|
Code |
Desc |
|
1 |
Deductible Amount |
|
2 |
Coinsurance Amount |
|
3 |
Co-payment Amount |
|
4 |
The procedure code is inconsistent with the modifier
used or a required modifier is missing. |
|
5 |
The procedure code/bill type is inconsistent with the
place of service. |
|
6 |
The procedure/revenue code is inconsistent with the
patient's age. |
|
7 |
The procedure/revenue code is inconsistent with the
patient's gender. |
|
8 |
The procedure code is inconsistent with the provider
type/specialty (taxonomy). |
|
9 |
The diagnosis is inconsistent with the patient's age. |
|
10 |
The diagnosis is inconsistent with the patient's
gender. |
|
11 |
The diagnosis is inconsistent with the procedure. |
|
12 |
The diagnosis is inconsistent with the provider type. |
|
13 |
The date of death precedes the date of service. |
|
14 |
The date of birth follows the date of service. |
|
15 |
Payment adjusted because the submitted authorization
number is missing, invalid, or does not apply to the billed services or
provider. |
|
16 |
Claim/service lacks information which is needed for
adjudication. Additional information is supplied using remittance advice
remarks codes whenever appropriate |
|
17 |
Payment adjusted because requested information was not
provided or was insufficient/incomplete. Additional
information is supplied using the remittance advice remarks codes wheneve |
|
18 |
Duplicate claim/service. |
|
19 |
Claim denied because this is a work-related
injury/illness and thus the liability of the Worker's Compensation Carrier. |
|
20 |
Claim denied because this injury/illness is covered by
the liability carrier. |
|
21 |
Claim denied because this injury/illness is the
liability of the no-fault carrier. |
|
22 |
Payment adjusted because this care may be covered by
another payer per coordination of benefits. |
|
23 |
Payment adjusted because charges have been paid by
another payer. |
|
24 |
Payment for charges adjusted. Charges are covered under
a capitation agreement/managed care plan. |
|
25 |
Payment denied. Your Stop loss deductible has not been
met. |
|
26 |
Expenses incurred prior to coverage. |
|
27 |
Expenses incurred after coverage terminated. |
|
29 |
The time limit for filing has expired. |
|
30 |
Payment adjusted because the patient has not met the
required eligibility, spend down, waiting, or
residency requirements. |
|
31 |
Claim denied as patient cannot be identified as our insured. |
|
32 |
Our records indicate that this dependent is not an
eligible dependent as defined. |
|
33 |
Claim denied. Insured has no dependent coverage. |
|
34 |
Claim denied. Insured has no coverage for newborns. |
|
35 |
Lifetime benefit maximum has been reached. |
|
38 |
Services not provided or authorized by designated
(network) providers. |
|
39 |
Services denied at the time
authorization/pre-certification was requested. |
|
40 |
Charges do not meet qualifications for emergent/urgent
care. |
|
42 |
Charges exceed our fee schedule or maximum allowable
amount. |
|
43 |
Gramm-Rudman reduction. |
|
44 |
Prompt-pay discount. |
|
45 |
Charges exceed your contracted/ legislated fee
arrangement. |
|
47 |
This (these) diagnosis(es) is (are) not covered, missing, or are invalid. |
|
49 |
These are non-covered services because this is a
routine exam or screening procedure done in conjunction with a routine exam. |
|
50 |
These are non-covered services because this is not
deemed a `medical necessity' by the payer. |
|
51 |
These are non-covered services because this is a pre-existing
condition |
|
52 |
The referring/prescribing/rendering provider is not
eligible to refer/prescribe/order/perform the service billed. |
