Denial-code cheat sheet

These are the claim adjustment reason codes MedFlow’s denial router uses, and the next step for each. Print this page for the billing desk. It is not a complete CARC manual.

CARC	What it means	Route	Next step
4	Procedure code inconsistent with the modifier used, or a required modifier is missing	Fix and resubmit	Correct the modifier and resubmit
11	Diagnosis is inconsistent with the procedure	Fix and resubmit	Coder reviews diagnosis linkage, then resubmit
16	Claim lacks information needed for adjudication	Send to clinic	Clinic supplies the missing item (e.g. referral number), then resubmit
18	Exact duplicate claim/service	Fix and resubmit	Void the duplicate; no resubmission
22	This care may be covered by another payer (coordination of benefits)	Send to clinic	Clinic confirms other insurance with the patient; bill primary first
27	Expenses incurred after coverage terminated	Bill patient	Ask patient for new coverage, otherwise bill patient
29	Time limit for filing has expired	Fix and resubmit	Appeal only with proof of timely filing; otherwise write off
50	Not deemed a medical necessity by the payer	Appeal	Appeal with clinical notes showing necessity
96	Non-covered charge	Bill patient	Bill patient if a signed waiver (ABN) is on file; Medicare covers the Annual Wellness Visit (G0438/G0439) instead
97	Payment is included in another service already adjudicated (bundled)	Fix and resubmit	Remove the bundled line or add a valid modifier, then resubmit
197	Precertification/authorization absent	Send to clinic	Clinic requests retro-authorization; then appeal

Source: the reason codes and routes in MedFlow. Payer manuals can add remark codes and exceptions. Read the remittance before you act.