96.

 ;;47;;This (these) diagnosis(es) is (are) not covered, missing, or are invalid;;4;;647;;This (these) diagnosis(es) is (are) not covered, missing, or are invalid.

 ;;48;;This (these) procedure(s) is (are) not covered;;4;;648;;This (these) procedure(s) is (are) not covered. Notes: Use code 96.

 ;;49;;Routine service done in conjunction with another routine/preventative exam;;4;;20;;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.

 ;;50;;Payer considers services not medically necessary;;4;;169;;These are non-covered services because this is not deemed a 'medical necessity' by the payer.

 ;;51;;Services are not covered due to a pre-existing condition;;4;;19;;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.

 ;;52;;Ref/prescrib/render/Prv not eligible to ref/prescrib/order/perform svc billed;;4;;178;;The referring/prescribing/rendering provider is not eligible to refer/prescribe/order/perform the service billed.

 ;;53;;Services by an immediate relative/member of the same household are not covered;;4;;653;;Services by an immediate relative or a member of the same household are not covered.

 ;;54;;Multiple physicians/assistants are not covered in this case;;4;;654;;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.

 ;;55;;Claim/svc denied. Proc/treatment considered experimental by the payer;;4;;655;;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.

 ;;56;;Procedure has not been proven to be effective by the payer;;4;;656;;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.

 ;;57;;Payment denied/reduced-doc not support level/#/length of svc/dosage/day's supply;;4;;657;;Payment denied/reduced because payer deems info submitted does not support level of service, this many services, length of service, dosage, or this day's supply.

 ;;58;;Treatment rendered inappropriate or invalid date of service;;4;;658;;Treatment was deemed by the payer to have been rendered in an inappropriate or invalid place of service.

 ;;59;;Charges adjusted-multiple surgery rules/concurrent anesthesia rules;;4;;659;;Processed based on multiple or concurrent procedure rules. (For example multiple surgery or diagnostic imaging, concurrent anesthesia.)

 ;;60;;Charges for outpat svcs w/this proximity to inpat svcs not covered;;4;;660;;Charges for outpatient services are not covered when performed within a period of time prior to or after inpatient services.

 ;;61;;Charges adjusted-penalty for failure to obtain second surgical opinion;;21;;661;;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.

 ;;62;;Payment denied/reduced-absence of/exceeded, pre-certification/authorization;;15;;662;;Payment denied/reduced for absence of, or exceeded, pre-certification/authorization.

 ;;63;;Correction to a prior claim;;4;;663;;Correction to a prior claim.

 ;;64;;Denial reversed per Medical Review;;22;;664;;Denial reversed per Medical Review.

 ;;65;;Procedure code was incorrect. This payment reflects the correct code;;4;;665;;Procedure code was incorrect. This payment reflects the correct code.

 ;;66;;Blood Deductible;;13;;666;;Blood Deductible.

 ;;67;;Lifetime reserve days;;4;;667;;Lifetime reserve days. (Handled in QTY, QTY01=LA)

 ;;68;;DRG weight;;16;;93;;DRG weight. (Handled in CLP12)

 ;;69;;Day outlier amount;;4;;669;;Day outlier amount.

 ;;70;;Cost outlier - Adjustment to compensate for additonal costs;;4;;670;;Cost outlier - Adjustment to compensate for additional costs.

 ;;71;;Primary Payer amount;;4;;165;;Primary Payer amount. Notes: Use code 23

 ;;72;;Coinsurance day;;14;;672;;Coinsurance day. (Handled in QTY, QTY01=CD)

 ;;73;;Administrative days;;4;;673;;Administrative days.

 ;;74;;Indirect Medical Education Adjustment;;4;;674;;Indirect Medical Education Adjustment.

 ;;75;;Direct Medical Education Adjustment;;4;;675;;Direct Medical Education Adjustment.

 ;;76;;Disproportionate Share Adjustment;;4;;676;;Disproportionate Share Adjustment.

 ;;77;;Covered days;;4;;677;;Covered days. (Handled in QTY, QTY01=CA)

 ;;78;;Non-Covered days/Room charge adjustment;;4;;678;;Non-Covered days/Room charge adjustment.

 ;;79;;Cost Report days;;4;;679;;Cost Report days. (Handled in MIA15)

 ;;80;;Outlier days;;4;;680;;Outlier days. (Handled in QTY, QTY01=OU)

 ;;81;;Discharges;;4;;681;;Discharges.

 ;;82;;PIP days;;4;;682;;PIP days.

 ;;83;;Total visits;;4;;683;;Total visits.

 ;;84;;Capital Adjustment;;4;;684;;Capital Adjustment. (Handled in MIA)

 ;;85;;Patient interest amount;;4;;685;;Patient Interest Adjustment (Use Only Group code PR) Notes: Only use when the payment of interest is the responsibility of the patient.

 ;;86;;Statutory Adjustment;;4;;686;;Statutory Adjustment. Notes: Duplicative of code 45.

 ;;87;;Transfer amount;;4;;687;;Transfer amount.

 ;;88;;Adj amt represents collection against receivable created in prior overpayment;;21;;688;;Adjustment amount represents collection against receivable created in prior overpayment.

 ;;89;;Professional fees removed from charges;;4;;689;;Professional fees removed from charges.

 ;;90;;Ingredient cost adjustment;;4;;690;;Ingredient cost adjustment. Usage: To be used for pharmaceuticals only.

 ;;91;;Dispensing fee adjustment;;3;;691;;Dispensing fee adjustment.

 ;;92;;Claim Paid in full;;22;;692;;Claim Paid in full.

 ;;93;;No Claim level Adjustments;;22;;693;;No Claim level Adjustments. Notes: As of 004010, CAS at the claim level is optional.

 ;;94;;Processed in excess of charges;;16;;694;;Processed in Excess of charges.

 ;;END