| 1 | Deductible Amount
Start: 01/01/1995 |
| 2 | Coinsurance Amount
Start: 01/01/1995 |
| 3 | Co-payment Amount
Start: 01/01/1995 |
| 4 | The procedure code is inconsistent with the modifier used or a required modifier is missing.
Start: 01/01/1995 |
| 5 | The procedure code/bill type is inconsistent with the place of service.
Start: 01/01/1995 |
| 6 | The procedure/revenue code is inconsistent with the patient's age.
Start: 01/01/1995 | Last Modified: 06/30/2002 |
| 7 | The procedure/revenue code is inconsistent with the patient's gender.
Start: 01/01/1995 | Last Modified: 06/30/2002 |
| 8 | The procedure code is inconsistent with the provider type/specialty (taxonomy).
Start: 01/01/1995 | Last Modified: 06/30/2002 |
| 9 | The diagnosis is inconsistent with the patient's age.
Start: 01/01/1995 |
| 10 | The diagnosis is inconsistent with the patient's gender.
Start: 01/01/1995 | Last Modified: 02/29/2000 |
| 11 | The diagnosis is inconsistent with the procedure.
Start: 01/01/1995 |
| 12 | The diagnosis is inconsistent with the provider type.
Start: 01/01/1995 |
| 13 | The date of death precedes the date of service.
Start: 01/01/1995 |
| 14 | The date of birth follows the date of service.
Start: 01/01/1995 |
| 15 | Payment adjusted because the submitted authorization number is missing, invalid, or does not apply to the billed services or provider. This change to be effective 4/1/2008: The authorization number is missing, invalid, or does not apply to the billed services or provider.
Start: 01/01/1995 | Last Modified: 09/30/2007 |
| 16 | Claim/service lacks information which is needed for adjudication. At least one Remark Code must be provided (may be comprised of either the Remittance Advice Remark Code or NCPDP Reject Reason Code.)
Start: 01/01/1995 | Last Modified: 06/30/2006 |
| 17 | Payment adjusted because requested information was not provided or was insufficient/incomplete. At least one Remark Code must be provided (may be comprised of either the Remittance Advice Remark Code or NCPDP Reject Reason Code.) This change to be effective 4/1/2008: Requested information was not provided or was insufficient/incomplete. At least one Remark Code must be provided (may be comprised of either the Remittance Advice Remark Code or NCPDP Reject Reason Code.)
Start: 01/01/1995 | Last Modified: 09/30/2007 |
| 18 | Duplicate claim/service.
Start: 01/01/1995 |
| 19 | Claim denied because this is a work-related injury/illness and thus the liability of the Worker's Compensation Carrier. This change to be effective 4/1/2008: This is a work-related injury/illness and thus the liability of the Worker's Compensation Carrier.
Start: 01/01/1995 | Last Modified: 09/30/2007 |
| 20 | Claim denied because this injury/illness is covered by the liability carrier. This change to be effective 4/1/2008: This injury/illness is covered by the liability carrier.
Start: 01/01/1995 | Last Modified: 09/30/2007 |
| 21 | Claim denied because this injury/illness is the liability of the no-fault carrier. This change to be effective 4/1/2008: This injury/illness is the liability of the no-fault carrier.
Start: 01/01/1995 | Last Modified: 09/30/2007 |
| 22 | Payment adjusted because this care may be covered by another payer per coordination of benefits. This change to be effective 4/1/2008: This care may be covered by another payer per coordination of benefits.
Start: 01/01/1995 | Last Modified: 09/30/2007 |
| 23 | Payment adjusted due to the impact of prior payer(s) adjudication including payments and/or adjustments. This change to be effective 4/1/2008: The impact of prior payer(s) adjudication including payments and/or adjustments.
Start: 01/01/1995 | Last Modified: 09/30/2007 |
| 24 | Payment for charges adjusted. Charges are covered under a capitation agreement/managed care plan. This change to be effective 4/1/2008: Charges are covered under a capitation agreement/managed care plan.
Start: 01/01/1995 | Last Modified: 09/30/2007 |
| 25 | Payment denied. Your Stop loss deductible has not been met.
Start: 01/01/1995 | Stop: 04/01/2008 |
| 26 | Expenses incurred prior to coverage.
Start: 01/01/1995 |
| 27 | Expenses incurred after coverage terminated.
Start: 01/01/1995 |
| 28 | Coverage not in effect at the time the service was provided.
Start: 01/01/1995 | Stop: 10/16/2003
Notes: Redundant to codes 26&27. |
| 29 | The time limit for filing has expired.
Start: 01/01/1995 |
| 30 | Payment adjusted because the patient has not met the required eligibility, spend down, waiting, or residency requirements.
Start: 01/01/1995 | Stop: 02/01/2006 |
| 31 | Claim denied as patient cannot be identified as our insured. This change to be effective 4/1/2008: Patient cannot be identified as our insured.
Start: 01/01/1995 | Last Modified: 09/30/2007 |
| 32 | Our records indicate that this dependent is not an eligible dependent as defined.
Start: 01/01/1995 |
| 33 | Claim denied. Insured has no dependent coverage. This change to be effective 4/1/2008: Insured has no dependent coverage.
Start: 01/01/1995 | Last Modified: 09/30/2007 |
| 34 | Claim denied. Insured has no coverage for newborns. This change to be effective 4/1/2008: Insured has no coverage for newborns.
