ORTHOPEDICS / CLAIM REVIEW
Advisory denial-risk worklist, not a guarantee or calibrated prediction. No US outcome cohort or complete payer policy set is available. A biller must verify every correction and appeal.
Next action: Confirm whether the lines represent the same joint and session. CMS policy allows one unit for that joint and its associated bursae; correct only after documentation review
Medicare NCCI 2026 chapter IV, arthrocentesis policy ↗ · NCCI_JOINT_UNITS
Next action: Confirm the practice billing NPI and complete box 33a
CMS-1500 field completeness ↗ · NPI_REQUIRED
Next action: Read the paired RARC and original remit to identify the missing element. Use the payer correction or records process; CARC alone does not establish appeal eligibility
ClaimAct DOCUMENTATION / supplied CARC 16 ↗ · CLAIMACT_DOCUMENTATION
Next action: Compare the original encounters and remit. Remove only a verified duplicate; do not change service times to bypass edits
Relay duplicate group; CARC 18 requires payer confirmation ↗ · RELAY_OVERLAP
Next action: Compare the original encounters and remit. Remove only a verified duplicate; do not change service times to bypass edits
Relay duplicate group; CARC 18 requires payer confirmation ↗ · RELAY_OVERLAP
No issue was found in the evaluated checks. Coverage, clinical necessity, eligibility and payer-specific edits still require review.
These drafts contain placeholders and must be reviewed. A correction or records response may be appropriate instead of an appeal.
DRAFT — HUMAN REVIEW REQUIRED Claim SYN-003, line SYN-L1 Payer claim number: [verify] Appeal address and deadline: [verify from payer] Request for review of the reported adjustment (CARC 16, RARC [missing]). The export reports: Missing information on original claim. Please confirm the specific missing information or coverage rule. The clinic must complete the verified factual basis below before submission. Basis for reconsideration: [insert verified facts and applicable payer policy]. Requested remedy: [corrected claim, records response, or appeal as directed by the payer]. Review references (these are not proof that this denial was incorrect): - ClaimAct DOCUMENTATION / supplied CARC 16: https://x12.org/codes/claim-adjustment-reason-codes Attachments to verify: original claim; complete remit; relevant clinical documentation; applicable policy; submission receipt when relevant. Do not submit until the biller verifies all placeholders, clinical facts, payer policy, deadline and destination.
claimact — executed
CARC detector matches; recommendations reviewed by pilot adapter; unversioned NCCI starter pairs excluded
relay — executed
Duplicate groups only. All proposed time adjustments discarded.
recall — executed
Baseline lookup; no US cohort admitted, all rates null.
jev — unavailable
Owned local model configuration is not mounted; no cloud fallback.
icd10 — not_evaluated
Billing export lacks clinical note evidence. No diagnosis is inferred or changed.
tickmark — executed
Local deterministic procedure-code format validation; not code-set validity