Use appropriate RA messages when processing claims.
For denials effective January 1, 2007, use the following RA messages:
Claim adjustment reason code 50:
“These are non-covered services because this is not deemed a “medical necessity” by the payer”.
Include the following RA messages if an ABN was issued:
• RA remark code M38:
“The patient is liable for the charges for this service as you informed the patient in writing before the service was furnished that we would not pay for it, and the patient agreed to pay.”
• Group code PR:
If an ABN was not issued include the following messages:
• RA remark code M27:
“The patient has been relieved of liability of payment of these items and services under the limitation of liability provision of the law. You, the provider, are ultimately liable for the patient’s waived charges, including any charges for coinsurance, since the items or services were not reasonable and necessary or constituted custodial care, and you knew or could reasonably have been expected to know, that they were not covered.
You may appeal this determination. You may ask for an appeal regarding both the coverage determination and the issue of whether you exercised due care. The appeal request must be filed within 120 days of the date you receive this notice. You must make the request through this office.”
• Group code CO: