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Medical Claims File Submission 837P

Utah



At A Glance

Name:Medical Claims File Submission 837P
State:Utah
Definition:Not Provided
VersionAugust 12, 2009 - v1.3

File Specification for Medical Claims File Submission 837P

Data Element ID Data Element Description Type Format Length
1 BHT Beginning of Hierarchical Transaction BHT06 To define the business hierarchical structure of the transaction set and identify the business application purpose and reference data, i.e., number, date, and time RP Reporting Use RP when the entire ST-SE envelope contains encounters. Use RP when the transaction is being sent to an entity (usually not a payer or a normal provider payer transmission intermediary) for purposes other than adjudication of a claim. Such an entity could be a state health data agency which is using the 837 for health data reporting purposes. ID 2/2
2 Functional Group Header GS08 Code indicating the version, release, subrelease, and industry identifier of the EDI standard being used, including the GS and GE segments; if code in DE455 in GS segment is X, then in DE 480 positions 1-3 are the version number; positions 4-6 are the release and subrelease, level of the version; and positions 7-12 are the industry or trade association identifiers (optionally assigned by user); if code in DE455 in GS segment is T, then other formats are allowed AN 1/12
3 Functional Group Header GS01 Code identifying a group of application related transaction sets AN 2/2
4 Submitter Name 1000A NM103 Individual last name or organizational name INDUSTRY: Submitter Last or Organization Name ALIAS: Submitter Name AN 2/80
5 Submitter Identifier 1000A NM109 Code identifying a party or other code INDUSTRY: Submitter Identifier ALIAS: Submitter Primary Identification Number SYNTAX: P0809 AN 2/80
6 Submitter EDI Contact Information 1000A PER01- 05 Code identifying the major duty or responsibility of the person or group named AN 2/80
7 Receiver Name 1000B NM103 Name Last or Organization Name Individual last name or organizational name INDUSTRY: Receiver Name AN 2/80
8 Receiver Identifier 1000B NM109 Not Provided AN 2/80
9 Billing Provider Name 2010AA NM103 Individual last name or organizational name INDUSTRY: Billing Provider Last or Organizational Name ALIAS: Billing Provider Name AN 2/80
10 Billing Provider ID 2010AA NM109 Individual last name or organizational name INDUSTRY: Billing Provider Last or Organizational Name ALIAS: Billing Provider Name AN 2/80
11 Billing Provider Secondary Identification 2010AA REF02 Tax Identifiing information of the Provider that was paid AN 1/30
12 Individual Relationship Code 2000B SBR02 Code indicating the relationship between two individuals or entities ALIAS: Relationship Code SEMANTIC: SBR02 specifies the relationship to the person insured. ID 2/2
13 Insured Group or Policy Number 2000B SBR03 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier INDUSTRY: Insured Group or Policy Number ALIAS: Group or Policy Number SEMANTIC: SBR03 is policy or group number. AN 1/30
14 Payer Name 2010BB NM103 Individual last name or organizational name AN 1/30
15 Subscriber Lname 2010BA NM103 Individual last name or organizational name INDUSTRY: Subscriber Last Name AN 1/35
16 Subscriber Fname 2010BA NM104 Individual first name INDUSTRY: Subscriber First Name AN 1/25
17 Subscriber Middle Name 2010BA NM105 Individual middle name or initial INDUSTRY: Subscriber Middle Name AN 1/25
18 Subscriber Primary Identifier 2010BA NM109 Code identifying a party or other code INDUSTRY: Subscriber Primary Identifier SYNTAX: P0809 AN 2/80
19 Subscriber Address1 2010BA N301 Address information INDUSTRY: Subscriber Address Line ALIAS: Subscriber Address 1 AN 1/55
20 Subscriber Address2 2010BA N302 Address information INDUSTRY: Subscriber Address Line ALIAS: Subscriber Address 2 AN 1/55
21 Subscriber City Name 2010BA N401 Free-form text for city name INDUSTRY: Subscriber City Name COMMENT: A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location. AN 2/30
22 Subscriber State 2010BA N402 Code (Standard State/Province) as defined by appropriate government agency INDUSTRY: Subscriber State Code COMMENT: N402 is required only if city name (N401) is in the U.S. or Canada. CODE SOURCE 22: States and Outlying Areas of the U.S. ID 2/2
23 Subscriber Zip Code 2010BA N403 Code defining international postal zone code excluding punctuation and blanks (zip code for United States) INDUSTRY: Subscriber Postal Zone or ZIP Code ALIAS: Subscriber Zip Code CODE SOURCE 51: ZIP Code ID 3/15
24 Subscriber Date of Birth 2010BA DMG02 Expression of a date, a time, or range of dates, times or dates and times INDUSTRY: Subscriber Birth Date ALIAS: Date of Birth - Patient SYNTAX: P0102 SEMANTIC: DMG02 is the date of birth. AN CCYYMMDD 1/35
25 Subscriber Gender 2010BA DMG03 Code indicating the sex of the individual INDUSTRY: Subscriber Gender Code ALIAS: Gender - Patient AN 1/1
26 Subscriber Secondary Identification Qualifier 2010BA REF01 Code qualifying the Reference Identification ID 2/3
27 Subscriber Secondary Identification 2010BA REF02 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier INDUSTRY: Subscriber Supplemental Identifier SYNTAX: R0203 AN 1/30
28 Patients Relationship to Insured 2000C PAT01 Code indicating the relationship between two individuals or entities ALIAS: Patients Relationship to Insured ID 2/2
29 Patient Lname 2010CA NM103 Individual last name or organizational name INDUSTRY: Patient Last Name AN 1/35
30 Patient Fname 2010CA NM104 Individual first name INDUSTRY: Patient First Name AN 1/25
31 Patient Middle Name 2010CA NM105 Individual middle name or initial INDUSTRY: Patient Middle Name ALIAS: Patient Middle Initial AN 1/25
32 Patient Primary Identifier 2010CA NM109 Code identifying a party or other code INDUSTRY: Patient Primary Identifier ALIAS: Patient's Primary Identification Number SYNTAX: P0809 AN 2/80
33 Patient Address1 2010BA/2010CA N301 Address information INDUSTRY: Patient Address Line ALIAS: Patient Address 1 AN 1/55
34 Patient Address2 2010CA N302 Address information INDUSTRY: Patient Address Line ALIAS: Patient Address 2 AN 1/55
35 Patient City Name 2010CA N401 Free-form text for city name INDUSTRY: Patient City Name COMMENT: A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location. AN 2/30
36 Patient State 2010CA N402 Code (Standard State/Province) as defined by appropriate government agency INDUSTRY: Patient State Code COMMENT: N402 is required only if city name (N401) is in the U.S. or Canada. CODE SOURCE 22: States and Outlying Areas of the U.S. ID 2/2
37 Patient Zip Code 2010CA N403 Code defining international postal zone code excluding punctuation and blanks (zip code for United States) INDUSTRY: Patient Postal Zone or ZIP Code ALIAS: Patient Zip Code CODE SOURCE 51: ZIP Code ID 3/15
38 Patient Date of Birth 2010CA DMG02 Expression of a date, a time, or range of dates, times or dates and times INDUSTRY: Patient Birth Date ALIAS: Date of Birth SYNTAX: P0102 SEMANTIC: DMG02 is the date of birth. AN 1/35
39 Patient Gender 2010CA DMG03 Code indicating the sex of the individual INDUSTRY: Patient Gender Code ALIAS: Gender - Patient AN 1/1
40 Patient Secondary Identification Qualifier 2010CA REF01 Code qualifying the Reference Identification ID 2/3
41 Patient Secondary Identification 2010CA REF02 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier INDUSTRY: Patient Secondary Identifier SYNTAX: R0203 AN 1/30
