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  1. FHIR Specification Feedback
  2. FHIR-26907

Replace CARIN BB Adjudication Denial Reason with X12 CARC / CMS RARC

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    • Icon: Change Request Change Request
    • Resolution: Persuasive with Modification
    • Icon: Highest Highest
    • US CARIN Blue Button (FHIR)
    • 0.1 [deprecated]
    • Financial Mgmt
    • (NA)
    • Terminology
    • Hide

      Delete CARIN Blue Button Adjudication Denial Reason Value Set

      Define Value Set:

      Defining URL: http://hl7.org/fhir/us/carin-bb/ValueSet/X12- ClaimAdjustmentReasonCodes-CMS- RemittanceAdviceRemarkCodes
      Name: X12-ClaimAdjustmentReasonCodes-CMS-RemittanceAdviceRemarkCodes
      Title: X12 Claim Adjustment Reason Codes (CARC) - CMS- Remittance Advice Remark Codes (RARC)
      Definition: The Value Set is a combination of two sets of codes:  X12 Claim Adjustment Reason Codes (CARC) and CMS Remittance Advice Remark Codes (RARC).  CARC codes describe why a claim or service line was paid differently than it was billed.  RARC codes provide additional explanation for an adjustment already described by a Claim Adjustment Reason Code (CARC) or convey information about remittance processing. 
      Use of X12 CARC codes require a license.  Reference https://x12.org/codes/.  RARC codes are available at http://www.wpc-edi.com/reference/codelists/healthcare/remittance-advice-remark-codes
      Copyright: CARC codes are owned, maintained and distributed by X12.  The Centers for Medicare & Medicaid Services (CMS) maintain Remittance Advice Remark Codes (RARC) used throughout the US health care industry.  
      Logical Definition: This value set includes codes from the following code systems:
      ·       Include all codes defined in https://x12.org/codes/claim-adjustment-reason-codes   
      ·       Include all codes defined in https://x12.org/codes/remittance-advice-remark-codes

      Bind with binding strength Required to the data elements adjudication.denialReason.reason and item.adjudication.denialReason.reason in the Inpatient Institutional and Outpatient Institutional Profiles.  Bind with binding strength Required to the slice data element item.adjudication.denialReason.reason in the Professional and Non-Clinician Profile.

      Define Code System: 

      Defining URL: https://x12.org/codes/claim-adjustment-reason-codes
      Name: X12-ClaimAdjustmentReasonCodes
      Title: X12 Claim Adjustment Reason Codes (CARC)
      Definition: CARC codes describe why a claim or service line was paid differently than it was billed.   Use of X12 CARC codes require a license.  Reference https://x12.org/codes/
      Copyright: CARC codes are owned, maintained and distributed by X12. 

      Define Code System:

      Defining URL: https://x12.org/codes/remittance-advice-remark-codes
      Name: CMS-RemittanceAdviceRemarkCodes
      Title: CMS- Remittance Advice Remark Codes (RARC)
      Definition: RARC codes provide additional explanation for an adjustment already described by a Claim Adjustment Reason Code (CARC) or convey information about remittance processing. 
      RARC codes are available at http://www.wpc-edi.com/reference/codelists/healthcare/remittance-advice-remark-codes
      Copyright: The Centers for Medicare & Medicaid Services (CMS) maintain Remittance Advice Remark Codes (RARC) used throughout the US health care industry.  
       