Start: 01/01/1995 | Last Modified: 09/30/2007 |
| 35 | Lifetime benefit maximum has been reached.
Start: 01/01/1995 | Last Modified: 10/31/2002 |
| 36 | Balance does not exceed co-payment amount.
Start: 01/01/1995 | Stop: 10/16/2003 |
| 37 | Balance does not exceed deductible.
Start: 01/01/1995 | Stop: 10/16/2003 |
| 38 | Services not provided or authorized by designated (network/primary care) providers.
Start: 01/01/1995 | Last Modified: 06/30/2003 |
| 39 | Services denied at the time authorization/pre-certification was requested.
Start: 01/01/1995 |
| 40 | Charges do not meet qualifications for emergent/urgent care.
Start: 01/01/1995 |
| 41 | Discount agreed to in Preferred Provider contract.
Start: 01/01/1995 | Stop: 10/16/2003 |
| 42 | Charges exceed our fee schedule or maximum allowable amount. (Use CARC 45)
Start: 01/01/1995 | Stop: 06/01/2007 | Last Modified: 10/31/2006 |
| 43 | Gramm-Rudman reduction.
Start: 01/01/1995 | Stop: 07/01/2006 |
| 44 | Prompt-pay discount.
Start: 01/01/1995 |
| 45 | Charge exceeds fee schedule/maximum allowable or contracted/legislated fee arrangement. (Use Group Codes PR or CO depending upon liability).
Start: 01/01/1995 | Last Modified: 10/31/2006 |
| 46 | This (these) service(s) is (are) not covered.
Start: 01/01/1995 | Stop: 10/16/2003
Notes: Use code 96. |
| 47 | This (these) diagnosis(es) is (are) not covered, missing, or are invalid.
Start: 01/01/1995 | Stop: 02/01/2006 |
| 48 | This (these) procedure(s) is (are) not covered.
Start: 01/01/1995 | Stop: 10/16/2003
Notes: 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.
Start: 01/01/1995 |
| 50 | These are non-covered services because this is not deemed a `medical necessity' by the payer.
Start: 01/01/1995 |
| 51 | These are non-covered services because this is a pre-existing condition
Start: 01/01/1995 |
| 52 | The referring/prescribing/rendering provider is not eligible to refer/prescribe/order/perform the service billed.
Start: 01/01/1995 | Stop: 02/01/2006 |
| 53 | Services by an immediate relative or a member of the same household are not covered.
Start: 01/01/1995 |
| 54 | Multiple physicians/assistants are not covered in this case .
Start: 01/01/1995 |
| 55 | Claim/service denied because procedure/treatment is deemed experimental/investigational by the payer. This change to be effective 4/1/2008: Procedure/treatment is deemed experimental/investigational by the payer.
Start: 01/01/1995 | Last Modified: 09/30/2007 |
| 56 | Claim/service denied because procedure/treatment has not been deemed `proven to be effective' by the payer. This change to be effective 4/1/2008: Procedure/treatment has not been deemed `proven to be effective' by the payer.
Start: 01/01/1995 | Last Modified: 09/30/2007 |
| 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.
Start: 01/01/1995 | Stop: 06/30/2007
Notes: 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. This change to be effective 4/1/2008: Treatment was deemed by the payer to have been rendered in an inappropriate or invalid place of service.
Start: 01/01/1995 | Last Modified: 09/30/2007 |
| 59 | Charges are adjusted based on multiple or concurrent procedure rules. (For example multiple surgery or diagnostic imaging, concurrent anesthesia.) This change to be effective 4/1/2008: Processed based on multiple or concurrent procedure rules. (For example multiple surgery or diagnostic imaging, concurrent anesthesia.)
Start: 01/01/1995 | Last Modified: 09/30/2007 |
| 60 | Charges for outpatient services with this proximity to inpatient services are not covered.
Start: 01/01/1995 |
| 61 | Charges adjusted as penalty for failure to obtain second surgical opinion. This change to be effective 4/1/2008: Penalty for failure to obtain second surgical opinion.
Start: 01/01/1995 | Last Modified: 09/30/2007 |
| 62 | Payment denied/reduced for absence of, or exceeded, pre-certification/authorization.
Start: 01/01/1995 | Stop: 04/01/2007 | Last Modified: 10/31/2006 |
| 63 | Correction to a prior claim.
Start: 01/01/1995 | Stop: 10/16/2003 |
| 64 | Denial reversed per Medical Review.
Start: 01/01/1995 | Stop: 10/16/2003 |
| 65 | Procedure code was incorrect. This payment reflects the correct code.
Start: 01/01/1995 | Stop: 10/16/2003 |
| 66 | Blood Deductible.
Start: 01/01/1995 |
| 67 | Lifetime reserve days. (Handled in QTY, QTY01=LA)
Start: 01/01/1995 | Stop: 10/16/2003 |
| 68 | DRG weight. (Handled in CLP12)
Start: 01/01/1995 | Stop: 10/16/2003 |
| 69 | Day outlier amount.
Start: 01/01/1995 |
| 70 | Cost outlier - Adjustment to compensate for additional costs.
Start: 01/01/1995 | Last Modified: 06/30/2001 |
| 71 | Primary Payer amount.
Start: 01/01/1995 | Stop: 06/30/2000
Notes: Use code 23. |
| 72 | Coinsurance day. (Handled in QTY, QTY01=CD)
Start: 01/01/1995 | Stop: 10/16/2003 |
| 73 | Administrative days.