43 Facility Type Code 2300 CLM05-1 Code identifying the type of facility where services were performed; the first and second positions of the Uniform Bill Type code or the Place of Service code from the Electronic Media Claims National Standard Format INDUSTRY: Facility Type Code AN 1/2
44 Claim Frequency Type Code (Type of Bill, Position 4) 2300 CLM05-3 Code specifying the frequency of the claim; this is the third position of the Uniform Billing Claim Form Bill Type INDUSTRY: Claim Frequency Code ALIAS: Claim Submission Reason Code CODE SOURCE 235: Claim Frequency Type Code ID 1/1
46 Original Reference Number 2300 REF02 When REF01=F8 Code qualifying the Reference Identification AN 1/30
47 Admissio Date 2300 DTP03 When DTP01=435 Not Provided AN 1/35
53 Discharge Date 2300 DTP03 WHEN DTP01=096 Not Provided AN CCYYMMDD 1/35
55 Patient Account Number 2300 CLM01 Claim Submitter's Identifier Identifier used to track a claim from creation by the health care provider through payment INDUSTRY: Patient Account Number ALIAS: Patient Control Number AN 1/20
56 Medical Record Number 2300 REF02 When REF01=EA Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier INDUSTRY: Medical Record Number AN 1/30
57 Total Claim Charge Amount 2300 CLM02 Monetary amount INDUSTRY: Total Claim Charge Amount ALIAS: Total Submitted Charges SEMANTIC: CLM02 is the total amount of all submitted charges of service segments for this claim. R 1/18
58 Patient Paid Amount 2300 AMT02 When AMT01=F5 Monetary amount INDUSTRY: Patient Amount Paid R 1/18
59 Coordination Of Benefits Payer Paid Amount 2320 AMT02 WHEN AMT01 = D Monetary amount INDUSTRY: Payer Paid Amount R 1/18
60 Service Facility Name 2310D NM103 Individual last name or organizational name INDUSTRY: Laboratory or Facility Name ALIAS: Laboratory/Facility Name AN 1/35
61 Service Facility ID Code 2310D NM109 Code identifying a party or other code INDUSTRY: Laboratory or Facility Primary Identifier ALIAS: Laboratory/Facility Primary Identifier SYNTAX: P0809 AN 2/80
62 Claim Adjudication Date 2330B DTP03 WHEN DTP01=573 Expression of a date, a time, or range of dates, times or dates and times INDUSTRY: Adjudication or Payment Date AN 1/35
63 Coordination of Benefits Allowed Amount 2320 AMT02 when AMT01 = B6 Monetary amount INDUSTRY: Allowed Amount R 1/18
64 Claim Adjustment Group Code 2320 CAS01 Claim Adjustment Group Code Code identifying the general category of payment adjustment ID 1/2
65 Claim Adjustment Reason Code 2320 CAS02 Claim Adjustment reason Code Code identifying the detailed reason the adjustment was made INDUSTRY: Adjustment Reason Code ALIAS: Adjustment Reason Code - Claim Level ID 1/5
66 Claim Level Adjustment Amount 2320 CAS03 Monetary amount INDUSTRY: Adjustment Amount ALIAS: Adjusted Amount - Claim Level SEMANTIC: CAS03 is the amount of adjustment. COMMENT: When the submitted charges are paid in full, the value for CAS03 should be zero. R 1/18
67 Laboratory or Facility Primary Identifier 2310D NM109 Code identifying a party or other code INDUSTRY: Laboratory or Facility Primary Identifier ALIAS: Laboratory/Facility Primary Identifier SYNTAX: P0809 AN 2/80
72 Principal Diagnosis 2300 HI01 -2 Code indicating a code from a specific industry code list INDUSTRY: Diagnosis Code AN 1/30
74 Diagnosis 2300 HI02 -2 Code indicating a code from a specific industry code list INDUSTRY: Diagnosis Code AN 1/30
75 Diagnosis 2300 HI03 -2 Code indicating a code from a specific industry code list INDUSTRY: Diagnosis Code AN 1/30
76 Diagnosis 2300 HI04 -2 Code indicating a code from a specific industry code list INDUSTRY: Diagnosis Code AN 1/30
77 Diagnosis 2300 HI05 -2 Code indicating a code from a specific industry code list INDUSTRY: Diagnosis Code AN 1/30
78 Diagnosis 2300 HI06 -2 Code indicating a code from a specific industry code list INDUSTRY: Diagnosis Code AN 1/30
79 Diagnosis 2300 HI07 -2 Code indicating a code from a specific industry code list INDUSTRY: Diagnosis Code AN 1/30
80 Diagnosis 2300 HI08 -2 Code indicating a code from a specific industry code list INDUSTRY: Diagnosis Code AN 1/30
81 Not Provided NOT USED HI09 C022 HEALTH CARE CODE INFORMATION AN 1/30
82 Not Provided NOT USED HI10 C022 HEALTH CARE CODE INFORMATION AN 1/30
83 Not Provided NOT USED HI11 C022 HEALTH CARE CODE INFORMATION AN CCYYMMDD or range: CCYYMMDD-CCYYMMDD 1/30
84 Not Provided NOT USED HI12 C022 HEALTH CARE CODE INFORMATION AN 1/30
101 Rendering Provider Specialty 2310B PRV03 or 2000A Reference Identification Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier INDUSTRY: Provider Taxonomy Code ALIAS: Provider Specialty Code Text 10
102 Rendering Provider LName 2310B NM103 Individual last name or organizational name INDUSTRY: Rendering Provider Last or Organization Name ALIAS: Rendering Provider Last Name AN 1/35
103 Rendering Provider FName 2310B NM104 Individual first name INDUSTRY: Rendering Provider First Name AN 1/25
104 Rendering Provider Name Middle 2310B NM105 Individual middle name or initial INDUSTRY: Rendering Provider Middle Name AN 1/25
105 Rendering Provider Name Suffix 2310B NM107 Suffix to individual name INDUSTRY: Rendering Provider Name Suffix ALIAS: Rendering Provider Generation AN 1/10
106 Rendering Provider Primary Identifier 2310B NM109 Code identifying a party or other code INDUSTRY: Rendering Provider Identifier ALIAS: Rendering Provider Primary Identifier SYNTAX: P0809 AN 2/80
107 Rendering Provider Secondary Identification 2310B REF02 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier INDUSTRY: Rendering Provider Secondary Identifier SYNTAX: R0203 AN 1/30
108 Line Counter 2400 LX01 Number assigned for differentiation within a transaction set ALIAS: Line Counter This is the service line number. Begin with 1 and increment by 1 for each new LX segment within a claim. NO 1/6
109 Date(s) of Service 2400 DTP03 WHEN DTP01=472 Code specifying type of date or time, or both date and time INDUSTRY: Date Time Qualifier AN CCYYMMDD or range: CCYYMMDD-CCYYMMDD 1/35
110 Procedure Code 2400 SV101-2 Identifying number for a product or service INDUSTRY: Procedure Code AN 1/48
111 Procedure Modifier - 1 2400 SV101-3 This identifies special circumstances related to the performance of the service, as defined by trading partners ALIAS: Procedure Modifier 1 AN 2/2
112 Procedure Modifier - 2 2400 SV101-4 This identifies special circumstances related to the performance of the service, as defined by trading partners ALIAS: Procedure Modifier 2 AN 2/2
113 Procedure Modifier - 3 2400 SV101-5 This identifies special circumstances related to the performance of the service, as defined by trading partners ALIAS: Procedure Modifier 3 AN 2/2
114 Procedure Modifier - 4 2400 SV101-6 This identifies special circumstances related to the performance of the service, as defined by trading partners ALIAS: Procedure Modifier 4 AN 2/2
116 Days or Units 2400 SV104 Numeric value of quantity INDUSTRY: Service Unit Count ALIAS: Units or Minutes SYNTAX: P0304 1/15
117 Line Item Charge Amount 2400 SV102 Monetary amount INDUSTRY: Line Item Charge Amount ALIAS: Submitted charge amount SEMANTIC: SV102 is the submitted charge amount. R 1/18
118 Allowed Amount 2400 AMT02 Monetary Amount INDUSTRY: Approved Amount R 1/18
119 Drug Identification 2410 LIN03 Code identifying the type/source of the descriptive number used in Product/Service ID (234) COMMENT: LIN02 through LIN31 provide for fifteen different product/service IDs for each item. For example: Case, Color, Drawing No., U.P.C. No., ISBN No., Model No., or SKU. INDUSTRY: Product or Service ID Qualifier AN 1/48
