JUNE 2016 MEETING DALLAS TX SUNDAY JUNE

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1 June 2016 Meeting Announcement The June 2016 Code Maintenance Committee meeting will be held in Dallas, TX on Sunday, June 5, 2016 at the Intercontinental Dallas. This is the same hotel where the ASC X12 Standing Meeting is held. Please see for meeting information. The Code Committee meets from 1:00 pm until 3:30 pm - usually in the same room as the Medicare Caucus. To request a new code, change or deletion, use this Request Form. Post to the June 2016 Agenda entry to reflect your topics for discussion, or reply to individual posting when new codes are listed. The agenda for the meeting will close on Friday, May 6, A virtual preliminary screening meeting will be scheduled to review requests. That meeting will be announced via the "Meeting Announcements" Online Conference. No voting will be held on that session, but requests will be screened to determine if additional outreach is needed. This timing permits groups to conduct conference calls prior to the Code Maintenance Committee meeting. Each October the committee will hold elections for the Chair and Vice-Chair position of the committee. In the even year (e.g. 2012, 2014) the Vice-Chair position election is held. In the odd year (2013, 2015) the Chair position election is held. Charter Within the On-Line Conference, there is a conference labeled Charter. Scans of the last known hard copy of the charter are posted. Group agrees to do work on line conference and then vote at the faceto-face meetings Go to online conference and add any comments. Working draft of the existing Enabling Document as well as the individual sections attached Codes Charter Draft.docx This discussion will be held following Old and New Business beginning with the first section after previously approved items in the draft. JUNE 5,

2 June 4, 2016 Deb Strickland s vice chair position is up at the Sept standing meeting. Nominations can begin at any time. Announcement the Code Maintenance Committee is now officially under X12. Nothing is changing, everything is remaining the same. As new information comes out, Merri-Lee Stine will share it. Charter work - we should be able to pick this up again after this meeting since we Old Business Tabled items January, Designation of group codes in code description Pat Wijtyk TGB WG3 Phone: List Name Description pwijtyk@wpchealthcare.com Revision Claim Adjustment Reason Code Various There has been questions raised related to the group codes that are designated in code descriptions and if it is required to follow the use of the group codes specified. Information was provided that a payer is not using the group codes listed in a specific code description because they feel it is not mandated. Can an FAQ be written to clarify this requirement? Patricia Wijtyk This is not a request for a code but help with determining how the industry uses the code descriptions and direction about the use of groups codes. Discussion Pre-Meeting January 8, 2016 Pat Wijtyk WG3 has done a lot of work tightening up the code descriptions. JUNE 5,

3 They have gotten word has gotten back to the wg that payers are saying they don t have to pay attention to it; they can do what they want. She just wants to open up dialogue. Pete Anderson the code sets are adopted under HIPAA. X12 can say this is an external code set and the definitions are defined by that entity. Bob Poiesz since payers seem to be saying it is in the Note it is not the description and not applicable. Maybe we need to submit an RFI to establish that the notes in these instances are to be followed (binding). Pat W. maybe an FAQ to address, not an RFI. Gail K. and Pete A. - agree in an FAQ. Merri-Lee in looking at CARC 16 the majority of the description is the note. Right now if you were trying to display as educational, this is the only piece they really need to know for what to do with the claim. This note describes how to use the code. Pat W. maybe this should be a bigger discussion on what to do with the notes. Deb S. NOTE was not used with Use with group code Merri-Lee we still need to draft an FAQ. Pat W. will be glad to organize discussion on drafting the FAQ. She will send to Bob P., Merri-Lee and Deb S. January 24, 2016 Merri-Lee had discussion in pre-meeting and had a small group draft. It has been drafted, but ML has not been able to review. This is being worked on. Pam Grosze overview of where it is going the question being posed. Do we have to do everything that is there? Recommendation - there are some CARCs that use usage and others that use notes. Merri-Lee will put the FAQ out on the online conference for everyone to review before it is published on the site. Keep an eye on it and she encourages everyone to review. Merri-Lee - Tabled for now as they work on the FAQ. Not a code request. Pre-Meeting May 13, 2016 Merri-Lee - Pat W. asking to defer. Pat - WG3 will discuss at standing meeting in June. Merri-Lee opened at the Jan session we discussed in pre-meeting. Pat W. WG3 is going to be discussing this week and would like to defer to next meeting. Pat W. made motion to table Gail Kocher seconded. VOTE RESULTS - NUMBER OF: YES 15 NO ABSTAIN JUNE 5,

