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 |
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B8 |
Claim/service not covered/reduced because alternative services were available, and should have been utilized. |
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|
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. |
|
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B11 |
The claim/service has been transferred to the proper payer/processor for processing. Claim/service not covered by this payer/processor. |
|
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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. |
|
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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 |
|
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B20 |
Payment adjusted because procedure/service was partially or fully furnished by another provider. Note: Changed as of 2/01 |
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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. |
|
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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. |
|
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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. |
|
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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 |
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|
2 |
Coinsurance Amount |
|
|
3 |
Co-payment Amount |
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|
4 |
The procedure code is inconsistent with the modifier used or a required modifier is missing. |
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|
5 |
The procedure code/bill type is inconsistent with the place of service. |
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|
6 |
The procedure/revenue code is inconsistent with the patient's age. Note: Changed as of 6/02 |
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|
7 |
The procedure/revenue code is inconsistent with the patient's gender. Note: Changed as of 6/2/2013 |
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8 |
The procedure code is inconsistent with the provider type/specialty (taxonomy). Note: Changed as of 6/02 |
|
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9 |
The diagnosis is inconsistent with the patient's age. |
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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. |
|
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13 |
The date of death precedes the date of service. |
|
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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 |
|
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147 |
Provider contracted/negotiated rate expired or not on file. Note: New as of 6/02 |
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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 |
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149 |
Lifetime benefit maximum has been reached for this service/benefit category. Note: New as of 10/02 |
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150 |
Payment adjusted because the payer deems the information submitted does not support this level of service. Note: New as of 10/02 |
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151 |
Payment adjusted because the payer deems the information submitted does not support this many services. Note: New as of 10/02 |
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152 |
Payment adjusted because the payer deems the information submitted does not support this length of service. Note: New as of 10/02 |
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153 |
Payment adjusted because the payer deems the information submitted does not support this dosage. Note: New as of 10/02 |
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154 |
Payment adjusted because the payer deems the information submitted does not support this day's supply. Note: New as of 10/02 |
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155 |
This claim is denied because the patient refused the service/procedure. Note: New as of 6/03 |
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156 |
Flexible spending account payments Note: New as of 9/03 |
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157 |
Payment denied/reduced because service/procedure was provided as a result of an act of war. Note: New as of 9/03 |
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158 |
Payment denied/reduced because the service/procedure was provided outside of the United States. Note: New as of 9/03 |
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159 |
Payment denied/reduced because the service/procedure was provided as a result of terrorism. Note: New as of 9/03 |
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160 |
Payment denied/reduced because injury/illness was the result of an activity that is a benefit exclusion. Note: New as of 9/03 |
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161 |
Provider performance bonus Note: New as of 2/04 |
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162 |
State-mandated Requirement for Property and Casualty, see Claim Payment Remarks Code for specific explanation. Note: New as of 2/04 |
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163 |
Claim/Service adjusted because the attachment referenced on the claim was not received. Note: New as of 6/04 |
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164 |
Claim/Service adjusted because the attachment referenced on the claim was not received in a timely fashion. Note: New as of 6/04 |
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165 |
Payment denied /reduced for absence of, or exceeded referral Note: New as of 10/04 |
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166 |
These services were submitted after this payers responsibility for processing claims under this plan ended. Note: New as of 2/05 |
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167 |
This (these) diagnosis(es) is (are) not covered. Note: New as of 6/05 |
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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 |
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169 |
Payment adjusted because an alternate benefit has been provided Note: New as of 6/05 |
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170 |
Payment is denied when performed/billed by this type of provider. Note: New as of 6/05 |
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171 |
Payment is denied when performed/billed by this type of provider in this type of facility. Note: New as of 6/05 |
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172 |
Payment is adjusted when performed/billed by a provider of this specialty Note: New as of 6/05 |
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173 |
Payment adjusted because this service was not prescribed by a physician Note: New as of 6/05 |
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174 |
Payment denied because this service was not prescribed prior to delivery Note: New as of 6/05 |
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175 |
Payment denied because the prescription is incomplete Note: New as of 6/05 |
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176 |
Payment denied because the prescription is not current Note: New as of 6/05 |
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177 |
Payment denied because the patient has not met the required eligibility requirements Note: New as of 6/05 |
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178 |
Payment adjusted because the patient has not met the required spend down requirements. Note: New as of 6/05 |
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179 |
Payment adjusted because the patient has not met the required waiting requirements Note: New as of 6/05 |
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180 |
Payment adjusted because the patient has not met the required residency requirements Note: New as of 6/05 |
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181 |
Payment adjusted because this procedure code was invalid on the date of service Note: New as of 6/05 |
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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 |
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183 |
The referring provider is not eligible to refer the service billed. Note: New as of 6/05 |
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184 |
The prescribing/ordering provider is not eligible to prescribe/order the service billed. Note: New as of 6/05 |
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185 |
The rendering provider is not eligible to perform the service billed. Note: New as of 6/05 |
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186 |
Payment adjusted since the level of care changed Note: New as of 6/05 |
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187 |
Health Savings account payments Note: New as of 6/05 |