120 Prescription Number 2410 REF02 when REF01=XZ Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier INDUSTRY: Prescription Number ALIAS: Prescription Number SYNTAX: R0203 AN 1/30
121 Drug Units Qualifier 2410 CTP05-1 Code specifying the units in which a value is being expressed, or manner in which a measurement has been taken ALIAS: Code qualifier R 1/15
122 Drug Number of Units 2410 CTP04 Numeric value of quantity INDUSTRY: National Drug Unit Count ALIAS: National Drug Unit Count SYNTAX: P0405 R 1/15
123 Drug Cost or Unit Price 2410 CTP03 Price per unit of product, service, commodity, etc. INDUSTRY: Drug Unit Price ALIAS: Drug Unit Price SYNTAX: C1103 R 1/15
124 Line Adjustment Group Code 2430 CAS01 Claim Adjustment Group Code Code identifying the general category of payment adjustment ID 1/2
125 Line Adjustment Reason Code 2430 CAS02 Claim Adjustment reason Code Code identifying the detailed reason the adjustment was made INDUSTRY: Adjustment Reason Code ALIAS: Adjustment Reason Code - Line Level ID 1/5
126 Line Level Adjustment Amount 2430 CAS03 Monetary amount INDUSTRY: Adjustment Amount ALIAS: Adjusted Amount - Line Level SEMANTIC: CAS03 is the amount of adjustment. COMMENT: When the submitted charges are paid in full, the value for CAS03 should be zero. R 1/18

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Codes and Values

Data Element ID Data Element Code Value
1 BHT Beginning of Hierarchical Transaction BHT06 RP
12 Individual Relationship Code 2000B SBR02 01 Spouse
04 Grandfather or Grandmother
05 Grandson or Granddaughter
07 Nephew or Niece
09 Adopted Child
10 Foster Child
15 Ward
17 Stepson or Stepdaughter
18 Self
19 Child
20 Employee
21 Unknown
22 Handicapped Dependent
23 Sponsored Dependent
24 Dependent of a Minor Dependent
29 Significant Other
32 Mother
33 Father
34 Other Adult
36 Emancipated Minor
39 Organ Donor
40 Cadaver Donor
41 Injured Plaintiff
43 Child Where Insured Has No Financial Responsibility
53 Life Partner
G8 Other Relationship
25 Subscriber Gender 2010BA DMG03 F Female
M Male
U Unknown
26 Subscriber Secondary Identification Qualifier 2010BA REF01 1W Member Identification Number. If NM108 = M1 do not use this code.
23 Client Number. This code is intended to be used only in claims submitted to the Indian Health Service/Contract Health Services (IHS/CHS) Fiscal Intermediary for the purpose of reporting the Health Record Number.
IG Insurance Policy Number
SY Social Security Number
28 Patients Relationship to Insured 2000C PAT01 01 Spouse
04 Grandfather or Grandmother
05 Grandson or Granddaughter
07 Nephew or Niece
09 Adopted Child
10 Foster Child
15 Ward
17 Stepson or Stepdaughter
18 Self
19 Child
20 Employee
21 Unknown
22 Handicapped Dependent
23 Sponsored Dependent
24 Dependent of a Minor Dependent
29 Significant Other
32 Mother
33 Father
34 Other Adult
36 Emancipated Minor
39 Organ Donor
40 Cadaver Donor
41 Injured Plaintiff
43 Child Where Insured Has No Financial Responsibility
53 Life Partner
G8 Other Relationship
40 Patient Secondary Identification Qualifier 2010CA REF01 1W Member Identification Number. If NM108 = M1 do not use this code.
23 Client Number. This code is intended to be used only in claims submitted to the Indian Health Service/Contract Health Services (IHS/CHS) Fiscal Intermediary for the purpose of reporting the Health Record Number.
IG Insurance Policy Number
SY Social Security Number
43 Facility Type Code 2300 CLM05-1 11 Office
12 Home
21 Inpatient Hospital
22 Outpatient Hospital
23 Emergency Room - Hospital
24 Ambulatory Surgical Center
25 Birthing Center
26 Military Treatment Facility
31 Skilled Nursing Facility
32 Nursing Facility
33 Custodial Care Facility
34 Hospice
41 Ambulance - Land
42 Ambulance - Air or Water
50 Federally Qualified Health Center
51 Inpatient Psychiatric Facility
52 Psychiatric Facility Partial Hospitalization
53 Community Mental Health Center
54 Intermediate Care Facility/Mentally Retarded
55 Residential Substance Abuse Treatment Facility
56 Psychiatric Residential Treatment Center
60 Mass Immunization Center
61 Comprehensive Inpatient Rehabilitation Facility
62 Comprehensive Outpatient Rehabilitation Facility
65 End Stage Renal Disease Treatment Facility
71 State or Local Public Health Clinic
72 Rural Health Clinic
81 Independent Laboratory
99 Other Unlisted Facially
44 Claim Frequency Type Code (Type of Bill, Position 4) 2300 CLM05-3 1 Original
6 Corrected
7 Replacement
64 Claim Adjustment Group Code 2320 CAS01 CO Contractual Obligations
CR Correction and Reversals
OA Other Adjustments
PI Payor Initiated Reductions
PR Patient Responsibility
65 Claim Adjustment Reason Code 2320 CAS02 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. Note: Changed as of 6/02
7 The procedure/revenue code is inconsistent with the patient's gender. Note: Changed as of 6/2/2013
8 The procedure code is inconsistent with the provider type/specialty (taxonomy). Note: Changed as of 6/02
9 The diagnosis is inconsistent with the patient's age.
10 The diagnosis is inconsistent with the patient's gender. Note: Changed as of 2/00
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. Note: Changed as of 2/01
16 Claim/service lacks information which is needed for adjudication. Additional information is supplied using remittance advice remarks codes whenever appropriate. This change to be effective 4/1/2007: At least one Remark Code must be provided (may be comprised of either the Remittance Advice Remark Code or NCPDP Reject Reason Code.) Note: Changed as of 2/02 and 6/06
17 Payment adjusted because requested information was not provided or was insufficient/incomplete. Additional information is supplied using the remittance advice remarks codes whenever appropriate. This change to be effective 4/1/2007: At least one Remark Code must be provided (may be comprised of either the Remittance Advice Remark Code or NCPDP Reject Reason Code.) Note: Changed as of 2/02 and 6/06
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. Note: Changed as of 2/01
23 Payment adjusted due to the impact of prior payer(s) adjudication including payments and/or adjustments Note: Changed as of 2/01, and 6/05
24 Payment for charges adjusted. Charges are covered under a capitation agreement/managed care plan. Note: Changed as of 6/00
25 Payment denied. Your Stop loss deductible has not been met.
26 Expenses incurred prior to coverage.
27 Expenses incurred after coverage terminated.
28 Coverage not in effect at the time the service was provided. Note: Inactive for 004010, since 6/98. Redundant to codes 26&27.
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. Note: Changed as of 2/01. This code will be deactivated on 2/1/2006.
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. Note: Changed as of 10/02
36 Balance does not exceed co-payment amount. Note: Inactive for 003040
37 Balance does not exceed deductible. Note: Inactive for 003040
38 Services not provided or authorized by designated (network/primary care) providers. Note: Changed as of 6/03
39 Services denied at the time authorization/pre-certification was requested.
40 Charges do not meet qualifications for emergent/urgent care.
41 Discount agreed to in Preferred Provider contract. Note: Inactive for 003040
42 Charges exceed our fee schedule or maximum allowable amount. Note: Changed as of 10/06. This code will be deactivated on 6/1/2007.