Start: 01/01/1995 | Stop: 10/16/2003 |
| 74 | Indirect Medical Education Adjustment.
Start: 01/01/1995 |
| 75 | Direct Medical Education Adjustment.
Start: 01/01/1995 |
| 76 | Disproportionate Share Adjustment.
Start: 01/01/1995 |
| 77 | Covered days. (Handled in QTY, QTY01=CA)
Start: 01/01/1995 | Stop: 10/16/2003 |
| 78 | Non-Covered days/Room charge adjustment.
Start: 01/01/1995 |
| 79 | Cost Report days. (Handled in MIA15)
Start: 01/01/1995 | Stop: 10/16/2003 |
| 80 | Outlier days. (Handled in QTY, QTY01=OU)
Start: 01/01/1995 | Stop: 10/16/2003 |
| 81 | Discharges.
Start: 01/01/1995 | Stop: 10/16/2003 |
| 82 | PIP days.
Start: 01/01/1995 | Stop: 10/16/2003 |
| 83 | Total visits.
Start: 01/01/1995 | Stop: 10/16/2003 |
| 84 | Capital Adjustment. (Handled in MIA)
Start: 01/01/1995 | Stop: 10/16/2003 |
| 85 | Patient Interest Adjustment (Use Only Group code PR)
Start: 01/01/1995 | Last Modified: 07/09/2007
Notes: Only use when the payment of interest is the responsibility of the patient. |
| 86 | Statutory Adjustment.
Start: 01/01/1995 | Stop: 10/16/2003
Notes: Duplicative of code 45. |
| 87 | Transfer amount.
Start: 01/01/1995 |
| 88 | Adjustment amount represents collection against receivable created in prior overpayment.
Start: 01/01/1995 | Stop: 06/30/2007 |
| 89 | Professional fees removed from charges.
Start: 01/01/1995 |
| 90 | Ingredient cost adjustment.
Start: 01/01/1995 |
| 91 | Dispensing fee adjustment.
Start: 01/01/1995 |
| 92 | Claim Paid in full.
Start: 01/01/1995 | Stop: 10/16/2003 |
| 93 | No Claim level Adjustments.
Start: 01/01/1995 | Stop: 10/16/2003
Notes: As of 004010, CAS at the claim level is optional. |
| 94 | Processed in Excess of charges.
Start: 01/01/1995 |
| 95 | Benefits adjusted. Plan procedures not followed. This change to be effective 4/1/2008: Plan procedures not followed.
Start: 01/01/1995 | Last Modified: 09/30/2007 |
| 96 | Non-covered charge(s). At least one Remark Code must be provided (may be comprised of either the Remittance Advice Remark Code or NCPDP Reject Reason Code.)
Start: 01/01/1995 | Last Modified: 06/30/2006 |
| 97 | Payment adjusted because the benefit for this service is included in the payment/allowance for another service/procedure that has already been adjudicated. This change to be effective 4/1/2008: The benefit for this service is included in the payment/allowance for another service/procedure that has already been adjudicated.
Start: 01/01/1995 | Last Modified: 09/30/2007 |
| 98 | The hospital must file the Medicare claim for this inpatient non-physician service.
Start: 01/01/1995 | Stop: 10/16/2003 |
| 99 | Medicare Secondary Payer Adjustment Amount.
Start: 01/01/1995 | Stop: 10/16/2003 |
| 100 | Payment made to patient/insured/responsible party/employer.
Start: 01/01/1995 | Last Modified: 01/27/2008 |
| 101 | Predetermination: anticipated payment upon completion of services or claim adjudication.
Start: 01/01/1995 | Last Modified: 02/28/1999 |
| 102 | Major Medical Adjustment.
Start: 01/01/1995 |
| 103 | Provider promotional discount (e.g., Senior citizen discount).
Start: 01/01/1995 | Last Modified: 06/30/2001 |
| 104 | Managed care withholding.
Start: 01/01/1995 |
| 105 | Tax withholding.
Start: 01/01/1995 |
| 106 | Patient payment option/election not in effect.
Start: 01/01/1995 |
| 107 | Claim/service adjusted because the related or qualifying claim/service was not identified on this claim. This change to be effective 4/1/2008: The related or qualifying claim/service was not identified on this claim.
Start: 01/01/1995 | Last Modified: 09/30/2007 |
| 108 | Payment adjusted because rent/purchase guidelines were not met. This change to be effective 4/1/2008: Rent/purchase guidelines were not met.
Start: 01/01/1995 | Last Modified: 09/30/2007 |
| 109 | Claim not covered by this payer/contractor. You must send the claim to the correct payer/contractor.
Start: 01/01/1995 |
| 110 | Billing date predates service date.
Start: 01/01/1995 |
| 111 | Not covered unless the provider accepts assignment.
Start: 01/01/1995 |
| 112 | Payment adjusted as not furnished directly to the patient and/or not documented. This change to be effective 4/1/2008: Service not furnished directly to the patient and/or not documented.
Start: 01/01/1995 | Last Modified: 09/30/2007 |
| 113 | Payment denied because service/procedure was provided outside the United States or as a result of war.
Start: 01/01/1995 | Stop: 06/30/2007 | Last Modified: 02/28/2001
Notes: Use Codes 157, 158 or 159. |
| 114 | Procedure/product not approved by the Food and Drug Administration.
Start: 01/01/1995 |
| 115 | Payment adjusted as procedure postponed, canceled, or delayed. This change to be effective 4/1/2008: Procedure postponed, canceled, or delayed.