4 Yes 11 Update narrative of CARC 245 and add the word denial. Meg Barber Anthem, Inc Phone: List Name Revision Claim Adjustment Reason Code 245 Description Provider performance program withhold/denial Requesting to add the word denial to current CARC 245 as withhold eludes to that this amount is being held and possibly may be reimbursed at a later time. We need a code that will also support where provider is not reimbursed - line of service or claim is denied due to performance rating guidelines Pat Wijtyk Gail Kocher Discussion Pat Wijtyk made motion for a new CARC. Performance program proficiency requirements not met. Use only with Group Codes CO or PI. (and then healthcare policy statement) Gail Kocher seconded Nancy Spector mixing two scenarios (previous adjustment and current adjustment) does this now address what is needed? Pat W. discussed on WG3 call and it was all resolved. Out of that discussion came the wording in the motion. Pat W. - Intent was to leave 245 alone and create a new code (278). VOTE RESULTS - NUMBER OF: YES 14 NO ABSTAIN_2 JUNE 5,

5 Yes. New code 278 Performance program proficiency requirements not met. (Use only with Group Codes CO or PI) Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. 13 New CARC to support Medicaid Rule Meg Barber Anthem, Inc Phone: List Name New Claim Adjustment Reason Code Description The state where the member is enrolled in Medicaid requires the provider to enroll in their Medicaid program before the claim can be considered. Per Medicaid certain states require providers to enroll in the Member's States Medicaid program prior to any claim benefits being processed. This condition occurs when a provider sees a member from another state (example can be when a member is traveling) There are no other RARC or CARC codes that can provide this detail of a denial for the provider to know what action to take. JUNE 5,

6 Discussion Pre-Meeting January 8, 2016 Pat. Wijtyk WG3 suggesting to use CARC 242 and request a new RARC. However, if they don t get the RARCs, they will need to look at it again. Should they put a note to table this until they find out whether they will get a RARC? Meg Barber submitted the RARC request and is waiting for a response. We can put it on hold until they find out about the RARC. Pat W. will make the motion to table. January 24, 2016 Margaret Weiker moves to table #13. Reason is because they have submitted a request for a RARC but have not yet gotten a response. Pre-Meeting May 13, 2016 Merri-Lee this one was in the same boat as last one. Pat W. RARC N767 was added with that wording. Meg B. this one can be closed out since the CARC was approved. Merri-Lee at the June 5 th meeting, request for it to be withdrawn. Pat W. a remark code was added N767, so this can be withdrawn, but Meg Barber is not in the current meeting. Meg submitted as Anthem. Christol Green (on behalf of Anthem) makes motion to withdraw. WITHDRAWN VOTE RESULTS - NUMBER OF: YES NO _0 ABSTAIN_0 New Business New items since the last meeting. 1 FAQ Topic for discussion JUNE 5,