43 Gramm-Rudman reduction. Note: Changed as of 6/06. This code will be deactivated on 7/1/2006.
44 Prompt-pay discount.
45 Charges exceed your contracted/ legislated fee arrangement. This change to be effective 6/1/07: Charge exceeds fee schedule/maximum allowable or contracted/legislated fee arrangement. (Use Group Codes PR or CO depending upon liability). Note: Changed as of 10/6/2013
46 This (these) service(s) is (are) not covered. Note: Inactive for 004010, since 6/00. Use code 96
47 This (these) diagnosis(es) is (are) not covered, missing, or are invalid. Note: Changed as of 6/00. This code will be deactivated on 2/1/2006.
48 This (these) procedure(s) is (are) not covered. Note: Inactive for 004010, since 6/00. Use code 96
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. Note: Changed as of 10/98. This code will be deactivated on 2/1/2006.
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. Note: Inactive for 004050. Split into codes 150, 151, 152, 153 and 154.
58 Payment adjusted because treatment was deemed by the payer to have been rendered in an inappropriate or invalid place of service. Note: Changed as of 2/01
59 Charges are adjusted based on multiple surgery rules or concurrent anesthesia rules. Note: Changed as of 6/00
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. Note: Changed as of 6/1/2000
62 Payment denied/reduced for absence of, or exceeded, pre-certification/authorization. Note: Changed as of 2/01 and 10/06. This code will be deactivated on 4/1/2007.
63 Correction to a prior claim. Note: Inactive for 003040
64 Denial reversed per Medical Review. Note: Inactive for 003040
65 Procedure code was incorrect. This payment reflects the correct code. Note: Inactive for 3040
66 Blood Deductible.
67 Lifetime reserve days. (Handled in QTY, QTY01=LA) Note: Inactive for 003040
68 DRG weight. (Handled in CLP12) Note: Inactive for 003040
69 Day outlier amount.
70 Cost outlier - Adjustment to compensate for additional costs. Note: Changed as of 6/01
71 Primary Payer amount. Note: Deleted as of 6/00. Use code 23.
72 Coinsurance day. (Handled in QTY, QTY01=CD) Note: Inactive for 003040
73 Administrative days. Note: Inactive for 003050
74 Indirect Medical Education Adjustment.
75 Direct Medical Education Adjustment.
76 Disproportionate Share Adjustment.
77 Covered days. (Handled in QTY, QTY01=CA) Note: Inactive for 003040
78 Non-Covered days/Room charge adjustment.
79 Cost Report days. (Handled in MIA15) Note: Inactive for 003050
80 Outlier days. (Handled in QTY, QTY01=OU) Note: Inactive for 003050
81 Discharges. Note: Inactive for 003040
82 PIP days. Note: Inactive for 003040
83 Total visits. Note: Inactive for 003040
84 Capital Adjustment. (Handled in MIA) Note: Inactive for 003050
85 Interest amount.
86 Statutory Adjustment. Note: Inactive for 004010, since 6/98. Duplicative of code 45.
87 Transfer amount.
88 Adjustment amount represents collection against receivable created in prior overpayment. Note: Inactive for 004050.
89 Professional fees removed from charges.
90 Ingredient cost adjustment.
91 Dispensing fee adjustment.
92 Claim Paid in full. Note: Inactive for 003040
93 No Claim level Adjustments. Note: Inactive for 004010, since 2/99. In 004010, CAS at the claim level is optional.
94 Processed in Excess of charges.
95 Benefits adjusted. Plan procedures not followed. Note: Changed as of 6/00
96 Non-covered charge(s). This change to be effective 4/1/2007: At least one Remark Code must be provided (may be comprised of either the Remittance Advice Remark Code or NCPDP Reject Reason Code.) Note: Changed as of 6/06
97 Payment adjusted because the benefit for this service is included in the payment/allowance for another service/procedure that has already been adjudicated Note: Changed as of 2/99 and 10/06.
98 The hospital must file the Medicare claim for this inpatient non-physician service. Note: Inactive for 003040
99 Medicare Secondary Payer Adjustment Amount. Note: Inactive for 003040
100 Payment made to patient/insured/responsible party.
101 Predetermination: anticipated payment upon completion of services or claim adjudication. Note: Changed as of 2/99
102 Major Medical Adjustment.
103 Provider promotional discount (e.g., Senior citizen discount). Note: Changed as of 6/01
104 Managed care withholding.
105 Tax withholding.
106 Patient payment option/election not in effect.
107 Claim/service adjusted because the related or qualifying claim/service was not identified on this claim. Note: Changed as of 6/03 and 10/06.
108 Payment adjusted because rent/purchase guidelines were not met. Note: Changed as of 6/02
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. Note: Changed as of 2/01
113 Payment denied because service/procedure was provided outside the United States or as a result of war. Note: Changed as of 2/01; Inactive for version 004060. Use Codes 157, 158 or 159
114 Procedure/product not approved by the Food and Drug Administration.
115 Payment adjusted as procedure postponed or canceled. Note: Changed as of 2/01
116 Payment denied. The advance indemnification notice signed by the patient did not comply with requirements. Note: Changed as of 2/01
117 Payment adjusted because transportation is only covered to the closest facility that can provide the necessary care. Note: Changed as of 2/01
118 Charges reduced for ESRD network support.
119 Benefit maximum for this time period or occurrence has been reached. Note: Changed as of 2/4/2013
120 Patient is covered by a managed care plan. Note: Inactive for 004030, since 6/99. Use code 24
121 Indemnification adjustment.
122 Psychiatric reduction.
123 Payer refund due to overpayment. Note: Inactive for 004030, since 6/99. Refer to implementation guide for proper handling of reversals.
124 Payer refund amount - not our patient. Note: Inactive for 004030, since 6/99. Refer to implementation guide for proper handling of reversals.
125 Payment adjusted due to a submission/billing error(s). Additional information is supplied using the remittance advice remarks codes whenever appropriate. This change to be effective 4/1/2007: At least one Remark Code must be provided (may be comprised of either the Remittance Advice Remark Code or NCPDP Reject Reason Code.) Note: Changed as of 2/02 and 6/06
126 Deductible -- Major Medical Note: New as of 2/97
127 Coinsurance -- Major Medical Note: New as of 2/97
128 Newborn's services are covered in the mother's Allowance. Note: New as of 2/97
129 Payment denied - Prior processing information appears incorrect. Note: Changed as of 2/01
130 Claim submission fee. Note: Changed as of 6/01
131 Claim specific negotiated discount. Note: New as of 2/97
132 Prearranged demonstration project adjustment. Note: New as of 2/97
133 The disposition of this claim/service is pending further review. Note: Changed as of 10/99
134 Technical fees removed from charges. Note: New as of 10/98
135 Claim denied. Interim bills cannot be processed. Note: New as of 10/98
136 Claim adjusted based on failure to follow prior payer?s coverage rules. (Use Group Code OA). Note: Changed as of 6/00 and 10/06.
