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Claim Adjustment Reason Codes • ASC X12 External Code Source 139 LAST UPDATED 11/1/2014

Claim adjustment reason codes communicate an adjustment, meaning that they must communicate why a claim or service line was paid differently than it was billed. If there is no adjustment to a claim/line, then there is no adjustment reason code.

Minutes from the October 2014 Meeting. Minutes from previous meetings can be found in the FAQs.

Filter Codes by Status: Show All Current | To Be Deactivated | Deactivated

1Deductible Amount
Start: 01/01/1995
2Coinsurance Amount
Start: 01/01/1995
3Co-payment Amount
Start: 01/01/1995
4The procedure code is inconsistent with the modifier used or a required modifier is missing. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
Start: 01/01/1995 | Last Modified: 09/20/2009
5The procedure code/bill type is inconsistent with the place of service. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
Start: 01/01/1995 | Last Modified: 09/20/2009
6The procedure/revenue code is inconsistent with the patient's age. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
Start: 01/01/1995 | Last Modified: 09/20/2009
7The procedure/revenue code is inconsistent with the patient's gender. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
Start: 01/01/1995 | Last Modified: 09/20/2009
8The procedure code is inconsistent with the provider type/specialty (taxonomy). Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
Start: 01/01/1995 | Last Modified: 09/20/2009
9The diagnosis is inconsistent with the patient's age. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
Start: 01/01/1995 | Last Modified: 09/20/2009
10The diagnosis is inconsistent with the patient's gender. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
Start: 01/01/1995 | Last Modified: 09/20/2009
11The diagnosis is inconsistent with the procedure. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
Start: 01/01/1995 | Last Modified: 09/20/2009
12The diagnosis is inconsistent with the provider type. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
Start: 01/01/1995 | Last Modified: 09/20/2009
13The date of death precedes the date of service.
Start: 01/01/1995
14The date of birth follows the date of service.
Start: 01/01/1995
15The authorization number is missing, invalid, or does not apply to the billed services or provider.
Start: 01/01/1995 | Last Modified: 09/30/2007
16Claim/service lacks information or has submission/billing error(s) which is needed for adjudication. Do not use this code for claims attachment(s)/other documentation. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.) Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
Start: 01/01/1995 | Last Modified: 11/01/2013
17Requested 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: 09/21/2008 | Stop: 07/01/2009
18Exact duplicate claim/service (Use only with Group Code OA except where state workers' compensation regulations requires CO)
Start: 01/01/1995 | Last Modified: 06/02/2013
19This 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
20This injury/illness is covered by the liability carrier.
Start: 01/01/1995 | Last Modified: 09/30/2007
21This injury/illness is the liability of the no-fault carrier.
Start: 01/01/1995 | Last Modified: 09/30/2007
22This care may be covered by another payer per coordination of benefits.
Start: 01/01/1995 | Last Modified: 09/30/2007
23The impact of prior payer(s) adjudication including payments and/or adjustments. (Use only with Group Code OA)
Start: 01/01/1995 | Last Modified: 09/30/2012
24Charges are covered under a capitation agreement/managed care plan.
Start: 01/01/1995 | Last Modified: 09/30/2007
25Payment denied. Your Stop loss deductible has not been met.
Start: 01/01/1995 | Stop: 04/01/2008
26Expenses incurred prior to coverage.
Start: 01/01/1995
27Expenses incurred after coverage terminated.
Start: 01/01/1995
28Coverage not in effect at the time the service was provided.
Start: 01/01/1995 | Stop: 10/16/2003
Notes: Redundant to codes 26&27.
29The time limit for filing has expired.
Start: 01/01/1995
30Payment adjusted because the patient has not met the required eligibility, spend down, waiting, or residency requirements.
Start: 01/01/1995 | Stop: 02/01/2006
31Patient cannot be identified as our insured.