Start: 01/01/1995 | Last Modified: 09/30/2007 |
| 116 | Payment denied. The advance indemnification notice signed by the patient did not comply with requirements. This change to be effective 4/1/2008: The advance indemnification notice signed by the patient did not comply with requirements.
Start: 01/01/1995 | Last Modified: 09/30/2007 |
| 117 | Payment adjusted because transportation is only covered to the closest facility that can provide the necessary care. This change to be effective 4/1/2008: Transportation is only covered to the closest facility that can provide the necessary care.
Start: 01/01/1995 | Last Modified: 09/30/2007 |
| 118 | Charges reduced for ESRD network support. This change to be effective 4/1/2008: ESRD network support adjustment.
Start: 01/01/1995 | Last Modified: 09/30/2007 |
| 119 | Benefit maximum for this time period or occurrence has been reached.
Start: 01/01/1995 | Last Modified: 02/29/2004 |
| 120 | Patient is covered by a managed care plan.
Start: 01/01/1995 | Stop: 06/30/2007
Notes: Use code 24. |
| 121 | Indemnification adjustment. This change effective 4/1/2008: Indemnification adjustment - compensation for outstanding member responsibility.
Start: 01/01/1995 | Last Modified: 09/30/2007 |
| 122 | Psychiatric reduction.
Start: 01/01/1995 |
| 123 | Payer refund due to overpayment.
Start: 01/01/1995 | Stop: 06/30/2007
Notes: Refer to implementation guide for proper handling of reversals. |
| 124 | Payer refund amount - not our patient.
Start: 01/01/1995 | Stop: 06/30/2007 | Last Modified: 06/30/1999
Notes: Refer to implementation guide for proper handling of reversals. |
| 125 | Payment adjusted due to a submission/billing error(s). At least one Remark Code must be provided (may be comprised of either the Remittance Advice Remark Code or NCPDP Reject Reason Code.) This change to be effective 4/1/2008: Submission/billing error(s). At least one Remark Code must be provided (may be comprised of either the Remittance Advice Remark Code or NCPDP Reject Reason Code.)
Start: 01/01/1995 | Last Modified: 09/30/2007 |
| 126 | Deductible -- Major Medical
Start: 02/28/1997 | Stop: 04/01/2008 | Last Modified: 09/30/2007
Notes: Use Group Code PR and code 1. |
| 127 | Coinsurance -- Major Medical
Start: 02/28/1997 | Stop: 04/01/2008 | Last Modified: 09/30/2007
Notes: Use Group Code PR and code 2. |
| 128 | Newborn's services are covered in the mother's Allowance.
Start: 02/28/1997 |
| 129 | Payment denied - Prior processing information appears incorrect. This change to be effective 4/1/2008: Prior processing information appears incorrect.
Start: 02/28/1997 | Last Modified: 09/30/2007 |
| 130 | Claim submission fee.
Start: 02/28/1997 | Last Modified: 06/30/2001 |
| 131 | Claim specific negotiated discount.
Start: 02/28/1997 |
| 132 | Prearranged demonstration project adjustment.
Start: 02/28/1997 |
| 133 | The disposition of this claim/service is pending further review.
Start: 02/28/1997 | Last Modified: 10/31/1999 |
| 134 | Technical fees removed from charges.
Start: 10/31/1998 |
| 135 | Claim denied. Interim bills cannot be processed. This change to be effective 4/1/2008: Interim bills cannot be processed.
Start: 10/31/1998 | Last Modified: 09/30/2007 |
| 136 | Claim adjusted based on failure to follow prior payer’s coverage rules. (Use Group Code OA). This change to be effective 4/1/2008: Failure to follow prior payer’s coverage rules. (Use Group Code OA).
Start: 10/31/1998 | Last Modified: 09/30/2007 |
| 137 | Payment/Reduction for Regulatory Surcharges, Assessments, Allowances or Health Related Taxes. This change to be effective 4/1/2008: Regulatory Surcharges, Assessments, Allowances or Health Related Taxes.
Start: 02/28/1999 | Last Modified: 09/30/2007 |
| 138 | Claim/service denied. Appeal procedures not followed or time limits not met. This change to be effective 4/1/2008: Appeal procedures not followed or time limits not met.
Start: 06/30/1999 | Last Modified: 09/30/2007 |
| 139 | Contracted funding agreement - Subscriber is employed by the provider of services.
Start: 06/30/1999 |
| 140 | Patient/Insured health identification number and name do not match.
Start: 06/30/1999 |
| 141 | Claim adjustment because the claim spans eligible and ineligible periods of coverage. This change to be effective 4/1/2008: Claim spans eligible and ineligible periods of coverage.
Start: 06/30/1999 | Last Modified: 09/30/2007 |
| 142 | Claim adjusted by the monthly Medicaid patient liability amount. This change to be effective 4/1/2008: Monthly Medicaid patient liability amount.
Start: 06/30/2000 | Last Modified: 09/30/2007 |
| 143 | Portion of payment deferred.
Start: 02/28/2001 |
| 144 | Incentive adjustment, e.g. preferred product/service.
Start: 06/30/2001 |
| 145 | Premium payment withholding
Start: 06/30/2002 | Stop: 04/01/2008 | Last Modified: 09/30/2007
Notes: Use Group Code CO and code 45. |
| 146 | Payment denied because the diagnosis was invalid for the date(s) of service reported. This change to be effective 4/1/2008: Diagnosis was invalid for the date(s) of service reported.