137 Payment/Reduction for Regulatory Surcharges, Assessments, Allowances or Health Related Taxes. Note: New as of 2/99
138 Claim/service denied. Appeal procedures not followed or time limits not met. Note: New as of 6/1/1999
139 Contracted funding agreement - Subscriber is employed by the provider of services. Note: New as of 6/99
140 Patient/Insured health identification number and name do not match. Note: New as of 6/99
141 Claim adjustment because the claim spans eligible and ineligible periods of coverage. Note: Changed as of 6/00
142 Claim adjusted by the monthly Medicaid patient liability amount. Note: New as of 6/00
143 Portion of payment deferred. Note: New as of 2/01
144 Incentive adjustment, e.g. preferred product/service. Note: New as of 6/01
145 Premium payment withholding Note: New as of 6/02
146 Payment denied because the diagnosis was invalid for the date(s) of service reported. Note: New as of 6/02
147 Provider contracted/negotiated rate expired or not on file. Note: New as of 6/02
148 Claim/service rejected at this time because information from another provider was not provided or was insufficient/incomplete. Note: New as of 6/02
149 Lifetime benefit maximum has been reached for this service/benefit category. Note: New as of 10/02
150 Payment adjusted because the payer deems the information submitted does not support this level of service. Note: New as of 10/02
151 Payment adjusted because the payer deems the information submitted does not support this many services. Note: New as of 10/02
152 Payment adjusted because the payer deems the information submitted does not support this length of service. Note: New as of 10/02
153 Payment adjusted because the payer deems the information submitted does not support this dosage. Note: New as of 10/02
154 Payment adjusted because the payer deems the information submitted does not support this day's supply. Note: New as of 10/02
155 This claim is denied because the patient refused the service/procedure. Note: New as of 6/03
156 Flexible spending account payments Note: New as of 9/03
157 Payment denied/reduced because service/procedure was provided as a result of an act of war. Note: New as of 9/03
158 Payment denied/reduced because the service/procedure was provided outside of the United States. Note: New as of 9/03
159 Payment denied/reduced because the service/procedure was provided as a result of terrorism. Note: New as of 9/03
160 Payment denied/reduced because injury/illness was the result of an activity that is a benefit exclusion. Note: New as of 9/03
161 Provider performance bonus Note: New as of 2/04
162 State-mandated Requirement for Property and Casualty, see Claim Payment Remarks Code for specific explanation. Note: New as of 2/04
163 Claim/Service adjusted because the attachment referenced on the claim was not received. Note: New as of 6/04
164 Claim/Service adjusted because the attachment referenced on the claim was not received in a timely fashion. Note: New as of 6/04
165 Payment denied /reduced for absence of, or exceeded referral Note: New as of 10/04
166 These services were submitted after this payers responsibility for processing claims under this plan ended. Note: New as of 2/05
167 This (these) diagnosis(es) is (are) not covered. Note: New as of 6/05
168 Payment denied as Service(s) have been considered under the patient's medical plan. Benefits are not available under this dental plan Note: New as of 6/05
169 Payment adjusted because an alternate benefit has been provided Note: New as of 6/05
170 Payment is denied when performed/billed by this type of provider. Note: New as of 6/05
171 Payment is denied when performed/billed by this type of provider in this type of facility. Note: New as of 6/05
172 Payment is adjusted when performed/billed by a provider of this specialty Note: New as of 6/05
173 Payment adjusted because this service was not prescribed by a physician Note: New as of 6/05
174 Payment denied because this service was not prescribed prior to delivery Note: New as of 6/05
175 Payment denied because the prescription is incomplete Note: New as of 6/05
176 Payment denied because the prescription is not current Note: New as of 6/05
177 Payment denied because the patient has not met the required eligibility requirements Note: New as of 6/05
178 Payment adjusted because the patient has not met the required spend down requirements. Note: New as of 6/05
179 Payment adjusted because the patient has not met the required waiting requirements Note: New as of 6/05
180 Payment adjusted because the patient has not met the required residency requirements Note: New as of 6/05
181 Payment adjusted because this procedure code was invalid on the date of service Note: New as of 6/05
182 Payment adjusted because the procedure modifier was invalid on the date of service Note: New as of 6/05. Modified on 8/8/2005
183 The referring provider is not eligible to refer the service billed. Note: New as of 6/05
184 The prescribing/ordering provider is not eligible to prescribe/order the service billed. Note: New as of 6/05
185 The rendering provider is not eligible to perform the service billed. Note: New as of 6/05
186 Payment adjusted since the level of care changed Note: New as of 6/05
187 Health Savings account payments Note: New as of 6/05
188 This product/procedure is only covered when used according to FDA recommendations. Note: New as of 6/05
189 Not otherwise classified' or 'unlisted' procedure code (CPT/HCPCS) was billed when there is a specific procedure code for this procedure/service Note: New as of 6/05
190 Payment is included in the allowance for a Skilled Nursing Facility (SNF) qualified stay. Note: New as of 10/05
191 Claim denied because this is not a work related injury/illness and thus not the liability of the workers? compensation carrier. Note: New as of 10/05
192 Non standard adjustment code from paper remittance advice. Note: New as of 10/05
193 Original payment decision is being maintained. This claim was processed properly the first time. Note: New as of 2/06
194 Payment adjusted when anesthesia is performed by the operating physician, the assistant surgeon or the attending physician Note: New as of 2/06
195 Payment denied/reduced due to a refund issued to an erroneous priority payer for this claim/service Note: New as of 2/06
196 Claim/service denied based on prior payer's coverage determination. Note: New as of 6/06. Changed 10/06. This code will be deactivated on 2/1/2007, on that date, begin to use value 136
197 Payment denied/reduced for absence of precertification/authorization Note: New as of 10/06
198 Payment denied/reduced for exceeded, precertification/authorization Note: New as of 10/06
199 Revenue code and Procedure code do not match. Note: New as of 10/06
200 Expenses incurred during lapse in coverage Note: New as of 10/06
201 Workers Compensation case settled. Patient is responsible for amount of this claim/service through WC ?Medicare set aside arrangement? or other agreement. (Use group code PR). Note: New as of 10/06
A0 Patient refund amount.
A1 Claim/Service denied. At least one Remark Code must be provided (may be comprised of either the Remittance Advice Remark Code or NCPDP Reject Reason Code). Note: Changed as of 10/06
A2 Contractual adjustment. Note: Inactive for version 004060. Use Code 45 with Group Code 'CO' or use another appropriate specific adjustment code.
A3 Medicare Secondary Payer liability met. Note: Inactive for 004010, since 6/98.
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.
B2 Covered visits. Note: Inactive for 003040
B3 Covered charges. Note: Inactive for 003040
B4 Late filing penalty.
B5 Payment adjusted because coverage/program guidelines were not met or were exceeded. Note: Changed as of 2/01
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. Note: Changed as of 2/01. This code will be deactivated on 2/1/2006.
B7 This provider was not certified/eligible to be paid for this procedure/service on this date of service. Note: Changed as of 10/98
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. Note: Changed as of 2/01
B15 Payment adjusted because this service/procedure requires that a qualifying service/procedure be received and covered. The qualifying other service/procedure has not been received/adjudicated. Note: Changed as of 2/01 and 10/06.
B16 Payment adjusted because `New Patient' qualifications were not met. Note: Changed as of 2/01
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. Note: Changed as of 2/01. This code will be deactivated on 2/1/2006.
B18 Payment adjusted because this procedure code and modifier were invalid on the date of service Note: Changed as of 2/01, 6/05
B19 Claim/service adjusted because of the finding of a Review Organization. Note: Inactive for 003070
B20 Payment adjusted because procedure/service was partially or fully furnished by another provider. Note: Changed as of 2/01
B21 The charges were reduced because the service/care was partially furnished by another physician. Note: Inactive for 003040
B22 This payment is adjusted based on the diagnosis. Note: Changed as of 2/01
B23 Payment denied because this provider has failed an aspect of a proficiency testing program. Note: Changed as of 2/01
D1 Claim/service denied. Level of subluxation is missing or inadequate. Note: Inactive for 004010, since 2/99. Use code 16 and remark codes if necessary.
D2 Claim lacks the name, strength, or dosage of the drug furnished. Note: Inactive for 004010, since 2/99. Use code 16 and remark codes if necessary.
D3 Claim/service denied because information to indicate if the patient owns the equipment that requires the part or supply was missing. Note: Inactive for 004010, since 2/99. Use code 16 and remark codes if necessary.
D4 Claim/service does not indicate the period of time for which this will be needed. Note: Inactive for 004010, since 2/99. Use code 16 and remark codes if necessary.
D5 Claim/service denied. Claim lacks individual lab codes included in the test. Note: Inactive for 004010, since 2/99. Use code 16 and remark codes if necessary.
D6 Inactive for 004010, since 2/99. Use code 16 and remark codes if necessary.
D7 Claim/service denied. Claim lacks date of patient's most recent physician visit. Note: Inactive for 004010, since 2/99. Use code 16 and remark codes if necessary.
