Healthcare Remittance & Payment (835)

HIPAAfree

Validate payment and remittance data — CARC/RARC codes, adjustment groups, paid vs billed consistency, and duplicate claim detection per X12 835 standards.

5 rules 2959 downloads4.3 avg (118)

remittance835paymentcarcrarcadjustmenteraeobclaim-payment

4.3(118 ratings)

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About this pack

Data quality checks for healthcare remittance advice and payment processing. Covers: - Claim Adjustment Reason Code (CARC) validation (1-999) - Remittance Advice Remark Code (RARC) format validation (M, N, MA prefix) - Adjustment group code validation (CO, PI, PR, OA, CR) - Paid vs billed amount consistency with tolerance-based balancing - Duplicate claim detection (same member + service date + provider + procedure + amount) Standards: X12 835 (Remittance Advice), CAQH CORE Code Combinations, WPC CARC/RARC, HIPAA

Sources & References

HIPAA — 45 CFR 162.1602

Health care payment and remittance advice transactions must use standardized CARC codes per X12 835 implementation guide

X12 — X12 835 Transaction Set - CAS Segment (Claim Adjustment)

Claim adjustment reason codes in the CAS segment must be valid numeric codes from the X12 CARC code list

CAQH CORE — CAQH CORE 360 Uniform Use of CARCs and RARCs Rule

Payers must use the appropriate CARC codes as defined by the CARC/RARC/GCRC Committee

X12 — X12 835 Transaction Set - LQ Segment (Health Care Remark Codes)

Remark codes in the LQ segment must conform to the RARC format maintained by CMS and the CARC/RARC Committee

X12 — X12 835 Transaction Set - CAS01 (Claim Adjustment Group Code)

The CAS segment group code must be one of the five defined values: CO, PI, PR, OA, or CR

X12 — X12 835 Transaction Set - CLP/SVC Segments (Claim/Service Payment Information)

Claim-level and service-level payment amounts must reconcile: billed = paid + adjustments + patient responsibility

CAQH CORE — CAQH CORE 382 ERA Claim Payment Balancing Rule

ERA claim payment information must balance at both the claim and service line level

X12 — X12 835 Transaction Set - Duplicate Claim Handling

Claims processors must detect and appropriately handle duplicate claims to prevent overpayment

CMS — CMS Program Integrity Manual, Chapter 3

Duplicate claim detection is a required component of Medicare and Medicaid program integrity controls

What's included

3format rules

2consistency rules

Checks included (5)

Claim Adjustment Reason Code (CARC) Validation(carc_code)

Validates that Claim Adjustment Reason Codes (CARCs) are 1 to 3 digits in the range 1-999. CARCs are used in X12 835 remittance advice transactions to communicate why a claim or service line was adjusted. Each code must be a numeric value maintained by the X12 Code Maintenance Committee and published by the Washington Publishing Company (WPC).

Remittance Advice Remark Code (RARC) Format(rarc_code)

Validates that Remittance Advice Remark Codes (RARCs) conform to the standard format: a prefix of M, N, or MA followed by one or more digits (e.g., M1, N432, MA130). RARCs provide additional explanation for claim adjustments in X12 835 remittance transactions and supplement CARC codes with more specific information.

Claim Adjustment Group Code Validation(adjustment_group_code)

Validates that the claim adjustment group code is one of the five standard codes defined for X12 835 remittance transactions: CO (Contractual Obligation), PI (Payer Initiated Reduction), PR (Patient Responsibility), OA (Other Adjustment), or CR (Correction and/or Reversal). The group code categorizes why the adjustment was made.

Paid vs Billed Amount Consistency

Validates financial consistency in remittance data: paid amount must be >= 0 and <= billed amount, allowed amount must be >= 0, and the sum of paid_amount + patient_responsibility + adjustment_amount should approximately equal the billed_amount within a configurable tolerance. This ensures the remittance balances and prevents overpayments or missing adjustments.

Duplicate Claim Detection

Flags potential duplicate claims by identifying records with the same member_id, service_date, provider_npi, procedure_code, and billed_amount within a configurable time window (default 30 days). Duplicate claims can result in overpayments and compliance violations, and should be reviewed before payment processing.