7 Description: Merri-Lee Stine The below draft FAQ has been presented for the Committee's review: Proposed FAQ wording and response. Also need to revise CARCs with the word 'note' in the description to make more effective. FAQ question: What parts of the code lists does the committee consider required to be followed in order to comply with the code list usage? FAQ Response: Various codes include not just a description of the code value, but also usage, notes or parenthetical statements or guidance for additional information. The committee intends that users comply with the meaning and instructions imparted by all aspects of the code lists. Examples: - When a Claim Adjustment Reason Code (CARC) includes the statement "At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.)", then usage of the code without also including a Remittance Advice Remark Code that is not an "Alert" at the appropriate level associated with the CARC does not comply with the code list. - When a CARC includes the statement "Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.", senders should consider including the policy information and receivers should look to that information for additional guidance. - When a CARC includes the statement "(Use Only Group code PR)", usage of the CARC with a Claim Adjustment Group Code other than PR does not comply with the code list. - When a Claim Status Reason Code includes "Usage: This code requires use of an Entity Code.", usage of the code without including an Entity Code within the same Health Care Claim Status element does not comply with the code list. - When a Claim Status Category Code includes "(Note: A Claim Status Code identifying the type of information requested, must be reported)", usage of an appropriate status code is required. All CARCs need to be revised to replace the word 'Note' with 'Usage' Codes WITH Healthcare Policy statement: 4,5,6,7,8,9,10,11,12,16,40,49,50,51,54,55,56,58,59,61,96,97,107,108,152,167,170,171,172,179,183,184,185,222,231,240,269,B7,B8,B15, Codes with other note: 45,90,133,192,219,229,232,262,263,264,265,266 JUNE 5,

8 P2, P4, P6, P8, P12, P13, P14, P21, P22, P23 Discussion Pre-Meeting May 13, 2016 Merri-Lee there is a separate thread on the online conference for FAQ. Need to review and provide comments. Pat W. WG3 will do that during the standing meeting. No discussion items. Merri-Lee is there a motion regarding the FAQs Margaret W. makes motion to table. Gail K. seconded. Margaret W. -motion to take from the table. Pat. W. seconded, YES_16 NO _0 ABSTAIN 0_ Discussion: Merri-Lee FAQ #1 (see code list on the Online Conference)We are talking about compliance. Pat W. this isn t compliance, should consider. Sue Thompson suggests to move the guidance item to the bottom of the others because those are compliance issues. Betsy Clore agrees that the one is not like the others. How would someone know that it is a should and not must? Additionally thinks the wording needs to be consistent. Pete Anderson - recommends using the word guidance. Merri-Lee notes or usage in the CARC descriptions. Pete A. the FAQ can be worked on, but should not be loaded until all the codes have been updated from the meeting today. Gail K. are we saying all of these things apply and we suggest that you follow it? Using intend is like saying you should use it. She doesn t feel that it JUNE 5,

9 should say intends. We are either saying you are to use it or it is best practice. Pat W. if we say mandate usage for those that are compliance and then remove the healthcare policy one as an example. Gail K. is there still a comma after usage? Merri-Lee yes. Laurie B. concerned with the guidance for usage. By taking out the healthcare policy one, should also remove the word guidance from the FAQ. Struggling with additional information. It is not providing additional information. Merri-Lee suggested using instructions instead. Karen Shutt struggling with the verbiage. Suggests What instructions or statements within the code lists does the committee Agreed and Merri-Lee made update in the document. Laurie B. how about what does the committee consider? The instructions or statements within the code list? It sounds like the instructions for the list Merri-Lee what about what instructions or statements associated with a code does the committee consider compliance for code usage. ML made update to the main document. Nancy Reed why are we saying based on the code committee. Why aren t we saying based on the code set? The code set requires it. Merri-Lee updated the main document. Motion to accept the FAQ1 to approve the new wording of the question and answer and examples as modified. Pete seconded. Discussion: Pete are you going to make all the CARCs align to the FAQ with the word usage or make sure FAQs reflect note as the CARCs currently are worded. Merri-Lee we need to replace usage with note from the FAQ1. Laurie B. suggests removing also Pam G. the reason we are doing this to begin with is because the other parts were being disregarded. She is ok with getting rid of the not but also should remain. Laurie B flip the question around. What is the most important? Have the compliance first. Merri-Lee updated the main document. Pat W. accepts revisions. Margaret W. -Seconded accepts. VOTE: Approved. Pat W. FAQ1 agrees with withdrawing the code listed at the bottom of this FAQ request. JUNE 5,