Start: 01/01/1995 | Last Modified: 09/30/2007
32Our records indicate that this dependent is not an eligible dependent as defined.
Start: 01/01/1995
33Insured has no dependent coverage.
Start: 01/01/1995 | Last Modified: 09/30/2007
34Insured has no coverage for newborns.
Start: 01/01/1995 | Last Modified: 09/30/2007
35Lifetime benefit maximum has been reached.
Start: 01/01/1995 | Last Modified: 10/31/2002
36Balance does not exceed co-payment amount.
Start: 01/01/1995 | Stop: 10/16/2003
37Balance does not exceed deductible.
Start: 01/01/1995 | Stop: 10/16/2003
38Services not provided or authorized by designated (network/primary care) providers.
Start: 01/01/1995 | Last Modified: 06/02/2013 | Stop: 01/01/2013
Notes: CARC codes 242 and 243 are replacements for this deactivated code
39Services denied at the time authorization/pre-certification was requested.
Start: 01/01/1995
40Charges do not meet qualifications for emergent/urgent care. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
Start: 01/01/1995 | Last Modified: 09/20/2009
41Discount agreed to in Preferred Provider contract.
Start: 01/01/1995 | Stop: 10/16/2003
42Charges exceed our fee schedule or maximum allowable amount. (Use CARC 45)
Start: 01/01/1995 | Last Modified: 10/31/2006 | Stop: 06/01/2007
43Gramm-Rudman reduction.
Start: 01/01/1995 | Stop: 07/01/2006
44Prompt-pay discount.
Start: 01/01/1995
45Charge exceeds fee schedule/maximum allowable or contracted/legislated fee arrangement. (Use only with Group Codes PR or CO depending upon liability)
Start: 01/01/1995 | Last Modified: 07/01/2013
46This (these) service(s) is (are) not covered.
Start: 01/01/1995 | Stop: 10/16/2003
Notes: Use code 96.
47This (these) diagnosis(es) is (are) not covered, missing, or are invalid.
Start: 01/01/1995 | Stop: 02/01/2006
48This (these) procedure(s) is (are) not covered.
Start: 01/01/1995 | Stop: 10/16/2003
Notes: Use code 96.
49This is a non-covered service because it is a routine/preventive exam or a diagnostic/screening procedure done in conjunction with a routine/preventive exam. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
Start: 01/01/1995 | Last Modified: 11/01/2013
50These are non-covered services because this is not deemed a 'medical necessity' by the payer. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
Start: 01/01/1995 | Last Modified: 09/20/2009
51These are non-covered services because this is a pre-existing condition. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
Start: 01/01/1995 | Last Modified: 09/20/2009
52The referring/prescribing/rendering provider is not eligible to refer/prescribe/order/perform the service billed.
Start: 01/01/1995 | Stop: 02/01/2006
53Services by an immediate relative or a member of the same household are not covered.
Start: 01/01/1995
54Multiple physicians/assistants are not covered in this case. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
Start: 01/01/1995 | Last Modified: 09/20/2009
55Procedure/treatment is deemed experimental/investigational by the payer. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
Start: 01/01/1995 | Last Modified: 09/20/2009
56Procedure/treatment has not been deemed 'proven to be effective' by the payer. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
Start: 01/01/1995 | Last Modified: 09/20/2009
57Payment 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.
58Treatment was deemed by the payer to have been rendered in an inappropriate or invalid place of service. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
Start: 01/01/1995 | Last Modified: 09/20/2009
59Processed based on multiple or concurrent procedure rules. (For example multiple surgery or diagnostic imaging, concurrent anesthesia.) Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
Start: 01/01/1995 | Last Modified: 09/20/2009
60Charges for outpatient services are not covered when performed within a period of time prior to or after inpatient services.
Start: 01/01/1995 | Last Modified: 06/01/2008
61Penalty for failure to obtain second surgical opinion. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
Start: 01/01/1995 | Last Modified: 09/20/2009
62Payment denied/reduced for absence of, or exceeded, pre-certification/authorization.