D8 Claim/service denied. Claim lacks indicator that `x-ray is available for review.' Note: Inactive for 004010, since 2/99. Use code 16 and remark codes if necessary.
D9 Claim/service denied. Claim lacks invoice or statement certifying the actual cost of the lens, less discounts or the type of intraocular lens used. Note: Inactive for 004010, since 2/99. Use code 16 and remark codes if necessary.
D10 Claim/service denied. Completed physician financial relationship form not on file. Note: Inactive for 003070, since 8/97. Use code 17.
D11 Claim lacks completed pacemaker registration form. Note: Inactive for 003070, since 8/97. Use code 17.
D12 Claim/service denied. Claim does not identify who performed the purchased diagnostic test or the amount you were charged for the test. Note: Inactive for 003070, since 8/97. Use code 17.
D13 Claim/service denied. Performed by a facility/supplier in which the ordering/referring physician has a financial interest. Note: Inactive for 003070, since 8/97. Use code 17.
D14 Claim lacks indication that plan of treatment is on file. Note: Inactive for 003070, since 8/97. Use code 17.
D15 Claim lacks indication that service was supervised or evaluated by a physician. Note: Inactive for 003070, since 8/97. Use code 17.
D16 Claim lacks prior payer payment information. Note: Inactive as of version 5010. Use code 16 with appropriate claim payment remark code [N4].
D17 Claim/Service has invalid non-covered days. Note: Deactivation date changed from 2/1/2207 to 6/30/2007 on 2/8/2007. This code will be deactivated on 6/30/2007. Use code 16 with appropriate claim payment remark code [M32, M33].
D18 Claim/Service has missing diagnosis information. Note: Deactivation date changed from 2/1/2207 to 6/30/2007 on 2/8/2007. This code will be deactivated on 6/30/2007. Use code 16 with appropriate claim payment remark code [MA63, MA65].
D19 Claim/Service lacks Physician/Operative or other supporting documentation Note: Deactivation date changed from 2/1/2207 to 6/30/2007 on 2/8/2007. This code will be deactivated on 6/30/2007. Use code 16 with appropriate claim payment remark code [M29, M30, M35, M66].
D20 Claim/Service missing service/product information. Note: Deactivation date changed from 2/1/2207 to 6/30/2007 on 2/8/2007. This code will be deactivated on 6/30/2007. Use code 16 with appropriate claim payment remark code [M20, M67, M19, MA67].
D21 This (these) diagnosis(es) is (are) missing or are invalid Note: New as of 6/05. Deactivation date changed from 2/1/2207 to 6/30/2007 on 2/8/2007. This code will be deactivated on 6/30/2007.
W1 Workers Compensation State Fee Schedule Adjustment Note: New as of 2/00
124 Line Adjustment Group Code 2430 CAS01 CO Contractual Obligations
CR Correction and Reversals
OA Other Adjustments
PI Payor Initiated Reductions
PR Patient Responsibility
125 Line Adjustment Reason Code 2430 CAS02 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. Note: Changed as of 6/02
7 The procedure/revenue code is inconsistent with the patient's gender. Note: Changed as of 6/2/2013
8 The procedure code is inconsistent with the provider type/specialty (taxonomy). Note: Changed as of 6/02
9 The diagnosis is inconsistent with the patient's age.
10 The diagnosis is inconsistent with the patient's gender. Note: Changed as of 2/00
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. Note: Changed as of 2/01
16 Claim/service lacks information which is needed for adjudication. Additional information is supplied using remittance advice remarks codes whenever appropriate. This change to be effective 4/1/2007: At least one Remark Code must be provided (may be comprised of either the Remittance Advice Remark Code or NCPDP Reject Reason Code.) Note: Changed as of 2/02 and 6/06
17 Payment adjusted because requested information was not provided or was insufficient/incomplete. Additional information is supplied using the remittance advice remarks codes whenever appropriate. This change to be effective 4/1/2007: At least one Remark Code must be provided (may be comprised of either the Remittance Advice Remark Code or NCPDP Reject Reason Code.) Note: Changed as of 2/02 and 6/06
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. Note: Changed as of 2/01
23 Payment adjusted due to the impact of prior payer(s) adjudication including payments and/or adjustments Note: Changed as of 2/01, and 6/05
24 Payment for charges adjusted. Charges are covered under a capitation agreement/managed care plan. Note: Changed as of 6/00
25 Payment denied. Your Stop loss deductible has not been met.
26 Expenses incurred prior to coverage.
27 Expenses incurred after coverage terminated.
28 Coverage not in effect at the time the service was provided. Note: Inactive for 004010, since 6/98. Redundant to codes 26&27.
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. Note: Changed as of 2/01. This code will be deactivated on 2/1/2006.
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. Note: Changed as of 10/02
36 Balance does not exceed co-payment amount. Note: Inactive for 003040
37 Balance does not exceed deductible. Note: Inactive for 003040
38 Services not provided or authorized by designated (network/primary care) providers. Note: Changed as of 6/03
39 Services denied at the time authorization/pre-certification was requested.
40 Charges do not meet qualifications for emergent/urgent care.
41 Discount agreed to in Preferred Provider contract. Note: Inactive for 003040
42 Charges exceed our fee schedule or maximum allowable amount. Note: Changed as of 10/06. This code will be deactivated on 6/1/2007.
43 Gramm-Rudman reduction. Note: Changed as of 6/06. This code will be deactivated on 7/1/2006.
44 Prompt-pay discount.
45 Charges exceed your contracted/ legislated fee arrangement. This change to be effective 6/1/07: Charge exceeds fee schedule/maximum allowable or contracted/legislated fee arrangement. (Use Group Codes PR or CO depending upon liability). Note: Changed as of 10/6/2013
46 This (these) service(s) is (are) not covered. Note: Inactive for 004010, since 6/00. Use code 96
47 This (these) diagnosis(es) is (are) not covered, missing, or are invalid. Note: Changed as of 6/00. This code will be deactivated on 2/1/2006.
48 This (these) procedure(s) is (are) not covered. Note: Inactive for 004010, since 6/00. Use code 96
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. Note: Changed as of 10/98. This code will be deactivated on 2/1/2006.
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. Note: Inactive for 004050. Split into codes 150, 151, 152, 153 and 154.
58 Payment adjusted because treatment was deemed by the payer to have been rendered in an inappropriate or invalid place of service. Note: Changed as of 2/01
59 Charges are adjusted based on multiple surgery rules or concurrent anesthesia rules. Note: Changed as of 6/00
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. Note: Changed as of 6/1/2000
62 Payment denied/reduced for absence of, or exceeded, pre-certification/authorization. Note: Changed as of 2/01 and 10/06. This code will be deactivated on 4/1/2007.
63 Correction to a prior claim. Note: Inactive for 003040
64 Denial reversed per Medical Review. Note: Inactive for 003040
65 Procedure code was incorrect. This payment reflects the correct code. Note: Inactive for 3040
66 Blood Deductible.
67 Lifetime reserve days. (Handled in QTY, QTY01=LA) Note: Inactive for 003040
68 DRG weight. (Handled in CLP12) Note: Inactive for 003040
69 Day outlier amount.
70 Cost outlier - Adjustment to compensate for additional costs. Note: Changed as of 6/01
71 Primary Payer amount. Note: Deleted as of 6/00. Use code 23.
72 Coinsurance day. (Handled in QTY, QTY01=CD) Note: Inactive for 003040
73 Administrative days. Note: Inactive for 003050
74 Indirect Medical Education Adjustment.
75 Direct Medical Education Adjustment.
76 Disproportionate Share Adjustment.
77 Covered days. (Handled in QTY, QTY01=CA) Note: Inactive for 003040
78 Non-Covered days/Room charge adjustment.
79 Cost Report days. (Handled in MIA15) Note: Inactive for 003050
80 Outlier days. (Handled in QTY, QTY01=OU) Note: Inactive for 003050
81 Discharges. Note: Inactive for 003040
82 PIP days. Note: Inactive for 003040
83 Total visits. Note: Inactive for 003040
84 Capital Adjustment. (Handled in MIA) Note: Inactive for 003050
85 Interest amount.
86 Statutory Adjustment. Note: Inactive for 004010, since 6/98. Duplicative of code 45.
87 Transfer amount.
88 Adjustment amount represents collection against receivable created in prior overpayment. Note: Inactive for 004050.
89 Professional fees removed from charges.
90 Ingredient cost adjustment.
91 Dispensing fee adjustment.
92 Claim Paid in full. Note: Inactive for 003040
93 No Claim level Adjustments. Note: Inactive for 004010, since 2/99. In 004010, CAS at the claim level is optional.
94 Processed in Excess of charges.
95 Benefits adjusted. Plan procedures not followed. Note: Changed as of 6/00
96 Non-covered charge(s). This change to be effective 4/1/2007: At least one Remark Code must be provided (may be comprised of either the Remittance Advice Remark Code or NCPDP Reject Reason Code.) Note: Changed as of 6/06
97 Payment adjusted because the benefit for this service is included in the payment/allowance for another service/procedure that has already been adjudicated Note: Changed as of 2/99 and 10/06.
