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The glossary organizes concepts in an organic way, to build upon previously introduced concepts, or Jump to the explanation you need:
275 is the health care claim code for all the attached documents required for workers’ compensation.
A 277 is a health care claim acknowledgement code a claims administrator sends to a bill submitter to let the bill submitter know whether or not their e-bill submission contains the following: - All California workers’ compensation mandated information and attachments. - An injured worker that can be identified as the insured.
If the e-bill submission is complete and the patient can be identified as the insured, the claims administrator sends a 277 acceptance to the bill submitter informing the bill submitter that their e-bill has been forwarded for review.
If the e-bill is incomplete or the injured workers is completely unidentifiable as the insured, the claims administrator sends a 277 rejection accompanied by a secondary code that clearly specifies reason for rejection.
835 or Electronic EOR
835 is the health care claim code for remittance advice and all its requisite attachments. In order for an e-EOR to be complete, it must contain all the appropriate CARCs and RARCs.
837 is the health care claim code for a bill OR a request for second review.
837 + 275 = e-Bill
Because workers’ compensation bills always require attachments, workers’ comp e-bills always have both an 837 and a 275.
A 999 is an acknowledgement code sent to a bill submitter to let them know whether their e-bill has been accepted or rejected on the basis of X12 syntax.
Acknowledgment protocols require claims administrators to check for certain submission errors before a bill is forwarded for review. (To read about the benefits of these protocols, click here.) There are two different levels of acknowledgement protocols: The 999 level and the 277 level.
CARC (aka Claims Adjustment Reason Codes)
CARCs are codes that you utilize with your 835 to describe the reason for payment, reduction, or denial.
Computer software serves as interpreter and translator of X12 files. Computer software “reads” the X12 file and turns it into something that human beings can understand, and vice versa.
DWC BARC to CARC/RARC Crosswalk
In order to help you figure out which CARCs and RARCs you need, the DWC has created a crosswalk to these codes from the DWC Bill Adjustment Reason Codes.
EDI (aka Electronic Data Interchange)
EDI is the safe, secure, and standardized electronic transmission route for all X12 files sent between parties.
An EDI Agent is a company that provides claims administrators and/or workers’ comp bill submitters with the compliant technology and connectivity they need to e-bill. Examples Clearinghouses (for claims administrators), DaisyBill (for bill submitters).
RARC (aka Remittance Advice Remark Codes)
RARCs are codes that provide additional information about payments, adjustments or denials already described by a CARC. Some CARCs require RARCs.
When you receive e-bills (837s) or send electronic EORs (835s), they are translated into a computer language called ASCX12. X12 is completely unintelligible by humans. You’ll need specialized computer software in order to understand the information contained in an X12 file.