Inventory of Health Care Information Standards. Health Care Claim Adjustment Reason Codes

01/01/1997

A series of standard alphanumeric codes, and messages, that detail the reason why the payer made and adjustment to the health care claim payment. These codes are used in the ANSI ASC X12 Claim (837) and Payment/Advice (835) transaction sets, and in the UB92 and NSF flat file claim and associated payment transactions.

Developing Organization

These codes are developed and maintained by the Health Care Claim Adjustment Reason Code/Claim Status Code Committee. This committee is comprised of one voting member from the following groups:

  • American Dental Association
  • American Hospital Association
  • American Medical Association
  • Blue Shield Plans
  • Blue Cross Plans
  • Commercial Health Insurance Carriers
  • Health Care Financing Administration - Medicaid
  • Health Care Financing Administration - Medicare
  • Health Insurance Association of America
  • National Council for Prescription Drug Programs
  • Property and Casualty Insurance Industry
  • American Association of Health Plans
  • Association For Electronic Healthcare Transactions (AFHECT)
  • One X12N workgroup co-chair from each affected workgroup (835, 837, 276/277)

The committee is responsible for maintaining the quality and business applicability of the code lists for an electronic data interchange environment. It's objective is to meet the business needs of the user community while eliminating redundancy in the codes. The Blue Cross and Blue Shield Association serves as Secretariat for the committee.

Contact for more information:

Frank Pokorny

Manager, Electronic Commerce and National Standards

Blue Cross and Blue Shield Association

676 North St. Clair

Chicago, IL 60611

Phone: 312-330-6223

Fax: 312-440-5674

E-mail: us993fjp@ibmmail.com

Description

A series of approximately 175 standard numeric and alphanumeric codes, and messages, that detail the reason why the payer made and adjustment to the health care claim payment. An individual code may be up to three characters long. A set of that apply equally to services, products, drugs and equipment. Codes for Medicare A have the letter "A" in the first position; Medicare B show the letter "B".

Readiness

Codes are currently in use and revisions are made thrice annually, effective on February 28, June 30 and October 31 of each year. The most recent version of the code list will be able to be applied to all versions of the ASC X12 Draft Standards, except as limited within the code lists.

Health Care Claim Adjustment Reason Codes and the Health Care Claim Status Codes are available in electronic and print formats:

Electronic file -

Washington Publishing Company World Wide Web Site

http://www.wpc-edi.com

Paper Copy -

Blue Cross and Blue Shield Association

Inter-Plan Teleprocessing Service

676 North St. Clair

Chicago, IL 60611

Indicator of Market Acceptance

Health Care Claim Adjustment Reason Code is currently in wide use within the health care community for both EDI and flat file transactions, and for both private/commercial and government programs. Codes are developed and agreed upon by committee action

Level of Specificity

A set of approximately 175 numeric and alphanumeric codes that apply equally to services, products, drugs and equipment. Codes for Medicare A have the letter "A" in the first position; Medicare B show the letter "B". Codes are available on lists in simple ascending order, and by functional groups: treatment; insurance procedural; insurance contractual; other.

Identifiable Costs

Code lists are available at no charge from either the Washington Publishing Web Site or the Blue Cross and Blue Shield Association.