98 The hospital must file the Medicare claim for this inpatient non-physician service. Note: Inactive for 003040
99 Medicare Secondary Payer Adjustment Amount. Note: Inactive for 003040
100 Payment made to patient/insured/responsible party.
101 Predetermination: anticipated payment upon completion of services or claim adjudication. Note: Changed as of 2/99
102 Major Medical Adjustment.
103 Provider promotional discount (e.g., Senior citizen discount). Note: Changed as of 6/01
104 Managed care withholding.
105 Tax withholding.
106 Patient payment option/election not in effect.
107 Claim/service adjusted because the related or qualifying claim/service was not identified on this claim. Note: Changed as of 6/03 and 10/06.
108 Payment adjusted because rent/purchase guidelines were not met. Note: Changed as of 6/02
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. Note: Changed as of 2/01
113 Payment denied because service/procedure was provided outside the United States or as a result of war. Note: Changed as of 2/01; Inactive for version 004060. Use Codes 157, 158 or 159
114 Procedure/product not approved by the Food and Drug Administration.
115 Payment adjusted as procedure postponed or canceled. Note: Changed as of 2/01
116 Payment denied. The advance indemnification notice signed by the patient did not comply with requirements. Note: Changed as of 2/01
117 Payment adjusted because transportation is only covered to the closest facility that can provide the necessary care. Note: Changed as of 2/01
118 Charges reduced for ESRD network support.
119 Benefit maximum for this time period or occurrence has been reached. Note: Changed as of 2/4/2013
120 Patient is covered by a managed care plan. Note: Inactive for 004030, since 6/99. Use code 24
121 Indemnification adjustment.
122 Psychiatric reduction.
123 Payer refund due to overpayment. Note: Inactive for 004030, since 6/99. Refer to implementation guide for proper handling of reversals.
124 Payer refund amount - not our patient. Note: Inactive for 004030, since 6/99. Refer to implementation guide for proper handling of reversals.
125 Payment adjusted due to a submission/billing error(s). Additional information is supplied using the remittance advice remarks codes whenever appropriate. This change to be effective 4/1/2007: At least one Remark Code must be provided (may be comprised of either the Remittance Advice Remark Code or NCPDP Reject Reason Code.) Note: Changed as of 2/02 and 6/06
126 Deductible -- Major Medical Note: New as of 2/97
127 Coinsurance -- Major Medical Note: New as of 2/97
128 Newborn's services are covered in the mother's Allowance. Note: New as of 2/97
129 Payment denied - Prior processing information appears incorrect. Note: Changed as of 2/01
130 Claim submission fee. Note: Changed as of 6/01
131 Claim specific negotiated discount. Note: New as of 2/97
132 Prearranged demonstration project adjustment. Note: New as of 2/97
133 The disposition of this claim/service is pending further review. Note: Changed as of 10/99
134 Technical fees removed from charges. Note: New as of 10/98
135 Claim denied. Interim bills cannot be processed. Note: New as of 10/98
136 Claim adjusted based on failure to follow prior payer?s coverage rules. (Use Group Code OA). Note: Changed as of 6/00 and 10/06.
137 Payment/Reduction for Regulatory Surcharges, Assessments, Allowances or Health Related Taxes. Note: New as of 2/99
138 Claim/service denied. Appeal procedures not followed or time limits not met. Note: New as of 6/1/1999
139 Contracted funding agreement - Subscriber is employed by the provider of services. Note: New as of 6/99
140 Patient/Insured health identification number and name do not match. Note: New as of 6/99
141 Claim adjustment because the claim spans eligible and ineligible periods of coverage. Note: Changed as of 6/00
142 Claim adjusted by the monthly Medicaid patient liability amount. Note: New as of 6/00
143 Portion of payment deferred. Note: New as of 2/01
144 Incentive adjustment, e.g. preferred product/service. Note: New as of 6/01
145 Premium payment withholding Note: New as of 6/02
146 Payment denied because the diagnosis was invalid for the date(s) of service reported. Note: New as of 6/02
147 Provider contracted/negotiated rate expired or not on file. Note: New as of 6/02
148 Claim/service rejected at this time because information from another provider was not provided or was insufficient/incomplete. Note: New as of 6/02
149 Lifetime benefit maximum has been reached for this service/benefit category. Note: New as of 10/02
150 Payment adjusted because the payer deems the information submitted does not support this level of service. Note: New as of 10/02
151 Payment adjusted because the payer deems the information submitted does not support this many services. Note: New as of 10/02
152 Payment adjusted because the payer deems the information submitted does not support this length of service. Note: New as of 10/02
153 Payment adjusted because the payer deems the information submitted does not support this dosage. Note: New as of 10/02
154 Payment adjusted because the payer deems the information submitted does not support this day's supply. Note: New as of 10/02
155 This claim is denied because the patient refused the service/procedure. Note: New as of 6/03
156 Flexible spending account payments Note: New as of 9/03
157 Payment denied/reduced because service/procedure was provided as a result of an act of war. Note: New as of 9/03
158 Payment denied/reduced because the service/procedure was provided outside of the United States. Note: New as of 9/03
159 Payment denied/reduced because the service/procedure was provided as a result of terrorism. Note: New as of 9/03
160 Payment denied/reduced because injury/illness was the result of an activity that is a benefit exclusion. Note: New as of 9/03
161 Provider performance bonus Note: New as of 2/04
162 State-mandated Requirement for Property and Casualty, see Claim Payment Remarks Code for specific explanation. Note: New as of 2/04
163 Claim/Service adjusted because the attachment referenced on the claim was not received. Note: New as of 6/04
164 Claim/Service adjusted because the attachment referenced on the claim was not received in a timely fashion. Note: New as of 6/04
165 Payment denied /reduced for absence of, or exceeded referral Note: New as of 10/04
166 These services were submitted after this payers responsibility for processing claims under this plan ended. Note: New as of 2/05
167 This (these) diagnosis(es) is (are) not covered. Note: New as of 6/05
168 Payment denied as Service(s) have been considered under the patient's medical plan. Benefits are not available under this dental plan Note: New as of 6/05
169 Payment adjusted because an alternate benefit has been provided Note: New as of 6/05
170 Payment is denied when performed/billed by this type of provider. Note: New as of 6/05
171 Payment is denied when performed/billed by this type of provider in this type of facility. Note: New as of 6/05
172 Payment is adjusted when performed/billed by a provider of this specialty Note: New as of 6/05
173 Payment adjusted because this service was not prescribed by a physician Note: New as of 6/05
174 Payment denied because this service was not prescribed prior to delivery Note: New as of 6/05
175 Payment denied because the prescription is incomplete Note: New as of 6/05
176 Payment denied because the prescription is not current Note: New as of 6/05
177 Payment denied because the patient has not met the required eligibility requirements Note: New as of 6/05
178 Payment adjusted because the patient has not met the required spend down requirements. Note: New as of 6/05
179 Payment adjusted because the patient has not met the required waiting requirements Note: New as of 6/05
180 Payment adjusted because the patient has not met the required residency requirements Note: New as of 6/05
181 Payment adjusted because this procedure code was invalid on the date of service Note: New as of 6/05
182 Payment adjusted because the procedure modifier was invalid on the date of service Note: New as of 6/05. Modified on 8/8/2005
183 The referring provider is not eligible to refer the service billed. Note: New as of 6/05
184 The prescribing/ordering provider is not eligible to prescribe/order the service billed. Note: New as of 6/05
185 The rendering provider is not eligible to perform the service billed. Note: New as of 6/05
186 Payment adjusted since the level of care changed Note: New as of 6/05
187 Health Savings account payments Note: New as of 6/05
188 This product/procedure is only covered when used according to FDA recommendations. Note: New as of 6/05
189 Not otherwise classified' or 'unlisted' procedure code (CPT/HCPCS) was billed when there is a specific procedure code for this procedure/service Note: New as of 6/05
190 Payment is included in the allowance for a Skilled Nursing Facility (SNF) qualified stay. Note: New as of 10/05
191 Claim denied because this is not a work related injury/illness and thus not the liability of the workers? compensation carrier. Note: New as of 10/05
192 Non standard adjustment code from paper remittance advice. Note: New as of 10/05
193 Original payment decision is being maintained. This claim was processed properly the first time. Note: New as of 2/06
194 Payment adjusted when anesthesia is performed by the operating physician, the assistant surgeon or the attending physician Note: New as of 2/06
195 Payment denied/reduced due to a refund issued to an erroneous priority payer for this claim/service Note: New as of 2/06
196 Claim/service denied based on prior payer's coverage determination. Note: New as of 6/06. Changed 10/06. This code will be deactivated on 2/1/2007, on that date, begin to use value 136
197 Payment denied/reduced for absence of precertification/authorization Note: New as of 10/06
198 Payment denied/reduced for exceeded, precertification/authorization Note: New as of 10/06
199 Revenue code and Procedure code do not match. Note: New as of 10/06
200 Expenses incurred during lapse in coverage Note: New as of 10/06
201 Workers Compensation case settled. Patient is responsible for amount of this claim/service through WC ?Medicare set aside arrangement? or other agreement. (Use group code PR). Note: New as of 10/06
A0 Patient refund amount.
