CARC 260 Active

PR-260: Processed Under Medicaid ACA Enhanced Fee Schedule

TL;DR

Your claim was processed under the Medicaid ACA Enhanced Fee Schedule. If the rate applied is incorrect, verify eligibility and coding, then appeal with documentation showing the correct fee schedule should apply.

Action
Review & Decide
Who Pays
Patient
Appeal
No
Patient Impact
Direct Financial
Disclaimer
This content is for informational purposes only and does not constitute professional billing advice. Always verify information against your payer contracts and current coding guidelines. Consult a certified billing specialist for specific claim issues.

What Does PR-260 Mean?

CARC 260 indicates that the claim was processed using the Medicaid ACA Enhanced Fee Schedule rates established under the Affordable Care Act. This code appears when the payment amount reflects the ACA-enhanced Medicaid rates, which may differ from what the provider expected based on standard Medicaid or other fee schedules.

The ACA enhanced certain Medicaid payment rates, particularly for primary care services provided by qualifying physicians. When this code appears, it means the payer applied these enhanced rates to your claim. The adjustment may result in a higher or lower payment than your billed charges, depending on the rate differential.

If the payment amount appears incorrect, the issue may be an eligibility verification problem, a coding error that triggered the wrong fee schedule, or a service that does not qualify for the enhanced rates. Reviewing the claim details against the published Medicaid ACA Enhanced Fee Schedule for your state is the first diagnostic step.

How to Resolve

Verify the fee schedule rate was correctly applied, check eligibility and coding, and appeal if the wrong rate was used.

  1. Review claim details for accuracy Check procedure codes, diagnosis codes, and modifiers to ensure they correctly represent the service and align with the ACA enhanced fee schedule requirements.
  2. Verify patient Medicaid eligibility Confirm the patient's Medicaid eligibility status during the date of service and whether the enhanced fee schedule applies.
  3. Cross-check the applied rate Compare the payment amount against the published Medicaid ACA Enhanced Fee Schedule rates for your state and service code.
  4. Identify coding discrepancies If the rate appears incorrect, check whether a coding error caused the wrong fee schedule tier to be applied.
  5. Appeal if the wrong rate was used If the incorrect fee schedule was applied, file an appeal with documentation showing the correct rate, the applicable ACA provision, and evidence that the service qualifies for a different rate.
  6. Follow up on appeal status Track the appeal and provide additional documentation as requested by the Medicaid agency.
Do Not Appeal This Code

Processed Under Medicaid ACA Enhanced Fee Schedule reflects a fee-schedule or contracted-rate reduction — the difference between billed charges and the negotiated allowed amount. The reduction is the contracted rate itself, not a denial of coverage, so an appeal isn't the right action. Confirm the contracted rate was applied correctly and accept the adjustment.

Also Filed As

The same CARC 260 may appear with different Group Codes:

CO-260 OA-260

Related Denial Codes

PR-45 — Charge Exceeds Fee Schedule/Maximum Allowable PR-139 — Contracted Funding Agreement — Subscriber Employed by Provider PR-222 — Exceeds Contracted Maximum Hours/Days/Units PR-308 — Contracted Funding Agreement Adjustment PR-P12 — Workers' Compensation Jurisdictional Fee Schedule Adjustment

Sources

  1. https://www.mdclarity.com/denial-code/260
  2. https://resdac.org/sites/datadocumentation.resdac.org/files/Adjustment%20Reason%20Code%20Code%20Table%20(TAF%20Claims).txt
  3. https://x12.org/codes/claim-adjustment-reason-codes
  4. Codes maintained by X12. Visit x12.org for official definitions.