10 VOTE RESULTS - NUMBER OF: YES NO _0 ABSTAIN 0_ 2 Need a CARC that tells Medicaid provider the deductible amt on the claim is greater than Medicare deductible amt Jo Steinert Ohio Department of Medicaid Phone: List Jo.Steinert@medicaid.ohio.gov New Claim Adjustment Reason Code Description: Medicare deductible submitted to state Medicaid is greater than the Medicare deductible amount CMS issues annually for that date of service or date of discharge State of Ohio Medicaid has a need for a CARC that relays the message to a Medicaid provider seeking Medicare deductible payment for a QMB or QMB plus eligible and the deductible amount submitted on the claim to Medicaid is greater than the Medicare deductible amount CMS issues annually for that date of service or date of discharge. Patricia Wijtyk TGBWG3 reviewed the request and does not support a new CARC. The appropriate CARC to be used is dependent on the action to be taken by the submitter of the claim. For example, if the claim data must be corrected and resubmitted, then CARC 16 must be used. The message submitted in the request would supplement any CARC reported. Discussion: JUNE 5,

11 Pre-Meeting May 13, 2016 Gail K. can we give a better example? The example that WG3 gave doesn t match the request title. Deb S. the request indicates if the amount is wrong. Merri-Lee what is the action on the submitter s part? Gail she doesn t think there is any, it would be a write off. Bob P. thinks it needs more information for this request. Gail thinks they are saying provider is submitting a claim to Medicare and that the deductible to be reimbursed is the Medicaid. Believes it is a noncovered not a resubmit. Need to be able to communicate to the provider. $1,100 is deductible and $1,000 was paid. Asking for $100 and not going to pay. Need a code to deny this. Bob P. the explanation appears that there is an error. Deb S. will go back to Joe and figure out what the issue really is. She will have Chad review and comment. Pat W. bottom line, there is a CARC and this needs to be a RARC request. Pat W. makes motion to disapprove. Gail K. seconded Discussion: Gail K. thought we were going to get more clarification? The discussion on the pre-meeting we couldn t even agree what the requester was asking for. Merri-Lee - Deb was to reach out to the Stuart P. most of the Medicaids across the country do crossover with Medicare. Doesn t know how the provider can submit more of a deductible. Cost savings. Seems strange that Ohio is not rejecting these claims. Maria Antonelli Ohio Medicaid. She can ask Jo why she submitted this request. They already have an edit to deny. She is not sure what her reason was. Need a better code to communicate specifically the deductible. Why are they denying the COBs or crossover claims? Merri-Lee what is happening today? Probably using COB doesn t match. Pat. W. - the additional message would serve better as a remark code. If it is truly needed then they can come back and re-request. Gail K. is ok with that. If we deny and the submitter comes back with another request they need to make sure it is clear. VOTE RESULTS - NUMBER OF: YES 15 NO 0 ABSTAIN_0 Yes - denied JUNE 5,

12 3 Currently a Health Care Services Type code does not exist for Early Intervention services for 270/271 Transaction Set reporting Stephen McCourt Massachusetts Department of Public Health Phone: (617) List steve.mccourt@state.ma.us New Health Care Service Type Description: Early Intervention Nationally, Early Intervention is a federally mandated, state run program that provides therapeutic and developmental services to infants and toddlers from birth to age three. Early Intervention programs provide coordinated developmental services that are therapeutic in nature to children who have developmental delays, or have a high potential for developmental delay, due to medical, biological or environmental factors. Services are provided by certified Early Intervention providers and are reimbursed by Medicaid and commercial insurers as medically necessary. Services include combinations of therapies including physical therapy, occupational therapy, speech/language pathology, nursing care and psychological counseling. The duration of therapeutic services may last for months or potentially years until the child reaches age three. Currently a Health Care Services Type Code does not exist for Early Intervention services for 270/271 Transaction Set reporting. JUNE 5,

