ERA Management Rule Examples
Example 1
If you enter 253 as a CARC Rule, and a System Rule already exists for CO, the CO will take higher precedence over 253.
- Instead, enter CO253 in the CARC Rule which will take precedence over CO because it is more specific.
Example 2
- System Rule for Paid $0, Allowed $0 to send to the Denial Worklist; and
- A CARC Rule for CO18 to Post as Remitted:
- The ERA shows that the Payer Paid $0 and Allowed $0; and
- There is CO18 CARC reported on the EOB.
- It will Post as Remitted because the CO18 specific CARC rule takes precedence over the System Rule, Paid $0, Allowed $0.
Example 3
- System Rule for Paid $0, Allowed $0 to send to the Denial Worklist; and
- A CARC Rule for CO253 to Post as Remitted, and
- No rule for CO18.
- The ERA shows that the Payer Paid $0 and Allowed $0; and
- CARCs CO253 and CO18 are reported on the EOB.
- The Encounter will go to the Denial Worklist because one CARC has a rule and the other does not.
- Because the CO18 does not have a rule, the System Rule, Paid $0 and Allowed $0, takes precedence and the Encounter will be sent to the Denial Worklist.
- Each CARC Code on the Remit (with the exception of CO45 and PR codes) must have its own rule in order for the CARC Rules to override the System Rule Event.
Example 4
- System Rule for Paid $0, Allowed $0 to send to the Denial Worklist; and
- A CARC Rule for CO253 to Post as Remitted, and
- A CARC Rule for 18 (not CO18)
- Both CARCS have a Rule.
- Both Rules are in play, with the CO253 taking precedence because it is more specific.
Example 5: Competing Rules OA23 and CO279
- System Rule
- CO: Do not Post - Transfer Balance to Next Party (Non-specific)
- CO279: No specific rule
- OA: Do not Post - Transfer Balance to Next Party (Non-specific)
- MCD SEC RULE
- CO: Do not Post - Write Off Patient Balances - No Worklist (Non-specific)
- CO279: No specific rule
- OA23: Do not Post - Write Off Patient Balances - No Worklist (Specific)
The Remit will go on Hold because Non-specific CO has conflicting Rules (Transfer Balance to Next Party vs Write Off Patient Balances).
- ALL CARC codes on the Line Item must be set to the same result.
- Add CO279 to Rule Set for MCD SEC RULE and set to Write Off Patient Balances.
- OR, change CO in both Rule Sets to Write Off Patient Balances.
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