Start: 01/01/1995 | Last Modified: 10/31/2006 | Stop: 04/01/2007
63Correction to a prior claim.
Start: 01/01/1995 | Stop: 10/16/2003
64Denial reversed per Medical Review.
Start: 01/01/1995 | Stop: 10/16/2003
65Procedure code was incorrect. This payment reflects the correct code.
Start: 01/01/1995 | Stop: 10/16/2003
66Blood Deductible.
Start: 01/01/1995
67Lifetime reserve days. (Handled in QTY, QTY01=LA)
Start: 01/01/1995 | Stop: 10/16/2003
68DRG weight. (Handled in CLP12)
Start: 01/01/1995 | Stop: 10/16/2003
69Day outlier amount.
Start: 01/01/1995
70Cost outlier - Adjustment to compensate for additional costs.
Start: 01/01/1995 | Last Modified: 06/30/2001
71Primary Payer amount.
Start: 01/01/1995 | Stop: 06/30/2000
Notes: Use code 23.
72Coinsurance day. (Handled in QTY, QTY01=CD)
Start: 01/01/1995 | Stop: 10/16/2003
73Administrative days.
Start: 01/01/1995 | Stop: 10/16/2003
74Indirect Medical Education Adjustment.
Start: 01/01/1995
75Direct Medical Education Adjustment.
Start: 01/01/1995
76Disproportionate Share Adjustment.
Start: 01/01/1995
77Covered days. (Handled in QTY, QTY01=CA)
Start: 01/01/1995 | Stop: 10/16/2003
78Non-Covered days/Room charge adjustment.
Start: 01/01/1995
79Cost Report days. (Handled in MIA15)
Start: 01/01/1995 | Stop: 10/16/2003
80Outlier days. (Handled in QTY, QTY01=OU)
Start: 01/01/1995 | Stop: 10/16/2003
81Discharges.
Start: 01/01/1995 | Stop: 10/16/2003
82PIP days.
Start: 01/01/1995 | Stop: 10/16/2003
83Total visits.
Start: 01/01/1995 | Stop: 10/16/2003
84Capital Adjustment. (Handled in MIA)
Start: 01/01/1995 | Stop: 10/16/2003
85Patient 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.
86Statutory Adjustment.
Start: 01/01/1995 | Stop: 10/16/2003
Notes: Duplicative of code 45.
87Transfer amount.
Start: 01/01/1995 | Last Modified: 09/20/2009 | Stop: 01/01/2012
88Adjustment amount represents collection against receivable created in prior overpayment.
Start: 01/01/1995 | Stop: 06/30/2007
89Professional fees removed from charges.
Start: 01/01/1995
90Ingredient cost adjustment. Note: To be used for pharmaceuticals only.
Start: 01/01/1995 | Last Modified: 07/01/2009
91Dispensing fee adjustment.
Start: 01/01/1995
92Claim Paid in full.
Start: 01/01/1995 | Stop: 10/16/2003
93No Claim level Adjustments.
Start: 01/01/1995 | Stop: 10/16/2003
Notes: As of 004010, CAS at the claim level is optional.
94Processed in Excess of charges.
Start: 01/01/1995
95Plan procedures not followed.
Start: 01/01/1995 | Last Modified: 09/30/2007
96Non-covered charge(s). At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.) Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
Start: 01/01/1995 | Last Modified: 09/20/2009
97The benefit for this service is included in the payment/allowance for another service/procedure that has already been adjudicated. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
Start: 01/01/1995 | Last Modified: 09/20/2009
98The hospital must file the Medicare claim for this inpatient non-physician service.
Start: 01/01/1995 | Stop: 10/16/2003
99Medicare Secondary Payer Adjustment Amount.
Start: 01/01/1995 | Stop: 10/16/2003
100Payment made to patient/insured/responsible party/employer.
