The Health Insurance Portability and Accountability Act of 1996 (HIPAA) mandates that all health plans (ie, Medicare, state Medicaid programs, and commercial payers), health care clearinghouses, and certain other health care providers conduct standard electronic transactions using valid standard codes.

In January 2009, the Department of Health and Human Services published modifications to HIPAA and adopted updated versions of the standards for electronic transactions. By January 1, 2012, electronic claim submission software must be 5010 compliant (an update from the current 4010 standard).

Be aware of the revised and new Claim Adjustment Reason Codes (CARCs) and Remittance Advice Remark Codes (RARCs).

CARCs reflect the reason that a line item or claim was paid differently from how it was billed because of specific payment policies. For example, code 50 advises the biller that a service is non-covered because the payer considers it not medically necessary. The Medicare remittance advice will include...

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