Start: 06/30/2002 | Last Modified: 09/30/2007 |
| 147 | Provider contracted/negotiated rate expired or not on file.
Start: 06/30/2002 |
| 148 | Claim/service rejected at this time because information from another provider was not provided or was insufficient/incomplete. This change to be effective 4/1/2008: Information from another provider was not provided or was insufficient/incomplete.
Start: 06/30/2002 | Last Modified: 09/30/2007 |
| 149 | Lifetime benefit maximum has been reached for this service/benefit category.
Start: 10/31/2002 |
| 150 | Payment adjusted because the payer deems the information submitted does not support this level of service. This change to be effective 4/1/2008: Payer deems the information submitted does not support this level of service.
Start: 10/31/2002 | Last Modified: 09/30/2007 |
| 151 | Payment adjusted because the payer deems the information submitted does not support this many/frequency of services.
Start: 10/31/2002 | Last Modified: 01/27/2008 |
| 152 | Payment adjusted because the payer deems the information submitted does not support this length of service. This change to be effective 4/1/2008: Payer deems the information submitted does not support this length of service.
Start: 10/31/2002 | Last Modified: 09/30/2007 |
| 153 | Payment adjusted because the payer deems the information submitted does not support this dosage. This change to be effective 4/1/2008: Payer deems the information submitted does not support this dosage.
Start: 10/31/2002 | Last Modified: 09/30/2007 |
| 154 | Payment adjusted because the payer deems the information submitted does not support this day's supply. This change to be effective 4/1/2008: Payer deems the information submitted does not support this day's supply.
Start: 10/31/2002 | Last Modified: 09/30/2007 |
| 155 | This claim is denied because the patient refused the service/procedure. This change to be effective 4/1/2008: Patient refused the service/procedure.
Start: 06/30/2003 | Last Modified: 09/30/2007 |
| 156 | Flexible spending account payments
Start: 09/30/2003 |
| 157 | Payment denied/reduced because service/procedure was provided as a result of an act of war. This change to be effective 4/1/2008: Service/procedure was provided as a result of an act of war.
Start: 09/30/2003 | Last Modified: 09/30/2007 |
| 158 | Payment denied/reduced because the service/procedure was provided outside of the United States. This change to be effective 4/1/2008: Service/procedure was provided outside of the United States.
Start: 09/30/2003 | Last Modified: 09/30/2007 |
| 159 | Payment denied/reduced because the service/procedure was provided as a result of terrorism. This change to be effective 4/1/2008: Service/procedure was provided as a result of terrorism.
Start: 09/30/2003 | Last Modified: 09/30/2007 |
| 160 | Payment denied/reduced because injury/illness was the result of an activity that is a benefit exclusion. This change to be effective 4/1/2008: Injury/illness was the result of an activity that is a benefit exclusion.
Start: 09/30/2003 | Last Modified: 09/30/2007 |
| 161 | Provider performance bonus
Start: 02/29/2004 |
| 162 | State-mandated Requirement for Property and Casualty, see Claim Payment Remarks Code for specific explanation.
Start: 02/29/2004 |
| 163 | Claim/Service adjusted because the attachment referenced on the claim was not received. This change to be effective 4/1/2008: Attachment referenced on the claim was not received.
Start: 06/30/2004 | Last Modified: 09/30/2007 |
| 164 | Claim/Service adjusted because the attachment referenced on the claim was not received in a timely fashion. This change to be effective 4/1/2008: Attachment referenced on the claim was not received in a timely fashion.
Start: 06/30/2004 | Last Modified: 09/30/2007 |
| 165 | Payment denied /reduced for absence of, or exceeded referral. This change to be effective 4/1/2008: Referral absent or exceeded.
Start: 10/31/2004 | Last Modified: 09/30/2007 |
| 166 | These services were submitted after this payers responsibility for processing claims under this plan ended.
Start: 02/28/2005 |
| 167 | This (these) diagnosis(es) is (are) not covered.
Start: 06/30/2005 |
| 168 | Payment denied as Service(s) have been considered under the patient's medical plan. Benefits are not available under this dental plan. This change to be effective 4/1/2008: Service(s) have been considered under the patient's medical plan. Benefits are not available under this dental plan.
Start: 06/30/2005 | Last Modified: 09/30/2007 |
| 169 | Payment adjusted because an alternate benefit has been provided. This change to be effective 4/1/2008: Alternate benefit has been provided.
Start: 06/30/2005 | Last Modified: 09/30/2007 |
| 170 | Payment is denied when performed/billed by this type of provider.
Start: 06/30/2005 |
| 171 | Payment is denied when performed/billed by this type of provider in this type of facility.
Start: 06/30/2005 |
| 172 | Payment is adjusted when performed/billed by a provider of this specialty
Start: 06/30/2005 |
| 173 | Payment adjusted because this service was not prescribed by a physician. This change to be effective 4/1/2008: Service was not prescribed by a physician.
Start: 06/30/2005 | Last Modified: 09/30/2007 |
| 174 | Payment denied because this service was not prescribed prior to delivery. This change to be effective 4/1/2008: Service was not prescribed prior to delivery.
Start: 06/30/2005 | Last Modified: 09/30/2007 |
| 175 | Payment denied because the prescription is incomplete. This change to be effective 4/1/2008: Prescription is incomplete.