Start: 01/01/1995 | Last Modified: 01/27/2008
101Predetermination: anticipated payment upon completion of services or claim adjudication.
Start: 01/01/1995 | Last Modified: 02/28/1999
102Major Medical Adjustment.
Start: 01/01/1995
103Provider promotional discount (e.g., Senior citizen discount).
Start: 01/01/1995 | Last Modified: 06/30/2001
104Managed care withholding.
Start: 01/01/1995
105Tax withholding.
Start: 01/01/1995
106Patient payment option/election not in effect.
Start: 01/01/1995
107The related or qualifying claim/service was not identified on this claim. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
Start: 01/01/1995 | Last Modified: 09/20/2009
108Rent/purchase guidelines were not met. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
Start: 01/01/1995 | Last Modified: 09/20/2009
109Claim/service not covered by this payer/contractor. You must send the claim/service to the correct payer/contractor.
Start: 01/01/1995 | Last Modified: 01/29/2012
110Billing date predates service date.
Start: 01/01/1995
111Not covered unless the provider accepts assignment.
Start: 01/01/1995
112Service not furnished directly to the patient and/or not documented.
Start: 01/01/1995 | Last Modified: 09/30/2007
113Payment denied because service/procedure was provided outside the United States or as a result of war.
Start: 01/01/1995 | Last Modified: 02/28/2001 | Stop: 06/30/2007
Notes: Use Codes 157, 158 or 159.
114Procedure/product not approved by the Food and Drug Administration.
Start: 01/01/1995
115Procedure postponed, canceled, or delayed.
Start: 01/01/1995 | Last Modified: 09/30/2007
116The advance indemnification notice signed by the patient did not comply with requirements.
Start: 01/01/1995 | Last Modified: 09/30/2007
117Transportation is only covered to the closest facility that can provide the necessary care.
Start: 01/01/1995 | Last Modified: 09/30/2007
118ESRD network support adjustment.
Start: 01/01/1995 | Last Modified: 09/30/2007
119Benefit maximum for this time period or occurrence has been reached.
Start: 01/01/1995 | Last Modified: 02/29/2004
120Patient is covered by a managed care plan.
Start: 01/01/1995 | Stop: 06/30/2007
Notes: Use code 24.
121Indemnification adjustment - compensation for outstanding member responsibility.
Start: 01/01/1995 | Last Modified: 09/30/2007
122Psychiatric reduction.
Start: 01/01/1995
123Payer refund due to overpayment.
Start: 01/01/1995 | Stop: 06/30/2007
Notes: Refer to implementation guide for proper handling of reversals.
124Payer refund amount - not our patient.
Start: 01/01/1995 | Last Modified: 06/30/1999 | Stop: 06/30/2007
Notes: Refer to implementation guide for proper handling of reversals.
125Submission/billing error(s). At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.)
Start: 01/01/1995 | Last Modified: 09/20/2009 | Stop: 11/01/2013
126Deductible -- Major Medical
Start: 02/28/1997 | Last Modified: 09/30/2007 | Stop: 04/01/2008
Notes: Use Group Code PR and code 1.
127Coinsurance -- Major Medical
Start: 02/28/1997 | Last Modified: 09/30/2007 | Stop: 04/01/2008
Notes: Use Group Code PR and code 2.
128Newborn's services are covered in the mother's Allowance.
Start: 02/28/1997
129Prior processing information appears incorrect. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.)
Start: 02/28/1997 | Last Modified: 01/30/2011
130Claim submission fee.
Start: 02/28/1997 | Last Modified: 06/30/2001
131Claim specific negotiated discount.
Start: 02/28/1997
132Prearranged demonstration project adjustment.
Start: 02/28/1997
133The disposition of the claim/service is pending further review. (Use only with Group Code OA). This change effective 3/1/2015: The disposition of this service line is pending further review. (Use only with Group Code OA). NOTE: Use of this code requires a reversal and correction when the service line is finalized (use only in Loop 2110 CAS segment of the 835 or Loop 2430 of the 837).
