Arkansas Medicaid Denial Reason Codes: Resubmission and Appeals

Arkansas Medicaid denial codes are the standardized messages on your Remittance Advice that explain why a claim wasn’t paid. Each code points at one specific problem: a lapse in patient eligibility, another insurer that should have paid first, a bad data field, a missing prior authorization, or a service the program doesn’t cover as billed. Once you can read the code, you know whether to correct and resubmit, request reconsideration, or write the claim off.¹

How to Read Codes on the Remittance Advice

Every processed claim generates a Remittance Advice showing payment, reduction, or denial at the claim line level. Denials use two national code sets: Claim Adjustment Reason Codes (CARC) explain the financial adjustment, and Remittance Advice Remark Codes (RARC) add context about what went wrong or what to do next.²

Arkansas Medicaid also uses internal Explanation of Benefit (EOB) codes that generally map back to a CARC or RARC. If you don’t recognize an EOB code on the RA, checking the corresponding national code usually clarifies the issue.

Patient Eligibility Denials

Eligibility denials mean the patient’s coverage didn’t line up with the service date. They’re the most common category and usually the easiest to prevent with a coverage check before the appointment.

CARC 13 — the patient’s date of death precedes the date of service.²
CARC 140 — the patient’s health identification number and name don’t match what’s on file.²
RARC N129 — the patient isn’t eligible because of their age, which often comes up with ARKids First claims when a child ages out of the program.³

Verify the Medicaid ID, name spelling, and coverage dates through the provider portal before resubmitting. CARC 140 is often just a transposed digit or a misspelled name. One thing to watch: if a patient received retroactive eligibility, the claim is still subject to the standard 12-month filing deadline from the date of service, with no exceptions.⁴

Third-Party Liability Denials

Arkansas Medicaid is the payer of last resort. If the patient has private insurance, Medicare, or any other coverage, that source pays first. CARC 22 flags this — the service may be covered by another payer under coordination of benefits.²

Bill the primary insurer, then submit to Medicaid with the primary payer’s Explanation of Benefits attached. Medicaid pays the difference between what the primary insurer paid and the Medicaid-allowed amount, but only if the primary payment was less than the Medicaid rate. If the primary paid equal to or more than what Medicaid would have allowed, Medicaid owes nothing.⁵

Submission and Formatting Denials

These denials have nothing to do with whether the service was appropriate. The claim has a data problem that kept the system from processing it. Fixing them is usually simple once you find the bad field.

CARC 16 — the claim lacks information needed for processing, or contains a billing error. A catch-all that could mean anything from a missing diagnosis code to an incomplete provider address.²
CARC 18 — the claim is an exact duplicate of one already submitted.²
RARC M77 — the place of service code is missing, incomplete, or invalid.⁶
Arkansas EOB 1100 — the National Provider Identifier on the claim doesn’t match the NPI linked to your Arkansas Medicaid enrollment.

CARC 18 duplicate denials often happen when a corrected claim is submitted as a brand-new claim instead of a replacement. If you need to correct and resubmit, use claim frequency code 7 with the original claim’s Internal Control Number rather than sending a fresh claim.

CARC 29 means the filing deadline has passed.² Arkansas Medicaid requires every claim to be filed within 12 months of the date of service, with no exceptions, including claims involving retroactive eligibility and Medicare crossover claims.⁴ A CARC 29 denial is essentially unrecoverable.

Prior Authorization Denials

Arkansas Medicaid requires prior authorization for certain surgical and medical procedures, and the Arkansas Foundation for Medical Care (AFMC) handles those reviews. Perform a procedure that needed authorization without one, and the claim comes back denied.⁷

CARC 197 is the standard code for missing precertification or authorization.² First confirm whether the service actually required authorization under Arkansas Medicaid policy. If it did and the authorization wasn’t obtained, you’ll need to request a retroactive authorization where the program allows it, or absorb the cost.

An AFMC prior authorization request needs the patient’s Medicaid number, the CPT code, all relevant diagnoses, and clinical documentation of medical necessity. If AFMC denies the request, you have 35 calendar days from the date on the denial letter to request reconsideration in writing, with a copy of the denial letter and additional supporting documentation. You get one reconsideration per request.⁷

Service and Coverage Denials

These codes turn on whether the service is covered or was billed in a way that fits the program’s rules.

CARC 96 — the charge is not covered. Either the service isn’t a Medicaid benefit, or it isn’t covered under the circumstances billed.
CARC 97 — the service is bundled into the payment for another procedure already paid on the same claim.²
CARC 7 — the procedure or revenue code doesn’t match the patient’s gender.²
CARC 9 — the diagnosis is inconsistent with the patient’s age.²

CARC 7 and CARC 9 are usually data-entry mistakes: a gender field coded wrong in the practice management system, or a diagnosis pulled from the wrong chart. Check the demographics before assuming the claim is truly non-payable.

CARC 97 bundling denials are trickier. Sometimes the right modifier, such as modifier 59 for a distinct procedural service, will unbundle the claim and allow separate payment. Other times, the service genuinely is included in the primary procedure’s reimbursement and no modifier changes that. Check the Arkansas Medicaid policy manual for the specific procedure before resubmitting.

Correcting and Resubmitting a Denied Claim

Once you know the code and have fixed the underlying problem, the corrected claim has to be resubmitted within the same 12-month window from the original date of service. That window applies to resubmissions and adjustments just as it does to first-time claims.⁴

For an electronic correction, use claim frequency code 7 (replacement of prior claim) and include the original claim’s 13-digit Internal Control Number from the Remittance Advice. To cancel a claim entirely, use frequency code 8 (void/cancel prior claim).⁸ Submitting a corrected claim as a brand-new claim typically triggers a duplicate denial under CARC 18.

For payment adjustments where a claim was underpaid, overpaid, or paid with incorrect information, use the Adjustment Request Form (HP-AR-004) sent to Gainwell Technologies. If any required field on the form is missing, Gainwell returns it without processing.¹

Reconsideration and Appeals

When you believe the claim was wrongly denied on the merits and a simple correction won’t fix it, Arkansas Medicaid has a two-step dispute process.

Administrative Reconsideration

You have 30 calendar days from receiving notice of the denial to request administrative reconsideration. That 30-day clock starts running five days after the date on the written notice. The request must be in writing and include a copy of the denial notice plus any additional documentation supporting the claim, such as medical records establishing medical necessity.⁹

Formal Appeal

If reconsideration upholds the denial, you can file a formal appeal within 10 calendar days of receiving the reconsideration decision. Skip the reconsideration step and the appeal deadline is 30 calendar days from the original denial notice. Either way, the appeal must be in writing and must specifically identify which findings or decisions are being challenged and why they conflict with applicable law or professional standards. Appeals go to the Arkansas Department of Health, Office of Medicaid Provider Appeals.⁹

Prior authorization denials follow the separate AFMC track described above, not the Office of Medicaid Provider Appeals. Missing any of these deadlines forfeits the right to dispute the denial, so tracking notice dates is worth building into the billing workflow.

1
Arkansas Department of Human Services. Adjustment Request Form – Medicaid XIX
2
X12. Claim Adjustment Reason Codes
3
X12. Remittance Advice Remark Codes
4
Cornell Law Institute. Arkansas Code R 024 – SecIII-2-17 Billing
5
AFMC. Third-Party Liability
6
CMS. Pub 100-04 Medicare Claims Processing
7
AFMC. Prior Authorization – Arkansas Medicaid Review Services
8
ResDAC. Claim Frequency Code (FFS)
9
Arkansas Department of Human Services. Medicaid Administrative Reconsiderations and Appeals