|
53 |
Services by an immediate relative or a member of the
same household are not covered. |
|
54 |
Multiple physicians/assistants are not covered in this case. |
|
55 |
Claim/service denied because procedure/treatment is
deemed experimental/investigational by the payer. |
|
56 |
Claim/service denied because procedure/treatment has
not been deemed `proven to be effective' by the payer. |
|
57 |
Payment denied/reduced because the payer deems the
information submitted does not support this level of service, this many services,
this length of service, this dosage, or this day's supply. |
|
58 |
Payment adjusted because treatment was deemed by the
payer to have been rendered in an inappropriate or invalid place of service. |
|
59 |
Charges are adjusted based on multiple surgery rules or
concurrent anesthesia rules. |
|
60 |
Charges for outpatient services with this proximity to
inpatient services are not covered. |
|
61 |
Charges adjusted as penalty for failure to obtain
second surgical opinion. |
|
62 |
Payment denied/reduced for absence of, or exceeded,
pre-certification/authorization. |
|
66 |
Blood Deductible. |
|
69 |
Day outlier amount. |
|
70 |
Cost outlier - Adjustment to compensate for additional
costs. |
|
74 |
Indirect Medical Education Adjustment. |
|
75 |
Direct Medical Education Adjustment. |
|
76 |
Disproportionate Share Adjustment. |
|
78 |
Non-Covered days/Room charge adjustment. |
|
85 |
Interest amount. |
|
87 |
Transfer amount. |
|
88 |
Adjustment amount represents collection against
receivable created in prior overpayment. |
|
89 |
Professional fees removed from charges. |
|
90 |
Ingredient cost adjustment. |
|
91 |
Dispensing fee adjustment. |
|
94 |
Processed in Excess of charges. |
|
95 |
Benefits adjusted. Plan procedures not followed. |
|
96 |
Non-covered charge(s). |
|
97 |
Payment is included in the allowance for another
service/procedure. |
|
100 |
Payment made to patient/insured/responsible party. |
|
101 |
Predetermination: anticipated payment upon completion
of services or claim adjudication. |
|
102 |
Major Medical Adjustment. |
|
103 |
Provider promotional discount (e.g., Senior citizen
discount). |
|
104 |
Managed care withholding. |
|
105 |
Tax withholding. |
|
106 |
Patient payment option/election not in effect. |
|
107 |
Claim/service denied because the related or qualifying
claim/service was not paid or identified on the claim. |
|
108 |
Payment adjusted because rent/purchase guidelines were
not met. |
|
109 |
Claim not covered by this payer/contractor. You must
send the claim to the correct payer/contractor. |
|
110 |
Billing date predates service date. |
|
111 |
Not covered unless the provider accepts assignment. |
|
112 |
Payment adjusted as not furnished directly to the
patient and/or not documented. |
|
113 |
Payment denied because service/procedure was provided
outside the |
|
114 |
Procedure/product not approved by the Food and Drug
Administration. |
|
115 |
Payment adjusted as procedure postponed or canceled. |
|
116 |
Payment denied. The advance indemnification notice signed
by the patient did not comply with requirements. |
|
117 |
Payment adjusted because transportation is only covered
to the closest facility that can provide the necessary care. |
|
118 |
Charges reduced for ESRD network support. |
|
119 |
Benefit maximum for this time period has been reached. |
|
120 |
Patient is covered by a managed care plan. |
|
121 |
Indemnification adjustment. |
|
122 |
Psychiatric reduction. |
|
123 |
Payer refund due to overpayment. |
|
124 |
Payer refund amount - not our patient. |
|
125 |
Payment adjusted due to a submission/billing error(s).
