SoonerCare claim adjustment codes under review

Posted on: 6/14/17

The Oklahoma Health Care Authority (OHCA) is working with OHA and a workgroup of three hospital systems to revamp the SoonerCare (Medicaid) claim adjustment reason codes for claim denials and claim line-item denials.

Payers use HIPAA-standard claim adjustment reason codes in electronic remittance advice files to communicate the reason for denied or adjusted health care claims or claim line items.

OHCA made some changes in their claim adjustment reason codes in 2016, but often reports just a general denial code “A1” in remittance files. This code does not explain the specific reason for their denial of payment for the claim or line item. As a result, providers must frequently make inquiries to find the specific problems resulting in nonpayment. More specific reason codes should allow providers to automate their claim follow-up and correction processes.

OHCA and the workgroup will individually review OHCA’s use of claim adjustment reason codes. Preliminary reviews indicate that changes may be significant. Providers will be able to review and test the changes in claim adjustment reason codes before these are implemented later in 2017. (Rick Snyder)

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