13 Discussion Pre-Meeting May 13, 2016 Aggie Dorio TOC there is an EO code would this work for Applied O Is this a program or a service? Gail agreed, is it a service or a program? Bob P. have all the components. We need to put them all together and establish an age group. Should this be done or keep them separate? Merri-Lee they are looking to do a group of service type codes. They can all be sent in an inquiry. Do we do that or require a service type. EO does say applied. She does not believe that this code would work. The age of the child can limit. The code can be tailored to age. She does not believe the request is asking for this. Bruce B. sees industry moving to early intervention. If there is a program that exists, shouldn t it be limited to the age group? Merri-Lee agrees and she doesn t see that limiting to age is the problem. It is getting together all the codes that could be used. Merri-Lee as a payer she questions who is submitting this transaction. Who really is the provider? This is not new. Head Start has been out there forever. Gail EO is not in the underline standard for status code. Merri-Lee that code was part of the blanket list for the initial load? Gail and Lu agrees. Bruce thinks it needs more discussion. There are too many codes imbed in it to know. Merri-Lee makes sense to reach out and contact the requestor. Aggie agreed. Margaret EPSVT is a program that all states have that is screening, etc. for a certain age and then there is another for when they become a teenager. It is the middle ground (age) that there is not a code for. Bruce googled early intervention and everything that pops up says basically the same thing that is in the request. Gail since Medicaid is at the state level, each state could be different. Deb will reach out to the requester. Merri-Lee Deb Strickland was going to reach out for clarification, but does not see a response. Aggie the requester said that he did not get a request to clarify. The requester did answer an to Nancy Sanchez-Caro (Aggie read). Aggie motion to table. Christol Green - seconded Merri-Lee since there are still questions, WG1 follow-up. WG10 to keep track. JUNE 5,

14 LuAnn H. from her perspective it definitely seems for the 270/271 they do need to have an early intervention code, but does not believe that the 278 will use it. Pete would like to suggest in general that the requesters be available during the pre-meetings. Stuart agrees with Pete and recommends that if the requester is not part of the pre-meeting it is automatically tabled. Merri-Lee we should discuss when we work on the charter. A good conversation to have. VOTE RESULTS - NUMBER OF: YES_15 NO 0 ABSTAIN_0 Yes 4 NDC code translated to HCPC code Lisa Tosi Blue Cross Blue Shield of Vermont Phone: List tosil@bcbsvt.com New Claim Adjustment Reason Code Description: The NDC code submitted for this service was translated to a HCPCS code for processing, please continue to submit the NDC on future claims for this item There is no CARC that closely resembles the remark code M70 Merri-Lee Stine sent on 4/22 to the requester: Hello- On 4/4/2016, a request was entered into the June agenda for the Codes Committee. A copy of the request is below for your convenience. Additional information would be helpful to assist the Committee review this JUNE 5,

15 request. The request references a change in the submitted information. Can you elaborate on how this would be used in the Remittance Advice? Would it be used in conjunction with an adjusted amount? If you can provide additional details around the scenario, the Committee may better understand the usage. Patricia Wijtyk TGBWG3 reviewed the request and does not support a new CARC. The 835 has the ability to report a change in service codes in the SVC segment where SVC01 reports the adjudicated code and SVC06 reports the originally submitted code. RARC M70 is used to reflect the message on future claims. Discussion Pre-Meeting May 13, 2016 Gail offered to reach out to the requester and ask what is really being requested. Merri-Lee reached out to this requester. Gail also reached out and both were told the same thing. Gail K. through her reaching out there is an from requester to withdraw. It turned out to be an education issue. WITHDRAWN VOTE RESULTS - NUMBER OF: YES NO ABSTAIN WITHDRAWN 5 Request to Remove STC Aggie Dorio Aetna JUNE 5,

16 Phone: List Description: Revision Health Care Service Type BW Mail Order Prescription Drug Brand Name There is no such thing and the STC 90 would cover a brand or generic drug dispensed by a mail order pharmacy Discussion: Pre-Meeting May 13, 2016 LuAnn this is specific to the 270/271. The 278 has codes specific to it, but this is for 270/271. From a Highmark perspective they would like to identify brand vs. generic. Merri-Lee are we saying 91 and 92 are not usable by the 270/271? Margaret need to look at Aggie s spreadsheet. Aggie for the mail order prescription in the industry technically there is no mail order drug. Gail sounds like WG10 has not gotten the final WG1 version. Aggie the spreadsheet of the list is on the WG1 CD space. It includes for both 278 and 271 transactions. Karen is it broken out? Margaret it is broken out as Retail or Mail Order Brand and Retail or Mail Order Generic. LuAnn Highmark needs to be able to identify if it is Mail Order Brand or Generic, or Retail Brand or Generic. Deb can Aggie bring copies so they don t have to display at the meeting? Aggie yes, she will bring. Aggie displayed service type codes. WG1/10/16 have been getting together on weekly bases and trying to clean up the service codes. Representatives from each industry were involved in these calls. Margaret on the pharmacy codes there are codes that say it is brand or generic, but because there are multiple for pharmacy there will be a bunch of codes. So, the thought is to combine and it will allow for multiples. JUNE 5,