Additional information is supplied using the remittance advice remarks codes
whenever appropriate. |
|
126 |
Deductible -- Major Medical |
|
127 |
Coinsurance -- Major Medical |
|
128 |
Newborn's services are covered in the mother's Allowance. |
|
129 |
Payment denied - Prior processing information appears
incorrect. |
|
130 |
Claim submission fee. |
|
131 |
Claim specific negotiated discount. |
|
132 |
Prearranged demonstration project adjustment. |
|
133 |
The disposition of this claim/service is pending
further review. |
|
134 |
Technical fees removed from charges. |
|
135 |
Claim denied. Interim bills cannot be processed. |
|
136 |
Claim Adjusted. Plan procedures of a prior payer were
not followed. |
|
137 |
Payment/Reduction for Regulatory Surcharges,
Assessments, Allowances or Health Related Taxes. |
|
138 |
Claim/service denied. Appeal procedures not followed or
time limits not met. |
|
139 |
Contracted funding agreement - Subscriber is employed
by the provider of services. |
|
140 |
Patient/Insured health identification number and name
do not match. |
|
141 |
Claim adjustment because the claim spans eligible and
ineligible periods of coverage. |
|
142 |
Claim adjusted by the monthly Medicaid patient
liability amount. |
|
143 |
Portion of payment deferred. |
|
144 |
Incentive adjustment, e.g. preferred
product/service. |
|
145 |
Premium payment withholding |
|
146 |
Payment denied because the diagnosis was invalid for
the date(s) of service reported. |
|
147 |
Provider contracted/negotiated rate expired or not on
file. |
|
148 |
Claim/service rejected at this time because information
from another provider was not provided or was insufficient/incomplete. |
|
149 |
Lifetime benefit maximum has been reached for this
service/benefit category. |
|
150 |
Payment adjusted because the payer deems the
information submitted does not support this level of service. |
|
151 |
Payment adjusted because the payer deems the
information submitted does not support this many services. |
|
152 |
Payment adjusted because the payer deems the
information submitted does not support this length of service. |
|
153 |
Payment adjusted because the payer deems the
information submitted does not support this dosage. |
|
154 |
Payment adjusted because the payer deems the
information submitted does not support this day's supply. |
|
155 |
This claim is denied because the patient refused the
service/procedure. |
|
A0 |
Patient refund amount. |
|
A1 |
Claim denied charges. |
|
A2 |
Contractual adjustment. |
|
A4 |
Medicare Claim PPS Capital Day Outlier Amount. |
|
A5 |
Medicare Claim PPS Capital Cost Outlier Amount. |
|
A6 |
Prior hospitalization or 30 day transfer requirement
not met. |
|
A7 |
Presumptive Payment Adjustment |
|
A8 |
Claim denied; ungroupable DRG |
|
B1 |
Non-covered visits. |
|
B4 |
Late filing penalty. |
|
B5 |
Payment adjusted because coverage/program guidelines
were not met or were exceeded. |
|
B6 |
This payment is adjusted when performed/billed by this
type of provider, by this type of provider in this type of facility, or by a
provider of this specialty. |
|
B7 |
This provider was not certified/eligible
to be paid for this procedure/service on this date of service. |
|
B8 |
Claim/service not covered/reduced because alternative
services were available, and should have been utilized. |
|
B9 |
Services not covered because the patient is enrolled in
a Hospice. |
|
B10 |
Allowed amount has been reduced because a component of
the basic procedure/test was paid. The beneficiary is not liable for more
than the charge limit for the basic procedure/test. |
|
B11 |
The claim/service has been transferred to the proper
payer/processor for processing. Claim/service not covered by this payer/processor. |
|
B12 |
Services not documented in patients' medical records. |
|
B13 |
Previously paid. Payment for this claim/service may
have been provided in a previous payment. |
|
B14 |
Payment denied because only one visit or consultation
per physician per day is covered. |
|
B15 |
Payment adjusted because this procedure/service is not
paid separately. |
|
B16 |
Payment adjusted because `New Patient' qualifications
were not met. |
|
B17 |
Payment adjusted because this service was not
prescribed by a physician, not prescribed prior to delivery, the prescription
is incomplete, or the prescription is not current. |
|
B18 |
Payment denied because this procedure code/modifier was
invalid on the date of service or claim submission. |
|
B20 |
Payment adjusted because procedure/service was partially
or fully furnished by another provider. |
|
B22 |
This payment is adjusted based on the diagnosis. |
|
B23 |
Payment denied because this provider has failed an
aspect of a proficiency testing program. |
|
W1 |
|