System Remittance Advice (RA) and 835 Limitations

Attention Nursing Homes, Hospitals, and Private Non-Medical Institutions, Appendix C & F (PNMI-C-F): Claims RA/835 Issues

Following the MIHMS upgrade, there are open issues affecting some RA/835s.  The issues are high priority for a fix that is underway; we are currently targeting to fix the issues by the end of October and will send another communication when the issues have been resolved. This message provides details of the issues and available workarounds until the issues are fixed. 

Cost of Care Reporting for Nursing Home, Hospital Claims, and PNMI-C-F 

Nursing Home and Hospital claims for members with cost of care are not being reported with the appropriate Claim Adjustment Reason Code (CARC) needed for balance billing members. 

  • PDF RA – CARC 142 is not being reported for cost of care. 
  • 835 – CARC 96 is being reported in error. 

As a workaround until the fix is in place, MaineCare will provide a report that can be accessed on the MaineCare Partner Portal. On the Dashboard, navigate to Reports > Other Reports > “Cost of Care Report.” This report will be available on Mondays for the claims finalized on the prior Wednesday. Because this week’s claims will be finalized on Thursday, the first report will be available no later than Tuesday, October 20, 2026.  

Spenddown Reporting for Provider Claims 

Claims with spenddown are not being reported with the appropriate CARC needed for balance billing members. 

  • PDF RA – CARC 142 is not being reported for spenddown claims.   
  • 835 – CARC 96 and/or CARC 178 is being reported in error. 

As a workaround until the fix is in place, MaineCare will provide a report that can be accessed on the MaineCare Partner Portal. On the dashboard, navigate to Reports > Other Reports > “Spend Down Report.” This report will be available on Mondays for the claims finalized on the prior Wednesday. Because this week’s claims will be finalized on Thursday, the first report will be available no later than Tuesday, October 20, 2026.  

Hospital Crossover Claims 

Hospital crossover claims are not reporting the correct CARC when the member has Medicare and full MaineCare coverage, and the claim balance is for deductible or coinsurance.  In this situation, you would normally expect a B1 CARC. 

  • PDF RA – CARC B1 is being reported appropriately. 
  • 835 – CARC 45 is being reported in error. 

As a one-time workaround, MaineCare will provide a report after this issue has been resolved. On the dashboard, navigate to Reports > Other Reports > “Bad Debt Write off Report.” We anticipate this report will be available by November 13, 2026, and will confirm once the issue is resolved. 

Claims Processed in Excess of Charges 

Claims processed in excess of billed charges are not being reported with the appropriate CARC. 

  • PDF RA – Reporting CARC 94 appropriately. 
  • 835 – Claims that pay more than the billed amount (i.e. FQHC, Hospitals with APC, DRGs) are reporting CARC 45 instead of CARC 94. 

MaineCare does not have a workaround for this issue, as CARC 45 and CARC 94 share the same Claim Adjustment Group Code of CO (Contractual Obligation). MaineCare can provide a report upon request; please contact your Provider Relations Specialist.  

For questions, please contact Provider Services at 1-866-690-5585.