17 Sherry W. this will be great to have clarity. P&C uses these codes and there has been confusion. Item #5 and #6 request for a stop date on these two codes. If agreed there will be a 6 month lead time to stop. Margaret W. motion to approve items #5 and #6 to delete those two codes. Gail K. seconded. Discussion: Gail K. understand normally a 6 month lead time, but since these are not used currently. She suggests making immediate so there is not lag time. Matt the price of the brand name is usually different even for mail order. #5 makes since to keep. Margaret W. this is what she said initially. Aggie this is really a duplicate. Service Type code 90 (mail order) and 91 and 92 says brand or generic. Lisa Barley Matt is talking about the pricing is different, but this is the benefits. Margaret W. motion is still to remove it. Tom Mort - Repeating elements to short cut, but the way he reads the guides it doesn t matter how it is delivered. VOTE RESULTS - NUMBER OF: YES 13 NO 0 ABSTAIN 3_ Yes. Remove codes 6 Request to Remove STC Aggie Dorio Aetna Phone: List dorioa@aetna.com Revision Health Care Service Type JUNE 5,

18 Description: BX Mail Order Prescription Drug Generic Name There is no such thing and the STC 90 would cover a brand or generic drug dispensed by a mail order pharmacy Discussion: Pre-Meeting May 13, 2016 See above #5 See above #5 VOTE RESULTS - NUMBER OF: YES NO ABSTAIN 7 Request to Change Name Aggie Dorio Aetna Phone: List Description dorioa@aetna.com Revision Health Care Service Type STC 88 - Pharmacy Request to change name to Retail/Independent Pharmacy Pharmacy is a very generic term and since codes exist for other types of pharmacies, the name needs to change to match the definition JUNE 5,

19 Discussion: Pre-Meeting May 13, 2016 Merri-Lee her reaction is that this is changing the use of the codes. LuAnn agrees. The definition of 88 already refers to pharmacy. Bob P. pharmacy is anything. Do we want to separate or include all the others? Margaret we got rid of the generic part of it to make it very specific. Bob there are times where you have generic and make very specific. Should there be a new one created to not confuse with the old set? Margaret makes sense. LuAnn is there anything else that a pharmacy uses that isn t related to drugs and would be excluded if this is approved? Margaret no, believes also updated definitions too. Where it would allow consulting services. Aggie read the definition. LuAnn it would be helpful to add this when it is discussed. Merri-Lee need to move on we only have 30 minutes left of meeting. LuAnn we can take the discussion offline. Aggie makes motion to change the name from pharmacy to retail/independent pharmacy. Gail K. seconded. Discussion: Amanda S. since this is a parent level STC it seems to be taking this a little more granular, so how will it affect the child STCs? Aggie would have to change it everywhere it is a parent. It wouldn t stand alone. Amamda as a group header do we need one for pharmacy as parent and then have the others as child STCs? Margaret pharmacy benefit at what point do we say pharmacy? We definitely need to change the description because this is a specifc pharmacy and there are other pharmacies. Bruce B. what about inpatient pharmacy? Margaret says it is kind of more like a philosophy discussion. It can t stay with the current description. JUNE 5,