Start: 06/30/2005 | Last Modified: 09/30/2007 |
| 176 | Payment denied because the prescription is not current. This change to be effective 4/1/2008: Prescription is not current.
Start: 06/30/2005 | Last Modified: 09/30/2007 |
| 177 | Payment denied because the patient has not met the required eligibility requirements. This change to be effective 4/1/2008: Patient has not met the required eligibility requirements.
Start: 06/30/2005 | Last Modified: 09/30/2007 |
| 178 | Payment adjusted because the patient has not met the required spend down requirements. This change to be effective 4/1/2008: Patient has not met the required spend down requirements.
Start: 06/30/2005 | Last Modified: 09/30/2007 |
| 179 | Payment adjusted because the patient has not met the required waiting requirements. This change to be effective 4/1/2008: Patient has not met the required waiting requirements.
Start: 06/30/2005 | Last Modified: 09/30/2007 |
| 180 | Payment adjusted because the patient has not met the required residency requirements. This change to be effective 4/1/2008: Patient has not met the required residency requirements.
Start: 06/30/2005 | Last Modified: 09/30/2007 |
| 181 | Payment adjusted because this procedure code was invalid on the date of service. This change to be effective 4/1/2008: Procedure code was invalid on the date of service.
Start: 06/30/2005 | Last Modified: 09/30/2007 |
| 182 | Payment adjusted because the procedure modifier was invalid on the date of service. This change to be effective 4/1/2008: Procedure modifier was invalid on the date of service.
Start: 06/30/2005 | Last Modified: 09/30/2007 |
| 183 | The referring provider is not eligible to refer the service billed.
Start: 06/30/2005 |
| 184 | The prescribing/ordering provider is not eligible to prescribe/order the service billed.
Start: 06/30/2005 |
| 185 | The rendering provider is not eligible to perform the service billed.
Start: 06/30/2005 |
| 186 | Payment adjusted since the level of care changed. This change to be effective 4/1/2008: Level of care change adjustment.
Start: 06/30/2005 | Last Modified: 09/30/2007 |
| 187 | Health Savings account payments
Start: 06/30/2005 |
| 188 | This product/procedure is only covered when used according to FDA recommendations.
Start: 06/30/2005 |
| 189 | 'Not otherwise classified' or 'unlisted' procedure code (CPT/HCPCS) was billed when there is a specific procedure code for this procedure/service
Start: 06/30/2005 |
| 190 | Payment is included in the allowance for a Skilled Nursing Facility (SNF) qualified stay.
Start: 10/31/2005 |
| 191 | Claim denied because this is not a work related injury/illness and thus not the liability of the workers’ compensation carrier. This change to be effective 4/1/2008: Not a work related injury/illness and thus not the liability of the workers’ compensation carrier.
Start: 10/31/2005 | Last Modified: 09/30/2007 |
| 192 | Non standard adjustment code from paper remittance advice. This change to be effective 4/1/2008: Non standard adjustment code from paper remittance. Note: This code is to be used by providers/payers providing Coordination of Benefits information to another payer in the 837 transaction only. This code is only used when the non-standard code cannot be reasonably mapped to an existing Claims Adjustment Reason Code, specifically Deductible, Coinsurance and Co-payment.
Start: 10/31/2005 | Last Modified: 09/30/2007 |
| 193 | Original payment decision is being maintained. Upon review, it was determined that this claim was processed properly.
Start: 02/28/2006 | Last Modified: 01/27/2008 |
| 194 | Payment adjusted when anesthesia is performed by the operating physician, the assistant surgeon or the attending physician. This change to be effective 4/1/2008: Anesthesia performed by the operating physician, the assistant surgeon or the attending physician.
Start: 02/28/2006 | Last Modified: 09/30/2007 |
| 195 | Payment denied/reduced due to a refund issued to an erroneous priority payer for this claim/service. This change to be effective 4/1/2008: Refund issued to an erroneous priority payer for this claim/service.
Start: 02/28/2006 | Last Modified: 09/30/2007 |
| 196 | Claim/service denied based on prior payer's coverage determination.
Start: 06/30/2006 | Stop: 02/01/2007
Notes: Use code 136. |
| 197 | Payment adjusted for absence of precertification/authorization/notification. This change effective 4/1/2008: Precertification/authorization/notification absent.
Start: 10/31/2006 | Last Modified: 09/30/2007 |
| 198 | Payment Adjusted for exceeding precertification/ authorization. This change to be effective 4/1/2008: Precertification/authorization exceeded.
Start: 10/31/2006 | Last Modified: 09/30/2007 |
| 199 | Revenue code and Procedure code do not match.
Start: 10/31/2006 |
| 200 | Expenses incurred during lapse in coverage
Start: 10/31/2006 |
| 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).
Start: 10/31/2006 |
| 202 | Payment adjusted due to non-covered personal comfort or convenience services. This change to be effective 4/1/2008: Non-covered personal comfort or convenience services.
Start: 02/28/2007 | Last Modified: 09/30/2007 |
| 203 | Payment adjusted for discontinued or reduced service. This change to be effective 4/1/2008: Discontinued or reduced service.
Start: 02/28/2007 | Last Modified: 09/30/2007 |
| 204 | This service/equipment/drug is not covered under the patient’s current benefit plan
Start: 02/28/2007 |
| 205 | Pharmacy discount card processing fee
Start: 07/09/2007 |
| 206 | NPI denial - Missing. This change to be effective 4/1/2008: National Provider Identifier - missing.
