Claim edit: Missing adjustment reason code

Stedi now rejects 837P professional, 837D dental, and 837I institutional claims that include an adjustment amount or quantity without a corresponding adjustment reason code.

How the edit works

In a healthcare claim, an adjustment is a dollar amount that reduces what the payer owes the provider. Adjustments can cover things like a contractual write-off or the patient's responsibility, such as a co-pay or deductible.

Payers apply adjustments during adjudication and return them, along with other payment information, to the provider in an Electronic Remittance Advice (ERA). Adjustments are provided at both the claim and service-line level.

In the ERA, each adjustment's dollar amount is paired with a Claim Adjustment Reason Code (CARC). The reason code explains why the adjustment was made.

When billing a secondary or tertiary payer – a process called coordination of benefits (COB) – the provider or their billing system copies the prior payer's adjustments onto the claim.

Each adjustment has a reason code, a dollar amount, and an optional quantity. Not all three are required, but if an amount or quantity is present, the reason code must be too.

Claim-level adjustment reason code

Service line-level adjustment reason code

If the amount or quantity is copied without the corresponding reason code, the payer can't process the adjustment and will reject the claim.

This edit catches the issue before the claim reaches the payer. It prevents payer rejections, which are slower and delay payment for the provider.

Rejection errors

If you submit a claim using Stedi's Claim Submission API endpoints and the claim fails the edit, you'll get back an error response in real time. The response includes details in the errors array:

{
  "errors": [
    {
      "code": "33",
      "description": "Missing Adjustment Reason Code. When an adjustment amount or quantity is present on the claim then a corresponding adjustment reason code is required. Correct and resubmit.",
      "followupAction": "Please Correct and Resubmit"
    }
  ]
}

{
  "errors": [
    {
      "code": "33",
      "description": "Missing Adjustment Reason Code. When an adjustment amount or quantity is present on the claim then a corresponding adjustment reason code is required. Correct and resubmit.",
      "followupAction": "Please Correct and Resubmit"
    }
  ]
}

{
  "errors": [
    {
      "code": "33",
      "description": "Missing Adjustment Reason Code. When an adjustment amount or quantity is present on the claim then a corresponding adjustment reason code is required. Correct and resubmit.",
      "followupAction": "Please Correct and Resubmit"
    }
  ]
}

If you submit a claim using SFTP and the claim fails the edit, Stedi will reject the claim with a 277CA claim acknowledgment. The acknowledgment will include a related claim status category code, claim status code, and error message:

STC*A6>521*[DATE]*U*[AMOUNT]********Missing Adjustment Reason Code. When an adjustment amount or quantity is present on the claim then a corresponding adjustment reason code is required. Correct and resubmit

STC*A6>521*[DATE]*U*[AMOUNT]********Missing Adjustment Reason Code. When an adjustment amount or quantity is present on the claim then a corresponding adjustment reason code is required. Correct and resubmit

STC*A6>521*[DATE]*U*[AMOUNT]********Missing Adjustment Reason Code. When an adjustment amount or quantity is present on the claim then a corresponding adjustment reason code is required. Correct and resubmit