SoonerCare claim adjustment changes coming

Posted on: 4/4/18

Hospitals and other Oklahoma Medicaid providers should soon find it easier to understand and process SoonerCare claim denial and adjustment reasons.

After April 7, electronic remittance advice (835) files for SoonerCare payments will include additional claim adjustment reason codes (CARCs) and/or remittance advice remark codes (RARCs). Prior to this change, SoonerCare 835 files included only a single CARC for an adjustment or denial, and it was often not specific about the reason for the claim adjustment.  

A workgroup created by OHA with representatives from the Oklahoma Health Care Authority (OHCA), Mercy, INTEGRIS, and SSM/St. Anthony agreed last year on a number of changes in the CARCs reported for common SoonerCare adjustments. But OHCA’s 835 files reported only one CARC, and it was usually a generic code that provided no information about the actual reason for the adjustment.  

To report multiple CARCs, OHCA will begin splitting the dollar amount of the adjustment into approximately equal amounts for each CARC, to a maximum of six. This change will be effective with payments made after April 7, 2018.

These electronic remittance advice changes will give providers more specific information needed to process adjustments or correct claims, reducing research and phone calls to OHCA. OHCA will consider making further revisions to the CARCs and RARCs they use, if appropriate. (Rick Snyder)

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