Start: 07/09/2007 | Last Modified: 09/30/2007 |
| 207 | NPI denial - Invalid format. This change effective 4/1/2008: National Provider identifier - Invalid format
Start: 07/09/2007 | Stop: 05/23/2008 | Last Modified: 09/30/2007 |
| 208 | NPI denial - not matched. This change to be effective 4/1/2008: National Provider Identifier - Not matched.
Start: 07/09/2007 | Last Modified: 09/30/2007 |
| 209 | Per regulatory or other agreement. The provider cannot collect this amount from the patient. However, this amount may be billed to subsequent payer. Refund to patient if collected. (Use Group code OA)
Start: 07/09/2007 |
| 210 | Payment adjusted because pre-certification/authorization not received in a timely fashion
Start: 07/09/2007 |
| 211 | National Drug Codes (NDC) not eligible for rebate, are not covered.
Start: 07/09/2007 |
| 212 | Administrative surcharges are not covered
Start: 11/05/2007 |
| 213 | Non-compliance with the physician self referral prohibition legislation or payer policy.
Start: 01/27/2008 |
| 214 | Workers' Compensation claim adjudicated as non-compensable. This Payer not liable for claim or service/treatment. (Note: To be used for Workers' Compensation only)
Start: 01/27/2008 |
| 215 | Based on subrogation of a third party settlement
Start: 01/27/2008 |
| 216 | Based on the findings of a review organization
Start: 01/27/2008 |
| 217 | Based on payer reasonable and customary fees. No maximum allowable defined by legislated fee arrangement. (Note: To be used for Workers' Compensation only)
Start: 01/27/2008 |
| 218 | Based on entitlement to benefits (Note: To be used for Workers' Compensation only)
Start: 01/27/2008 |
| 219 | Based on extent of injury (Note: To be used for Workers' Compensation only)
Start: 01/27/2008 |
| 220 | The applicable fee schedule does not contain the billed code. Please resubmit a bill with the appropriate fee schedule code(s) that best describe the service(s) provided and supporting documentation if required. (Note: To be used for Workers' Compensation only)
Start: 01/27/2008 |
| 221 | Workers' Compensation claim is under investigation. (Note: To be used for Workers' Compensation only. Claim pending final resolution)
Start: 01/27/2008 |
| A0 | Patient refund amount.
Start: 01/01/1995 |
| 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.)
Start: 01/01/1995 | Last Modified: 10/31/2006 |
| A2 | Contractual adjustment.
Start: 01/01/1995 | Stop: 01/01/2008 | Last Modified: 02/28/2007
Notes: Use Code 45 with Group Code 'CO' or use another appropriate specific adjustment code. |
| A3 | Medicare Secondary Payer liability met.
Start: 01/01/1995 | Stop: 10/16/2003 |
| A4 | Medicare Claim PPS Capital Day Outlier Amount.
Start: 01/01/1995 | Stop: 04/01/2008 | Last Modified: 09/30/2007 |
| A5 | Medicare Claim PPS Capital Cost Outlier Amount.
Start: 01/01/1995 |
| A6 | Prior hospitalization or 30 day transfer requirement not met.
Start: 01/01/1995 |
| A7 | Presumptive Payment Adjustment
Start: 01/01/1995 |
| A8 | Claim denied; ungroupable DRG. This change to be effective 4/1/2008: Ungroupable DRG.
Start: 01/01/1995 | Last Modified: 09/30/2007 |
| B1 | Non-covered visits.
Start: 01/01/1995 |
| B2 | Covered visits.
Start: 01/01/1995 | Stop: 10/16/2003 |
| B3 | Covered charges.
Start: 01/01/1995 | Stop: 10/16/2003 |
| B4 | Late filing penalty.
Start: 01/01/1995 |
| B5 | Payment adjusted because coverage/program guidelines were not met or were exceeded. This change to be effective 4/1/2008: Coverage/program guidelines were not met or were exceeded.
Start: 01/01/1995 | Last Modified: 09/30/2007 |
| 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.
Start: 01/01/1995 | Stop: 02/01/2006 |
| B7 | This provider was not certified/eligible to be paid for this procedure/service on this date of service.
Start: 01/01/1995 | Last Modified: 10/31/1998 |
| B8 | Claim/service not covered/reduced because alternative services were available, and should have been utilized. This change to be effective 4/1/2008: Alternative services were available, and should have been utilized.
Start: 01/01/1995 | Last Modified: 09/30/2007 |
| B9 | Services not covered because the patient is enrolled in a Hospice. This change to be effective 4/1/2008: Patient is enrolled in a Hospice.
Start: 01/01/1995 | Last Modified: 09/30/2007 |
| 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.
Start: 01/01/1995 |
| B11 | The claim/service has been transferred to the proper payer/processor for processing. Claim/service not covered by this payer/processor.
Start: 01/01/1995 |
| B12 | Services not documented in patients' medical records.
Start: 01/01/1995 |
| B13 | Previously paid. Payment for this claim/service may have been provided in a previous payment.
Start: 01/01/1995 |
| B14 | Payment denied because only one visit or consultation per physician per day is covered. This change to be effective 4/1/2008: Only one visit or consultation per physician per day is covered.
Start: 01/01/1995 | Last Modified: 09/30/2007 |
| 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. This change to be effective 4/1/2008: This service/procedure requires that a qualifying service/procedure be received and covered. The qualifying other service/procedure has not been received/adjudicated.