20 Bruce WG10 don t need place of service and getting rid of pharmacy as a general, then you lose LuAnn H. the codes cannot be used until the next publication of versions. Aggie there will also be more STCs brought to the committee as they continue WG1/10/16 work on this clean-up effort. Aggie has no problem tabling. Gail K. need to be cognizant of what these codes are when we are writing descriptions. Aggie this full list is out on WG1/10/16 imeet. As of today, there has been no discussion in WG1 space. Pete A. question on detail description, the long description, is that published anywhere? Aggie only place it is right now is in the spreadsheet. Donna with the question of urgency. It is necessary to get this approved before they finalize the BRTS front matter. Donna can we pull these and discuss in an interim call? Merri-Lee interim calls are usually reserved for when we don t finish an agenda. Gail K. things it would be better to have more discussion and tabling it, we need to Stacey if done in an interim and sooner rather than later, then yes, it would work into the 7030 timeline Bruce really things we can resolve this in joint meeting on Wed. of this week. Stacey if you can get it resolved then it would be a just a meeting for votes. Would need to be no later than end of July. Stacey codes can t be in the front matter. It will need to go into the TR2. Donna they are working on that Aggie doesn t think that there are any other codes that fall under the umbrella structure like pharmacy. Gail made motion to table with another code committee meeting in June and Luann - second to table #7 & #8 VOTE RESULTS - NUMBER OF: YES_13 NO 0 ABSTAIN_2 Yes JUNE 5,

21 8 Request a name change to a STC Aggie Dorio Aetna Phone: List Description: dorioa@aetna.com Revision Health Care Service Type 90 - Mail Order Prescription Drug Requesting to change the name to Mail Order Pharmacy There really is no such thing as a Mail Order Prescription Drug (you can obtain a prescription drug via a mail order pharmacy). Name change to match the definition and to provide an accurate name. Discussion: Tabled with #7 above. VOTE RESULTS - NUMBER OF: YES NO ABSTAIN Yes 9 Name Change for STC 75 Aggie Dorio JUNE 5,

22 Aetna Phone: List Description: Revision Health Care Service Type 75 - Prosthetic Device Requesting that we change the name to Prosthetic Based on HCPCS - there are procedures that are considered either base or add ons to the Prosthetic benefit. Ex: the prosthesis would be the base or device. They can then add a sock or cushion to the prosthesis (components that can be added to the device) that would not be considered part of the device. So with that we would ask that the word device be dropped from the name. Just having Prosthetic is more inclusive than Prosthetic Device. Discussion: Pre-Meeting May 13, 2016 Gail add an s to make plural. LuAnn and Bruce agreed. Luann made motion to approve. Bruce seconded. VOTE RESULTS - NUMBER OF: YES_12 NO _0 ABSTAIN_1 Yes 75 Prosthetics 10 CARC needed to support Dental actice and rentention phase max Meg Barber Anthem, Inc JUNE 5,

23 Phone: List New Claim Adjustment Reason Code Description: New CARC "The contract/policy has limits on the orthodontic active and retention phase of treatment" There are no good codes for dental to use. There is not a really good code combination currently. We settled on CARC 119 for now, but want request a new code. Truly to have a code that is more specific to the phases will avoid provider calls on clarification of what benefit is maxed. Patricia Wijtyk TGBWG3 reviewed the request and recommend the use of CARC149 with a new RARC for the message submitted. There was also a suggestion to use the word 'benefit' instead of policy/contract'. The submitter was on the call. Discussion: Pre-Meeting May 13, 2016 Meg already submitted that request. Pat W. motion to deny the request. Submitter should use CARC 149 and submit a request for a new remark code. LuAnn H. seconded. Discussion: Pat. W. - Submitter agreed and has already submitted a RARC request. VOTE RESULTS - NUMBER OF: YES 12 NO 0 ABSTAIN 3_ Yes - denied 11 JUNE 5,

