Example 04: Claim Adjustment Reason Code 45

Claim submitted for participating provider for office visit and other services. Only office visit
allowed/reimbursable. All other services have ‘zero’ allowed due to incidental or not covered. Office visit
has allowed of $80 and as the billed is greater than the maximum fee schedule, the difference of $70 is
reported with group code of CO and CARC code of 45.
Transmission

ISA*00* *00* *ZZ*ABCPAYER *ZZ*ABCPAYER *190827*0212*^*00501*191511902*0*P*|~
GS*HP*ABCD*ABCD*20190827*12345678*12345678*X*005010X221A1~
ST*835*10060875~
BPR*I*80.00*C*CHK************20190816~
TRN*1*CK NUMBER 1*1234567890~
REF*EV*FAC~
DTM*405*20190827~
N1*PR*ANY PLAN USA~
N3*1 WALK THIS WAY~
N4*ANYCITY*OH*45209~
PER*CX**TE*8661112222~
PER*BL*EDI*TE*8002223333*EM*EDI.SUPPORT@ANYPAYER.COM~
PER*IC**UR*WWW.ANYPAYER.COM~
N1*PE*PROVIDER*XX*1123454567~
N3*2255 ANY ROAD~
N4*ANY CITY*CA*12211~
REF*TJ*123456789~
LX*1~
CLP*PATACCT*1*400*80**MC*CLAIMNUMBER*11*1~
NM1*QC*1*DOE*JOHN*N***MI*ABC123456789~
REF*1L*12345F~
DTM*050*20190209~
PER*CX*G CUSTOMER SERVICE DEPARTMENT*TE*8004074627~
AMT*AU*150~
SVC*HC|99213*150*80**1~
DTM*472*20190101~
CAS*CO*45*70~
AMT*B6*80~
SVC*HC|85003*100*0**1~
DTM*472*20190101~

Enhanced part 1 of 3 from above

Enhanced part 2 of 3 from above

Enhanced part 3 of 3 from above