Start: 01/01/1995 | Last Modified: 09/30/2007 |
| B16 | Payment adjusted because `New Patient' qualifications were not met. This change to be effective 4/1/2008: `New Patient' qualifications were not met.
Start: 01/01/1995 | Last Modified: 09/30/2007 |
| 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.
Start: 01/01/1995 | Stop: 02/01/2006 |
| B18 | Payment adjusted because this procedure code and modifier were invalid on the date of service. This change to be effective 4/1/2008: This procedure code and modifier were invalid on the date of service.
Start: 01/01/1995 | Last Modified: 09/30/2007 |
| B19 | Claim/service adjusted because of the finding of a Review Organization.
Start: 01/01/1995 | Stop: 10/16/2003 |
| B20 | Payment adjusted because procedure/service was partially or fully furnished by another provider. This change to be effective 4/1/2008: Procedure/service was partially or fully furnished by another provider.
Start: 01/01/1995 | Last Modified: 09/30/2007 |
| B21 | The charges were reduced because the service/care was partially furnished by another physician.
Start: 01/01/1995 | Stop: 10/16/2003 |
| B22 | This payment is adjusted based on the diagnosis.
Start: 01/01/1995 | Last Modified: 02/28/2001 |
| B23 | Payment denied because this provider has failed an aspect of a proficiency testing program. This change effective 4/1/2008: Procedure billed is not authorized per your Clinical Laboratory Improvement Amendment (CLIA) proficiency test.
Start: 01/01/1995 | Last Modified: 09/30/2007 |
| D1 | Claim/service denied. Level of subluxation is missing or inadequate.
Start: 01/01/1995 | Stop: 10/16/2003
Notes: Use code 16 and remark codes if necessary. |
| D2 | Claim lacks the name, strength, or dosage of the drug furnished.
Start: 01/01/1995 | Stop: 10/16/2003
Notes: 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.
Start: 01/01/1995 | Stop: 10/16/2003
Notes: Use code 16 and remark codes if necessary. |
| D4 | Claim/service does not indicate the period of time for which this will be needed.
Start: 01/01/1995 | Stop: 10/16/2003
Notes: Use code 16 and remark codes if necessary. |
| D5 | Claim/service denied. Claim lacks individual lab codes included in the test.
Start: 01/01/1995 | Stop: 10/16/2003
Notes: Use code 16 and remark codes if necessary. |
| D6 | Claim/service denied. Claim did not include patient's medical record for the service.
Start: 01/01/1995 | Stop: 10/16/2003
Notes: Use code 16 and remark codes if necessary. |
| D7 | Claim/service denied. Claim lacks date of patient's most recent physician visit.
Start: 01/01/1995 | Stop: 10/16/2003
Notes: Use code 16 and remark codes if necessary. |
| D8 | Claim/service denied. Claim lacks indicator that `x-ray is available for review.'
Start: 01/01/1995 | Stop: 10/16/2003
Notes: 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.
Start: 01/01/1995 | Stop: 10/16/2003
Notes: Use code 16 and remark codes if necessary. |
| D10 | Claim/service denied. Completed physician financial relationship form not on file.
Start: 01/01/1995 | Stop: 10/16/2003
Notes: Use code 17. |
| D11 | Claim lacks completed pacemaker registration form.
Start: 01/01/1995 | Stop: 10/16/2003
Notes: 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.
Start: 01/01/1995 | Stop: 10/16/2003
Notes: Use code 17. |
| D13 | Claim/service denied. Performed by a facility/supplier in which the ordering/referring physician has a financial interest.
Start: 01/01/1995 | Stop: 10/16/2003
Notes: Use code 17. |
| D14 | Claim lacks indication that plan of treatment is on file.
Start: 01/01/1995 | Stop: 10/16/2003
Notes: Use code 17. |
| D15 | Claim lacks indication that service was supervised or evaluated by a physician.
Start: 01/01/1995 | Stop: 10/16/2003
Notes: Use code 17. |
| D16 | Claim lacks prior payer payment information.
Start: 01/01/1995 | Stop: 06/30/2007
Notes: Use code 16 with appropriate claim payment remark code [N4]. |
| D17 | Claim/Service has invalid non-covered days.
Start: 01/01/1995 | Stop: 06/30/2007
Notes: Use code 16 with appropriate claim payment remark code. |
| D18 | Claim/Service has missing diagnosis information.
Start: 01/01/1995 | Stop: 06/30/2007
Notes: Use code 16 with appropriate claim payment remark code. |
| D19 | Claim/Service lacks Physician/Operative or other supporting documentation
Start: 01/01/1995 | Stop: 06/30/2007
Notes: Use code 16 with appropriate claim payment remark code. |
| D20 | Claim/Service missing service/product information.
Start: 01/01/1995 | Stop: 06/30/2007
Notes: Use code 16 with appropriate claim payment remark code. |
| D21 | This (these) diagnosis(es) is (are) missing or are invalid
Start: 01/01/1995 | Stop: 06/30/2007 |
| D22 | Reimbursement was adjusted for the reasons to be provided in separate correspondence. (Note: To be used for Workers' Compensation only) - Temporary code to be added for timeframe only until 01/01/2009. Another code to be established and/or for 06/2008 meeting for a revised code to replace or strategy to use another existing code
Start: 01/27/2008 | Stop: 01/01/2009 |
| W1 | Workers Compensation State Fee Schedule Adjustment
Start: 02/29/2000 |
HIPAA Code Lists 
