CMS Pub. 100-04, ch. 18, § 210.3

Remark Codes (RARCs), Group Codes, and Medicare Summary Notice

(MSN) Messages

(Rev. 13680; Issued: 03-26-26; Effective: 10-01-25; Implementation: 07-06-26)

Contractors shall use the appropriate claim adjustment reason codes (CARCs), remittance

advice remark codes (RARCs), group codes, or Medicare summary notice (MSN) messages

when denying payment for HCV screening, HCPCS G0472 or G0567 (effective 6/27/24):

• Denying services submitted on a TOB other than 13X, 14X, or 85X:

CARC 170 - Payment is denied when performed/billed by this type of provider. Note:

Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment

Information REF), if present.

RARC N95 – This provider type/provider specialty may not bill this service.

MSN 21.25: This service was denied because Medicare only covers this service in

certain settings.

Spanish Version: “El servicio fue denegado porque Medicare solamente lo cubre en

ciertas situaciones."

Group Code CO (Contractual Obligation) assigning financial liability to the provider (if a

claim is received with a GZ modifier indicating no signed ABN is on file).

NOTE: For modifier GZ, use CARC 50, Group Code CO, and MSN 8.81.

Denying services where previous HCV screening, HCPCS G047 or G0567 (effective

6/27/24), 2, is paid in history for claims with dates of service on and after June 2, 2014,

and the patient is not deemed high risk by the presence of ICD-10 diagnosis code Z72.89,

other problems related to lifestyle, and ICD-10 diagnosis code F19.20, other psychoactive

substance dependence, uncomplicated:

CARC 119 – Benefit maximum for this time period or occurrence has been reached.

RARC N386 - This decision was based on a National Coverage Determination (NCD). An

NCD provides a coverage determination as to whether a particular item or service is

covered. A copy of this policy is available at www.cms.gov/mcd/search.asp. If you do not

have web access, you may contact the contractor to request a copy of the NCD.

MSN 15.20 – The following policies NCD210.13 were used when we made this

decision.

Spanish Version – Las siguientes politicas NCD210.13 fueron utilizadas cuando se

tomo esta decision.

MSN 15.19 - Local Coverage Determinations (LCDs) help Medicare decide what is

covered. An LCD was used for your claim. You can compare your case to the LCD and

send information from your doctor if you think it could change our decision. Call 1-800-

MEDICARE (1-800-633-4227) for a copy of the LCD.

Spanish Version - Las Determinaciones Locales de Cobertura (LCDs en inglés) le ayudan

a decidir a Medicare lo que está cubierto. Un LCD se usó para su reclamación. Usted

puede comparar su caso con la determinación y enviar información de su médico si piensa

que puede cambiar nuestra decisión. Para obtener una copia del LCD, llame al 1-800-

MEDICARE (1-800-633-4227).

NOTE: Due to system requirement, FISS has combined messages 15.19 and 15.20 so that,

when used for the same line item, both messages will appear on the same MSN.

NOTE: For modifier GZ, use CARC 50, Group Code CO, and MSN 8.81.

NOTE: This edit shall be overridable.

Denying services for HCV screening, HCPCS G0472 or G0567 (effective 6/27/24), for

beneficiaries at high risk who have had continued illicit drug use since the prior negative

screening test, when claims are not submitted with ICD-10 diagnosis code Z72.89, and

ICD-10 diagnosis code F19.20, and/or 11 full months have not passed since the last

negative HCV screening test:

CARC 167 – This (these) diagnosis(es) is (are) not covered. Note: Refer to the 835

Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF),

if present.

RARC N386 - This decision was based on a National Coverage Determination (NCD). An

NCD provides a coverage determination as to whether a particular item or service is

covered. A copy of this policy is available at www.cms.gov/mcd/search.asp. If you do not

have web access, you may contact the contractor to request a copy of the NCD.

MSN 15.20: “The following policies [insert LMRP/LCD ID #(s) and NCD #(s)] were used

when we made this decision.

Spanish Version - Las siguientes políticas [añadir los #s de LMRP/LCD, por sus siglas en

inglés y los #s de NCD, por sus siglas en inglés] fueron utilizadas cuando se tomó esta

decisión.

Group Code CO assigning financial liability to the provider, if a claim is received with

a GZ modifier indicating no signed ABN is on file.

NOTE: For modifier GZ, use CARC 50, Group Code CO, and MSN 8.81.

NOTE: This edit shall be overridable.

• Denying services for HCV screening, G0472 or G0567 (effective 6/27/24), for

beneficiaries who do not meet the definition of high risk, but who were born from 1945

through 1965, when claims are submitted more than once in a lifetime:

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

RARC N386: “This decision was based on a National Coverage Determination (NCD).

An NCD provides a coverage determination as to whether a particular item or service is

covered. A copy of this policy is available at www.cms.gov/mcd/search.asp. If you do

not have web access, you may contact the contractor to request a copy of the NCD.”

