CMS Pub. 100-04, ch. 18, § 140.7

Claims Adjustment Reason Codes (CARCs), and Advance Beneficiary Notices (ABNs)

(Rev. 3329, Issued: 08-14-15, Effective: 01-01-12, Implementation: 09-14-15)

Messages for A/B MACs (A) and (B):

When paying claims for an AWV, A/B MACs (A) and (B) shall use the following Medicare Summary Notices

(MSNs):

MSN: 18.25: - “Your Annual Wellness Visit has been approved. You will qualify for another Annual Wellness Visit

12 months after the date of this visit.”

Spanish Version “Su Visita Anual de Bienestar ha sido aprobada. Usted tendrá derecho a otra Visita Anual de

Bienestar 12 meses después de la fecha de esta visita.”

When denying claims for a first AWV, HCPCS G0438, when a first AWV, HCPCS G0438, is already paid in history,

A/B MACs (A) and (B) shall use the following messages:

MSN 20.12: - “This service was denied because Medicare only covers this service once a lifetime.”

Spanish Version: “Este servicio fue negado porque Medicare sólo cubre este servicio una vez en la vida.”

CARC 149: “Lifetime benefit maximum has been reached for this service/benefit category.”

RARC N117: “This service is paid only once in a patient's lifetime.

Group Code - PR

When denying claims for a subsequent AWV, HCPCS G0439, because a previous AWV, HCPCS G0438 or G0439, is

paid in history within the past 12 months, A/B MACs (A) and (B) shall use the following messages:

MSN 18.26: “This service was denied because it occurred too soon after your last covered Annual Wellness Visit.

Medicare only covers one Annual Wellness Visit within a 12 month period.”

Spanish Version: “Este servicio fue negado porque ocurrió antes del período de 12 meses de su última Visita Anual

de Bienestar. Medicare sólo paga por una Visita Anual de Bienestar dentro de un período de 12 meses.”

CARC 119: “Benefit maximum for this time period or occurrence has been reached.”

RARC N130 “Consult plan benefit documents/guidelines for information about restrictions for this service.”

Group Code - PR

When denying claims for an AWV, HCPCS G0438 or G0439, because an IPPE, HCPCS G0402, is paid in history

with the past 12 months, A/B MACs (A) and (B) shall use the following messages:

(New) MSN 18.27: “This service was denied because it occurred too soon after your Initial Preventive Physical

Exam.”

Spanish Version: “Este servicio fue negado porque ocurrió demasiado pronto después de su examen físico preventivo

inicial.”

CARC 119: “Benefit maximum for this time period or occurrence has been reached.”

RARC N130: “Consult plan benefit documents/guidelines for information about restrictions for this service.”

Group Code - PR

When denying claims for an AWV, HCPCS G0438 or G0439, because the services were rendered within the first 12

months after the effective date of a beneficiary’s first Medicare Part B coverage period, A/B MACs (A) and (B) shall

use the following messages:

(New) MSN 18.24: “This service was denied. Medicare doesn’t cover an Annual Wellness Visit within the first 12

months of your Medicare Part B coverage. Medicare does cover a one-time initial preventive physical exam

(“Welcome to Medicare” physical exam) within the first 12 months of your Medicare Part B coverage”.

Spanish Version: “Este servicio fue negado. Medicare no cubre la Visita Anual de Bienestar durante los primeros 12

meses de su inscripción a la Parte B de Medicare. Medicare cubre un examen físico preventivo ("Bienvenido a

Medicare") durante los primeros 12 meses de su inscripción a la Parte B de Medicare.”

CARC 26: “Expenses incurred prior to coverage”

RARC N130: “Consult plan benefit documents/guidelines for information about restrictions for this service.”

Group Code - PR