24 Change the term penalty to adjustment Karen Shutt Highmark Phone: List Revision Claim Adjustment Reason Code 61 Description: Adjusted for failure to obtain second surgical opinion The term 'Penalty' to some in the industry implies a partial cutback, when in fact this CARC is being used in the industry for both a partial reduction (penalty) and also a full denial (also a penalty) of a service due to failure to obtain a second surgical opinion. Request the CARC be changed to use the term 'Adjusted', instead of 'penalty' which according to the CARC FAQs on the WPC site, 'Adjusted indicates: denied, zero payment, partial payment, reduced payment, penalty applied, additional payment, supplemental payment. Patricia Wijtyk TGBWG3 reviewed the request and support the change to the CARC. Discussion: Pre-Meeting May 13, 2016 Pat W. motion to approve as submitted. LuAnn H. seconded VOTE RESULTS - NUMBER OF: YES 12 NO _0 ABSTAIN_2 Yes name for CARC 61 changed to Adjusted for failure to obtain second surgical opinion. 12 JUNE 5,

25 Request to remove aa STC Aggie Dorio Aetna Phone: List Description: Revision Health Care Service Type STC 34 - Chiropractic Modality We are requesting that this STC be removed from the list The thought is that STC 33 would cover this service along with any other services that would be offered and therefore we do not need it to be spiked out. Discussion: Pre-Meeting May 13, 2016 LuAnn that makes sense Merri-Lee not sure why we had it in the first place Gail benefits are not provided like that now. Modality vs. manipulation. LuAnn H. motion to approve. Bruce B. seconded. Discussion: None Stacey B. not removing it from the guide just from the code set. Gail K. makes a motion to be effective immediately. LuAnn H. seconded. VOTE RESULTS - NUMBER OF: YES 14 NO _0 ABSTAIN 0_ Yes effective upon publication remove STC 34 JUNE 5,

26 13 Request to remove a STC Aggie Dorio Aetna Phone: List Description: dorioa@aetna.com Revision Health Care Service Type STC E29 - Technical Cardiac Rehabilitation Services Component We are requesting that this STC be removed from the code list. This STC along with others was to be a temporary fix until the 270/271 could return that it was technical vs professional. This has been accomplished with CR1299 and will be in the next version of the TR3. We are therefore asking that it be removed from the STC list. Discussion: Pre-Meeting May 13, 2016 LuAnn H. made motion to stop date effective upon publication E29, E30 & E31 (items #13, 14 & 15). Pat Wijtyk seconded. VOTE RESULTS - NUMBER OF: YES 14 NO 0 ABSTAIN_1 Yes Items #13, 14 & 15 stop date immediately upon publication. 14 JUNE 5,

27 Request to remove a STC Aggie Dorio Aetna Phone: List Description: dorioa@aetna.com Revision Health Care Service Type STC E30 - Professional Cardiac Rehabilitation Services Component Request to remove STC E30 from the service type code list This STC along with others was to be a temporary fix until the 270/271 could return that it was technical vs professional. This has been accomplished with CR1299 and will be in the next version of the TR3. We are therefore asking that it be removed from the STC list. Discussion: Pre-Meeting May 13, 2016 LuAnn H. made motion to stop date effective upon publication E29, E30 & E31 (items #13, 14 & 15). Pat Wijtyk seconded. VOTE RESULTS - NUMBER OF: YES 14 NO _0 ABSTAIN_1 Yes Items #13, 14 & 15 stop date immediately upon publication. 15 Request to remove a STC Aggie Dorio Aetna JUNE 5,

28 Phone: List Description: Revision Health Care Service Type STC E31 - Professional Intensive Cardiac Rehabilitation Services Component Request to remove this STC from the service type code list This STC along with others was to be a temporary fix until the 270/271 could return that it was technical vs professional. This has been accomplished with CR1299 and will be in the next version of the TR3. We are therefore asking that it be removed from the STC list. Discussion: Pre-Meeting May 13, 2016 LuAnn E32 goes together with E31, Aggie, did you mean to include E32? Aggie E32, E34 and E35 is being further researched. Once those are completed she will request to remove those too. LuAnn H. made motion to stop date effective upon publication E29, E30 & E31 (items #13, 14 & 15). Pat Wijtyk seconded. VOTE RESULTS - NUMBER OF: YES 14 NO _0 ABSTAIN_1 Yes Items #13, 14 & 15 stop date immediately upon publication. JUNE 5,