Denials
The following are results from the National Health Insurer Report Card (NHIRC) years 2008-2012 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 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 | 35.15% | 204 | 23.84% | 96 | 41.93% | 16 | 39.77% | 96 | 22.09% | 16 | 33.33% | 16 | 34.35% |
| 55 | 13.84% | 16 | 20.03% | 95 | 23.03% | 96 | 21.54% | 165 | 20.22% | 38 | 22.81% | 56 | 15.42% |
| 197 | 7.10% | 96 | 10.80% | 197 | 8.41% | 49 | 7.68% | 16 | 16.44% | 197 | 19.30% | 96 | 12.05% |
| 226 | 6.34% | 45 | 8.74% | 38 | 7.31% | B5 | 6.62% | 197 | 15.31% | 204 | 7.02% | 49 | 8.55% |
| 165 | 6.10% | 38 | 7.28% | 50 | 5.24% | 179 | 6.11% | 125 | 5.88% | 227 | 5.26% | 197 | 5.51% |
| 49 | 5.86% | 200 | 5.51% | 51 | 4.00% | 227 | 4.40% | 204 | 5.73% | 149 | 3.51% | B20 | 4.21% |
| 227 | 5.83% | 197 | 4.77% | 49 | 3.31% | 197 | 2.42% | B9 | 2.53% | 51 | 3.51% | 204 | 4.15% |
| 56 | 5.43% | 97 | 3.69% | other | 6.77% | 50 | 2.20% | 198 | 2.34% | other | 5.26% | 100 | 3.95% |
| 119 | 4.37% | 119 | 3.51% | other | 9.26% | 15 | 2.22% | 15 | 3.05% | ||||
| other | 9.98% | other | 11.83% | other | 7.24% | other | 8.76% | ||||||
**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 | 41.82% | N179 | 19.05% | Unused | N130 | 30.62% | N130 | 15.54% | N29 | 33.33% | N386 | 19.58% | |
| M41 | 11.32% | N193 | 11.23% | MA100 | 21.55% | N115 | 14.93% | M135 | 16.67% | MA130 | 19.27% | ||
| N179 | 8.78% | MA92 | 7.47% | M127 | 15.49% | N489 | 14.31% | N179 | 16.67% | N174 | 15.42% | ||
| N20 | 8.64% | N301 | 5.95% | N4 | 9.39% | MA130 | 9.16% | N517 | 16.67% | N429 | 9.79% | ||
| N54 | 7.65% | N174 | 5.56% | N225 | 8.46% | N431 | 6.65% | M80 | 5.56% | N54 | 9.06% | ||
| N56 | 6.49% | M127 | 5.41% | N366 | 4.12% | N427 | 5.64% | MA67 | 5.56% | M86 | 6.88% | ||
| N517 | 5.15% | N221 | 5.30% | M29 | 4.02% | M77 | 4.84% | N429 | 5.56% | N115 | 5.00% | ||
| N204 | 2.29% | N30 | 4.09% | other | 6.35% | N4 | 4.67% | other | -0.02% | M51 | 4.27% | ||
| other | 7.86% | N202 | 3.85% | N56 | 3.70% | N30 | 2.50% | ||||||
| N130 | 3.83% | M62 | 2.82% | N12 | 2.29% | ||||||||
| N155 | 3.83% | M139 | 2.69% | other | 5.94% | ||||||||
| other | 24.43% | other | 15.05% | ||||||||||
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 | 66.67% | 86.55% | 0.00% | 77.95% | 99.77% | 31.58% | 75.97% | 100.00% |
| 96 | 93.88% | 97.74% | 0.00% | 69.82% | 100.00% | 100.00% | 98.92% | 100.00% |
| 125 | Unused | 84.09% | Unused | Unused | 100.00% | 100.00% | Unused | 100.00% |
| 129 | Unused | 33.33% | 0.00% | Unused | Unused | Unused | 100.00% | Unused |
| 148 | Unused | 100.00% | Unused | Unused | Unused | Unused | Unused | Unused |
| 226 | 100.00% | Unused | 0.00% | Unused | Unused | Unused | 100.00% | 100.00% |
| 227 | 96.88% | 100.00% | Unused | 45.23% | Unused | 100.00% | 100.00% | Unused |
| 234 | Unused | Unused | Unused | Unused | Unused | Unused | Unused | Unused |
| 237 | 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.
2Source: 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).
