New York State’s Workers’ Compensation Board (WCB) issued an update to the mandatory Claim Adjustment Reason Codes (CARCs) and Remittance Advice Remark Codes (RARCs) required when payers object to a provider’s billed charges for treating an injured worker.
The update provides specific instructions regarding how payers must file payment objections for reasons of 1) apportionment and 2) missing taxpayer identification information.
Of equal importance, the WCB’s announcement once again affirms a fundamental requirement of electronic billing and payment: payers must respond to electronic bills with electronic Explanations of Review (e-EORs).
In New York, payers may not deny or adjust payment to a provider for the treatment of an injured worker without the Explanation of Review (EOR) citing specific reasoning.
The EOR (sometimes referred to as an “EOB,” or Explanations of Benefits) sent in response to the provider’s bill must justify all adjustments using standardized reason codes: the nationally recognized CARCs and RARCs (RARCs are supplemental codes used only in conjunction with CARCs; CARCs may be used alone). The Washington Publishing Company maintains the standards for both CARCs and RARCs.
The WCB’s August 2022 announcement specifies the CARCs and RARCs payers must use when refusing to pay all or some of a provider’s bill, as follows:
Objection |
Reason |
CARC |
RARC |
Payment Adjusted Due to Apportionment |
Apportionment of the liability among other injuries |
P32 |
n/a |
Request for Taxpayer Identification Number and Certification (W-9) not on file |
An attachment or other documentation is required to adjudicate this claim/service; payment is withheld pending receipt of the provider’s federal tax identification number on a form W-9 |
252 |
N836 |
The WCB also notes that payers should not treat a missing W-9 as a legal payment objection, stating:
Crucially, the WCB announcement made it even more clear that New York payers must respond to e-bills with e-EORs. The announcement states:
Despite apparent confusion on the part of some claims administrators and clearinghouses, workers’ comp e-billing cannot work in New York State without compliant e-EORs, which automatically post payment details to the provider’s e-billing software. To better facilitate the treatment of injured workers, both sides of the equation must uphold their responsibilities re: electronic billing and payment.
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