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188 |
This product/procedure is only covered when used according to FDA recommendations. Note: New as of 6/05 |
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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 |
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190 |
Payment is included in the allowance for a Skilled Nursing Facility (SNF) qualified stay. Note: New as of 10/05 |
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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 |
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192 |
Non standard adjustment code from paper remittance advice. Note: New as of 10/05 |
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193 |
Original payment decision is being maintained. This claim was processed properly the first time. Note: New as of 2/06 |
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194 |
Payment adjusted when anesthesia is performed by the operating physician, the assistant surgeon or the attending physician Note: New as of 2/06 |
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195 |
Payment denied/reduced due to a refund issued to an erroneous priority payer for this claim/service Note: New as of 2/06 |
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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 |
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197 |
Payment denied/reduced for absence of precertification/authorization Note: New as of 10/06 |
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198 |
Payment denied/reduced for exceeded, precertification/authorization Note: New as of 10/06 |
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199 |
Revenue code and Procedure code do not match. Note: New as of 10/06 |
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200 |
Expenses incurred during lapse in coverage Note: New as of 10/06 |
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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 |
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A0 |
Patient refund amount. |
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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 |
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A2 |
Contractual adjustment. Note: Inactive for version 004060. Use Code 45 with Group Code 'CO' or use another appropriate specific adjustment code. |
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A3 |
Medicare Secondary Payer liability met. Note: Inactive for 004010, since 6/98. |
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A4 |
Medicare Claim PPS Capital Day Outlier Amount. |
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A5 |
Medicare Claim PPS Capital Cost Outlier Amount. |
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A6 |
Prior hospitalization or 30 day transfer requirement not met. |
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A7 |
Presumptive Payment Adjustment |
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A8 |
Claim denied; ungroupable DRG |
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B1 |
Non-covered visits. |
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B2 |
Covered visits. Note: Inactive for 003040 |
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B3 |
Covered charges. Note: Inactive for 003040 |
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B4 |
Late filing penalty. |
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B5 |
Payment adjusted because coverage/program guidelines were not met or were exceeded. Note: Changed as of 2/01 |
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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. |
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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 |
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B8 |
Claim/service not covered/reduced because alternative services were available, and should have been utilized. |
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B9 |
Services not covered because the patient is enrolled in a Hospice. |
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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. |
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B11 |
The claim/service has been transferred to the proper payer/processor for processing. Claim/service not covered by this payer/processor. |
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B12 |
Services not documented in patients' medical records. |
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B13 |
Previously paid. Payment for this claim/service may have been provided in a previous payment. |
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B14 |
Payment denied because only one visit or consultation per physician per day is covered. Note: Changed as of 2/01 |
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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. |
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B16 |
Payment adjusted because `New Patient' qualifications were not met. Note: Changed as of 2/01 |
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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. |
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B18 |
Payment adjusted because this procedure code and modifier were invalid on the date of service Note: Changed as of 2/01, 6/05 |
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B19 |
Claim/service adjusted because of the finding of a Review Organization. Note: Inactive for 003070 |
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B20 |
Payment adjusted because procedure/service was partially or fully furnished by another provider. Note: Changed as of 2/01 |
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B21 |
The charges were reduced because the service/care was partially furnished by another physician. Note: Inactive for 003040 |
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B22 |
This payment is adjusted based on the diagnosis. Note: Changed as of 2/01 |
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B23 |
Payment denied because this provider has failed an aspect of a proficiency testing program. Note: Changed as of 2/01 |
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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. |
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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. |
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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. |
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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. |
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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. |
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D6 |
Inactive for 004010, since 2/99. Use code 16 and remark codes if necessary. |
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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. |
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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. |
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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. |
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D10 |
Claim/service denied. Completed physician financial relationship form not on file. Note: Inactive for 003070, since 8/97. Use code 17. |
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D11 |
Claim lacks completed pacemaker registration form. Note: Inactive for 003070, since 8/97. Use code 17. |
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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. |
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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. |
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D14 |
Claim lacks indication that plan of treatment is on file. Note: Inactive for 003070, since 8/97. Use code 17. |
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D15 |
Claim lacks indication that service was supervised or evaluated by a physician. Note: Inactive for 003070, since 8/97. Use code 17. |
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D16 |
Claim lacks prior payer payment information. Note: Inactive as of version 5010. Use code 16 with appropriate claim payment remark code [N4]. |
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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]. |
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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]. |
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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]. |
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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]. |
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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. |
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W1 |
Workers Compensation State Fee Schedule Adjustment Note: New as of 2/00 |