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Denials

The following are results from the National Health Insurer Report Card (NHIRC) years 2008-2013 that address denials.

Metric 11 - Percentages of claim lines denied
Description: What percentage of claim lines submitted are denied by the payer for reasons other than a claim edit? A denial is defined as: allowed amount equal to the billed charge and the payment equals $0.

Metric 11

 

**Metric 12 - Reason codes (Claim Adjusted Reason Codes [CARC])1
Description: What are the most frequently reported reason codes for a denial? View definitions.

Aetna Anthem Cigna HCSC Humana Regence UHC
CARC % CARC % CARC % CARC % CARC % CARC % CARC %
 96 37.18%  204 29.40%  96 29.17%  16 40.37%  125 23.66%  16 29.41%  16 30.19%
49 10.12%  16 19.95%  197 22.77%  96 17.47%  96 21.86%  204 23.23%  96 23.43%
 227 9.84%  96 10.46%   204 13.12%  227 11.21%  94 19.43%  50 9.79%  B20 8.46%
 55 9.59%  45 9.10%  49 11.65%  B5 6.85%  16 12.88%  167 6.94%  38 5.58%
 226 7.67%  38 4.79%  55 5.77%  179 5.94%  197 8.09%  51 5.98%  15 4.76%
 119 5.84%  227 4.32% 50 4.30%  49 5.64%  165 3.94%  226 4.61%  56 4.06%
 197 5.56%  other 21.97%   51 3.78%  197 4.04% 204 3.36%  49 4.45%  197 3.88%
 165  3.68%     other  9.44%  other 8.47%   other 6.78%   227 4.17%  227 3.23% 
 other 10.52%                   other 11.40%  49 3.23% 
                        204  3.10% 
                        other 10.08%

**Metric 13 - Remark codes (Remittance Advice Remark Codes [RARC])2
Description: What are the most frequently reported remark codes for a denial? View definitions.

Aetna Anthem Cigna HCSC Humana Regence UHC
RARC % RARC % RARC % RARC % RARC % RARC % RARC %
N130  33.89%  N29 13.22%  N130 58.23%  N130  22.45%  N22 24.83% N29  33.81% N115  31.06%
N179 12.22%  N193 11.87% N30  12.03%   MA100 20.50%  N115 21.74%  N429 10.60% N174 14.57%
M41 9.99%  N179 9.29% M118  8.54%   N366 16.24%  N130 9.54%  N179 9.93% M77 8.05%
N56 8.72%  N221 7.66% N175  6.65%   M127 10.38%  N4 5.92%  N517 9.46% N54 7.86%
N20 7.51%  N155 6.45% N216  4.11%   N4 9.29%  M77 4.65% N130  7.45% N429 6.14%
N54 7.16%   MA92 6.05% other  10.44%   N225 7.44%  N489 4.55%  N102  6.69% N386 5.75%
 N517 5.92%   N161 4.28%      N202 5.46%   MA130 3.36% M135  4.49% N179 5.27%
 N429 5.01%   N174 3.99%      M29 3.24%   M62 3.29%  N463 4.30% M51 4.70%
 other 9.58%   N301 3.92%      other 4.99%   N386 3.13%  N30  3.63% M86 4.22%
     N232 3.84%          M53 3.03%  other 9.65%  other 12.37% 
    M127 3.68%          other 15.96%        
    other   25.75%                    

Metric 14 - Percentage of reason codes (CARC) reported with a required remark code (RARC)
Description: What percentage of denials reported provided a required remark code when a reason code specifically states that a remark code should be reported?

Aetna

Anthem

Cigna

HCSC

Humana

Regence

UHC

Medicare

CARC

%

%

%

%

%

%

%

%

 16  97.00%  92.71% 34.78% 100.00% 100.00% 52.91% 57.35% 99.97%
 96  99.28% 86.07% 96.89% 100.00% 100.00% 50.00% 60.77% 56.26%
 125 50.00% 50.00% Unused Unused 100.00% 100.00% 100.00% 99.99%
 129 Unused 10.71% Unused Unused Unused 94.59% 100.00% Unused
 148  Unused  100.00% Unused Unused Unused 100.00% Unused Unused
 226  100.00% 100.00%  100.00% Unused 100.00% 100.00% 100.00% 100.00%
 227 100.00% 98.63% Unused 100.00% Unused 100.00% 100.00% Unused
 234 Unused Unused Unused Unused Unused Unused Unused Unused
 237  Unused Unused Unused Unused Unused Unused Unused Unused
 252  Unused Unused Unused Unused Unused Unused Unused Unused
 A1  Unused  100.00% Unused Unused Unused Unused Unused Unused

1Source: Blue Cross and Blue Shield Association. Visit Washington Publishing Company at www.wpc-edi.com/codes to obtain a complete listing of the Claim Adjustment Reason Codes (CARC) and to propose new or request a revision to existing CARCs.
2
Source: Centers for Medicare & Medicaid Services OIS/BSOG/DDIS. Visit Washington Publishing Company at www.wpc-edi.com/codes to obtain a complete listing of the Remittance Advice Remark Codes (RARC) and to propose new or request a revision to existing RARCs.

** = May not total 100% due to rounding error  
HCSC = Health Care Services Corporation
UHC= UnitedHealthcare
Unused = Not reported in sample

The AMA NHIRC results are based on data pulled from the nationally mandated Health Insurance Portability and Accountability Act of 1996 (HIPAA) electronic standard transactions.  The technical references for these transactions are the electronic remittance advice (ERA) (HIPAA ASC X12 835 Health Care Claim Payment/Advice Transaction) submitted to a physician in response to the receipt of an electronic claim submission (HIPAA ASC X12 837 Health Care Claim--professional transactions).