A Claim Adjustment Group Code consists of two alpha characters that assign the responsibility of a Claim Adjustment on the insurance Explanation of Benefits.
These 5 EOB Claim Adjustment Group Codes are:
CO Contractual Obligation
CR Corrections and Reversal
OA Other Adjustment
PI Payer Initiated Reductions
PR Patient Responsibility
These Group Codes are combined with Claim Adjustment Reason Codes that can be numeric or alpha-numeric, ranging from 1 to W2. Claim Adjustment Reason Codes are associated with an adjustment, meaning that they must communicate why a claim or service line was paid differently than it was billed. If there is no adjustment to a claim/line, then there is no adjustment reason code.
Top 5 examples of EOB Claim Adjustments are:
CO-45 indicates claim amount that must be written off based on payer contracted fee schedule.
CO-97 indicates the benefit for this service is included in the payment/allowance for another service/procedure that has already been adjudicated.
OA-23 indicates the impact of prior payer(s) adjudication including payments and/or adjustments.
PR-1 indicates amount applied to patient deductible.
PR-2 indicates amount applied to patient co-insurance.
For a complete list of claim adjustment reason codes, visit Washington Publishing Company's website by clicking here.