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 United States or as a result of war.

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

Workers Compensation State Fee Schedule Adjustment