      Show
      Delete CARIN Blue Button Adjudication Denial Reason Value Set Define Value Set: Defining URL: http://hl7.org/fhir/us/carin-bb/ValueSet/X12- ClaimAdjustmentReasonCodes-CMS- RemittanceAdviceRemarkCodes Name: X12-ClaimAdjustmentReasonCodes-CMS-RemittanceAdviceRemarkCodes Title: X12 Claim Adjustment Reason Codes (CARC) - CMS- Remittance Advice Remark Codes (RARC) Definition: The Value Set is a combination of two sets of codes:  X12 Claim Adjustment Reason Codes (CARC) and CMS Remittance Advice Remark Codes (RARC).  CARC codes describe why a claim or service line was paid differently than it was billed.  RARC codes provide additional explanation for an adjustment already described by a Claim Adjustment Reason Code (CARC) or convey information about remittance processing.  Use of X12 CARC codes require a license.  Reference https://x12.org/codes/ .  RARC codes are available at http://www.wpc-edi.com/reference/codelists/healthcare/remittance-advice-remark-codes .  Copyright: CARC codes are owned, maintained and distributed by X12.  The Centers for Medicare & Medicaid Services (CMS) maintain Remittance Advice Remark Codes (RARC) used throughout the US health care industry.   Logical Definition: This value set includes codes from the following code systems: ·       Include all codes defined in https://x12.org/codes/claim-adjustment-reason-codes    ·       Include all codes defined in https://x12.org/codes/remittance-advice-remark-codes Bind with binding strength Required to the data elements adjudication.denialReason.reason and item.adjudication.denialReason.reason in the Inpatient Institutional and Outpatient Institutional Profiles.  Bind with binding strength Required to the slice data element item.adjudication.denialReason.reason in the Professional and Non-Clinician Profile. Define Code System:  Defining URL: https://x12.org/codes/claim-adjustment-reason-codes Name: X12-ClaimAdjustmentReasonCodes Title: X12 Claim Adjustment Reason Codes (CARC) Definition: CARC codes describe why a claim or service line was paid differently than it was billed.   Use of X12 CARC codes require a license.  Reference https://x12.org/codes/ .  Copyright: CARC codes are owned, maintained and distributed by X12.  Define Code System: Defining URL: https://x12.org/codes/remittance-advice-remark-codes Name: CMS-RemittanceAdviceRemarkCodes Title: CMS- Remittance Advice Remark Codes (RARC) Definition: RARC codes provide additional explanation for an adjustment already described by a Claim Adjustment Reason Code (CARC) or convey information about remittance processing.  RARC codes are available at http://www.wpc-edi.com/reference/codelists/healthcare/remittance-advice-remark-codes .  Copyright: The Centers for Medicare & Medicaid Services (CMS) maintain Remittance Advice Remark Codes (RARC) used throughout the US health care industry.    
    • Mark Roberts/Pat Taylor: 10-0-2
    • Correction
    • Compatible, substantive

    Description

      Ballot feedback was that the Terminology Section of the IG requires a major overall, renaming the Value Sets and Code Systems and updating links.  Following is a recommended resolution for the Adjudication Denial Reasons:

      1)  Delete Value Set CARINBBAdjudicationDenialReason

      2)  Define X12CARCCMSRARC

      3)  Title:  X12-CARC-CMS-RARC

      4) Description:  The Value Set is a combination of two Code Systems:  X12 Claim Adjustment Reason Codes (CARC) and CMS Remittance Advice Remark Codes (RARC)

      5) Value Set: http://hl7.org/fhir/us/ValueSet/x12-carc–cms-rarc

      6)  Code System URIs: 

      CARC codes are available at https://nex12.org/index.php/codes/11-claim-adjustment-reason-codes

      RARC codes are available at https://nex12.org/index.php/codes/12-remittance-advice-remark-codes

      7)  Code System Definition:

      CARC codes are owned, maintained and distributed by X12.  Use of X12 codes require licenses. 

      RARC codes are owned by CMS and are available for use. 

      8)  Bind the ValueSet with binding strength required to adjudication.reason, item.adjudication in the Inpatient Facility and Outpatient Facility Profiles

      9)  Bind the ValueSet with binding strength required to item.adjudication in the Professional and Non-Clinician and Pharmacy Profiles

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            taylorpatriciab Patricia Taylor
            Patricia Taylor
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              Updated:
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