Changes to remit codes for Federally Qualified Health Centers, Rural Health Clinics and Tribal Health Centers

Starting Mar. 16, 2020, we’ll be reporting a different Explanation Code on paper remits and a different Claim Adjustment Reason Code on electronic remits for all Federally Qualified Health Centers (FQHCs), Rural Health Clinics (RHCs) and Tribal Health Centers (THCs).

We’re making this change to align with other payers, provide more clarity in our remits and eliminate the need for these providers to complete coding for the use of an additional Remittance Advice Remark Code.

What’s changing?

Today, we use the following codes:

Paper remit

  • Q11 – No compensation-reporting only

Electronic remit (835)

Claim Adjustment Reason Code (CARC)

  • 96 – Non-covered charge(s). At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.)

Remittance Advice Remark Code (RARC)

  • N59 – Alert: Please refer to your provider manual for additional program and provider information

Starting Mar. 16, 2020, we will no longer be using the codes listed above. Instead FQHC, RHC and THC providers will see the following codes on their remits:

Paper remit

  • R38 – Service not separately payable

Electronic remit (835)

Claim Adjustment Reason Code (CARC)

  • 97 – The benefit for this service is included in the payment/allowance for another service/procedure that has already been adjudicated. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.