MSN 15.20 – The following policies NCD210.13 were used when we made this

decision.

Spanish Version – Las siguientes politicas NCD210.13 fueron utilizadas cuando se

tomo esta decision.

MSN 15.19 - Local Coverage Determinations (LCDs) help Medicare decide what is

covered. An LCD was used for your claim. You can compare your case to the LCD, and

send information from your doctor if you think it could change our decision. Call 1-800-

MEDICARE (1-800-633-4227) for a copy of the LCD.

Spanish Version - Las Determinaciones Locales de Cobertura (LCDs en inglés) le ayudan

a decidir a Medicare lo que está cubierto. Un LCD se usó para su reclamación. Usted

puede comparar su caso con la determinación y enviar información de su médico si piensa

que puede cambiar nuestra decisión. Para obtener una copia del LCD, llame al 1-800-

MEDICARE (1-800-633-4227).

NOTE: Due to system requirement, FISS has combined messages 15.19 and 15.20 so that,

when used for the same line item, both messages will appear on the same MSN.

Group Code CO assigning financial liability to the provider, if a claim is received with

a GZ modifier indicating no signed ABN is on file.

NOTE: For modifier GZ, use CARC 50, Group Code CO, and MSN 8.81.

NOTE: This edit shall be overridable.

• Denying claim lines for HCV screening, G0472 or G0567 (effective 6/27/24), without the

appropriate POS code:

CARC 171 – Payment is denied when performed by this type of provider on this type of

facility. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110

Service Payment Information REF), if present.

RARC N428 - Not covered when performed in certain settings.

MSN 21.25 - This service was denied because Medicare only covers this service in

certain settings.

Spanish Version: “El servicio fue denegado porque Medicare solamente lo cubre en

ciertas situaciones."

Group Code CO assigning financial liability to the provider (if a claim is received

with a GZ modifier indicating no signed ABN is on file).

NOTE: For modifier GZ, use CARC 50, Group Code CO, and MSN 8.81.

• Denying claim lines for HCV screening, G0472 or G0567 (effective 6/27/24), that

are not submitted from the appropriate provider specialties:

CARC 184 - The prescribing/ordering provider is not eligible to prescribe/order the

service billed. NOTE: Refer to the 835 Healthcare Policy Identification Segment (loop

2110 Service Payment Information REF), if present.

RARC N574 – Our records indicate the ordering/referring provider is of a type/specialty

that cannot order or refer. Please verify that the claim ordering/referring provider

information is accurate or contact the ordering/referring provider.

MSN 21.18 - This item or service is not covered when performed or ordered by this provider.

Group Code CO assigning financial liability to the provider (if a claim is received with

a GZ modifier indicating no signed ABN is on file).

NOTE: For modifier GZ, use CARC 50, Group Code CO, and MSN 8.81.

• Denying claim lines for HCV screening, HCPCS G0472 or G0567 (effective 6/27/24),

if beneficiary born prior to 1945 and after 1965 who are not at high risk (absence of

ICD-10 diagnosis code Z72.89 or F19.20 or Z11.59:

CARC 96 - Non-covered charge(s). At least one Remark Code must be provided (may be

comprised of either the NCPDP Reject Reason [sic] Code, or Remittance Advice Remark

Code that is not an ALERT.) Note: Refer to the 835 Healthcare Policy Identification

Segment (loop 2110 Service Payment Information REF), if present.

RARC N386 - This decision was based on a National Coverage Determination (NCD).

An NCD provides a coverage determination as to whether a particular item or service is

covered. A copy of this policy is available at www.cms.gov/mcd/search.asp. If you do

not have web access, you may contact the contractor to request a copy of the NCD.

MSN 15.19 - Local Coverage Determinations (LCDs) help Medicare decide what is

covered. An LCD was used for your claim. You can compare your case to the LCD and

send information from your doctor if you think it could change our decision. Call 1-800-

MEDICARE (1-800-633-4227) for a copy of the LCD.

Spanish Version - Las Determinaciones Locales de Cobertura (LCDs en inglés) le

ayudan a decidir a Medicare lo que está cubierto. Un LCD se usó para su reclamación.

Usted puede comparar su caso con la determinación y enviar información de su médico

si piensa que puede cambiar nuestra decisión. Para obtener una copia del LCD, llame al

1-800-MEDICARE (1-800-633-4227).

MSN 15.20 – The following policies NCD210.13 were used when we made this decision.

Spanish Version – Las siguientes politicas NCD210.13 fueron utilizadas cuando se

tomo esta decision.

NOTE: Due to system requirement, FISS has combined messages 15.19 and

15.20 so that, when used for the same line item, both messages will appear on the same

MSN.

Group Code CO assigning financial liability to the provider (if a claim is received

with a GZ modifier indicating no signed ABN is on file).