A1 Claim/Service denied. At least one Remark Code must be provided (may be comprised of either the Remittance Advice Remark Code or NCPDP Reject Reason Code). Note: Changed as of 10/06
A2 Contractual adjustment. Note: Inactive for version 004060. Use Code 45 with Group Code 'CO' or use another appropriate specific adjustment code.
A3 Medicare Secondary Payer liability met. Note: Inactive for 004010, since 6/98.
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.
B2 Covered visits. Note: Inactive for 003040
B3 Covered charges. Note: Inactive for 003040
B4 Late filing penalty.
B5 Payment adjusted because coverage/program guidelines were not met or were exceeded. Note: Changed as of 2/01
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. Note: Changed as of 2/01. This code will be deactivated on 2/1/2006.
B7 This provider was not certified/eligible to be paid for this procedure/service on this date of service. Note: Changed as of 10/98
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. Note: Changed as of 2/01
B15 Payment adjusted because this service/procedure requires that a qualifying service/procedure be received and covered. The qualifying other service/procedure has not been received/adjudicated. Note: Changed as of 2/01 and 10/06.
B16 Payment adjusted because `New Patient' qualifications were not met. Note: Changed as of 2/01
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. Note: Changed as of 2/01. This code will be deactivated on 2/1/2006.
B18 Payment adjusted because this procedure code and modifier were invalid on the date of service Note: Changed as of 2/01, 6/05
B19 Claim/service adjusted because of the finding of a Review Organization. Note: Inactive for 003070
B20 Payment adjusted because procedure/service was partially or fully furnished by another provider. Note: Changed as of 2/01
B21 The charges were reduced because the service/care was partially furnished by another physician. Note: Inactive for 003040
B22 This payment is adjusted based on the diagnosis. Note: Changed as of 2/01
B23 Payment denied because this provider has failed an aspect of a proficiency testing program. Note: Changed as of 2/01
D1 Claim/service denied. Level of subluxation is missing or inadequate. Note: Inactive for 004010, since 2/99. Use code 16 and remark codes if necessary.
D2 Claim lacks the name, strength, or dosage of the drug furnished. Note: Inactive for 004010, since 2/99. Use code 16 and remark codes if necessary.
D3 Claim/service denied because information to indicate if the patient owns the equipment that requires the part or supply was missing. Note: Inactive for 004010, since 2/99. Use code 16 and remark codes if necessary.
D4 Claim/service does not indicate the period of time for which this will be needed. Note: Inactive for 004010, since 2/99. Use code 16 and remark codes if necessary.
D5 Claim/service denied. Claim lacks individual lab codes included in the test. Note: Inactive for 004010, since 2/99. Use code 16 and remark codes if necessary.
D6 Inactive for 004010, since 2/99. Use code 16 and remark codes if necessary.
D7 Claim/service denied. Claim lacks date of patient's most recent physician visit. Note: Inactive for 004010, since 2/99. Use code 16 and remark codes if necessary.
D8 Claim/service denied. Claim lacks indicator that `x-ray is available for review.' Note: Inactive for 004010, since 2/99. Use code 16 and remark codes if necessary.
D9 Claim/service denied. Claim lacks invoice or statement certifying the actual cost of the lens, less discounts or the type of intraocular lens used. Note: Inactive for 004010, since 2/99. Use code 16 and remark codes if necessary.
D10 Claim/service denied. Completed physician financial relationship form not on file. Note: Inactive for 003070, since 8/97. Use code 17.
D11 Claim lacks completed pacemaker registration form. Note: Inactive for 003070, since 8/97. Use code 17.
D12 Claim/service denied. Claim does not identify who performed the purchased diagnostic test or the amount you were charged for the test. Note: Inactive for 003070, since 8/97. Use code 17.
D13 Claim/service denied. Performed by a facility/supplier in which the ordering/referring physician has a financial interest. Note: Inactive for 003070, since 8/97. Use code 17.
D14 Claim lacks indication that plan of treatment is on file. Note: Inactive for 003070, since 8/97. Use code 17.
D15 Claim lacks indication that service was supervised or evaluated by a physician. Note: Inactive for 003070, since 8/97. Use code 17.
D16 Claim lacks prior payer payment information. Note: Inactive as of version 5010. Use code 16 with appropriate claim payment remark code [N4].
D17 Claim/Service has invalid non-covered days. Note: Deactivation date changed from 2/1/2207 to 6/30/2007 on 2/8/2007. This code will be deactivated on 6/30/2007. Use code 16 with appropriate claim payment remark code [M32, M33].
D18 Claim/Service has missing diagnosis information. Note: Deactivation date changed from 2/1/2207 to 6/30/2007 on 2/8/2007. This code will be deactivated on 6/30/2007. Use code 16 with appropriate claim payment remark code [MA63, MA65].
D19 Claim/Service lacks Physician/Operative or other supporting documentation Note: Deactivation date changed from 2/1/2207 to 6/30/2007 on 2/8/2007. This code will be deactivated on 6/30/2007. Use code 16 with appropriate claim payment remark code [M29, M30, M35, M66].
D20 Claim/Service missing service/product information. Note: Deactivation date changed from 2/1/2207 to 6/30/2007 on 2/8/2007. This code will be deactivated on 6/30/2007. Use code 16 with appropriate claim payment remark code [M20, M67, M19, MA67].
D21 This (these) diagnosis(es) is (are) missing or are invalid Note: New as of 6/05. Deactivation date changed from 2/1/2207 to 6/30/2007 on 2/8/2007. This code will be deactivated on 6/30/2007.
W1 Workers Compensation State Fee Schedule Adjustment Note: New as of 2/00
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