Start: 07/01/2014 | Last Modified: 09/28/2014
134Technical fees removed from charges.
Start: 10/31/1998
135Interim bills cannot be processed.
Start: 10/31/1998 | Last Modified: 09/30/2007
136Failure to follow prior payer's coverage rules. (Use only with Group Code OA)
Start: 10/31/1998 | Last Modified: 07/01/2013
137Regulatory Surcharges, Assessments, Allowances or Health Related Taxes.
Start: 02/28/1999 | Last Modified: 09/30/2007
138Appeal procedures not followed or time limits not met.
Start: 06/30/1999 | Last Modified: 09/30/2007
139Contracted funding agreement - Subscriber is employed by the provider of services.
Start: 06/30/1999
140Patient/Insured health identification number and name do not match.
Start: 06/30/1999
141Claim spans eligible and ineligible periods of coverage.
Start: 06/30/1999 | Last Modified: 09/30/2007 | Stop: 07/01/2012
142Monthly Medicaid patient liability amount.
Start: 06/30/2000 | Last Modified: 09/30/2007
143Portion of payment deferred.
Start: 02/28/2001
144Incentive adjustment, e.g. preferred product/service.
Start: 06/30/2001
145Premium payment withholding
Start: 06/30/2002 | Last Modified: 09/30/2007 | Stop: 04/01/2008
Notes: Use Group Code CO and code 45.
146Diagnosis was invalid for the date(s) of service reported.
Start: 06/30/2002 | Last Modified: 09/30/2007
147Provider contracted/negotiated rate expired or not on file.
Start: 06/30/2002
148Information from another provider was not provided or was insufficient/incomplete. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.)
Start: 06/30/2002 | Last Modified: 09/20/2009
149Lifetime benefit maximum has been reached for this service/benefit category.
Start: 10/31/2002
150Payer deems the information submitted does not support this level of service.
Start: 10/31/2002 | Last Modified: 09/30/2007
151Payment 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
152Payer deems the information submitted does not support this length of service. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
Start: 10/31/2002 | Last Modified: 09/20/2009
153Payer deems the information submitted does not support this dosage.
Start: 10/31/2002 | Last Modified: 09/30/2007
154Payer deems the information submitted does not support this day's supply.
Start: 10/31/2002 | Last Modified: 09/30/2007
155Patient refused the service/procedure.
Start: 06/30/2003 | Last Modified: 09/30/2007
156Flexible spending account payments. Note: Use code 187.
Start: 09/30/2003 | Last Modified: 01/25/2009 | Stop: 10/01/2009
157Service/procedure was provided as a result of an act of war.
Start: 09/30/2003 | Last Modified: 09/30/2007
158Service/procedure was provided outside of the United States.
Start: 09/30/2003 | Last Modified: 09/30/2007
159Service/procedure was provided as a result of terrorism.
Start: 09/30/2003 | Last Modified: 09/30/2007
160Injury/illness was the result of an activity that is a benefit exclusion.
Start: 09/30/2003 | Last Modified: 09/30/2007
161Provider performance bonus
Start: 02/29/2004
162State-mandated Requirement for Property and Casualty, see Claim Payment Remarks Code for specific explanation.
Start: 02/29/2004 | Stop: 07/01/2014
Notes: Use code P1
163Attachment/other documentation referenced on the claim was not received.
Start: 06/30/2004 | Last Modified: 06/02/2013
164Attachment/other documentation referenced on the claim was not received in a timely fashion.
Start: 06/30/2004 | Last Modified: 06/02/2013
165Referral absent or exceeded.
Start: 10/31/2004 | Last Modified: 09/30/2007
166These services were submitted after this payers responsibility for processing claims under this plan ended.
Start: 02/28/2005
167This (these) diagnosis(es) is (are) not covered. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
Start: 06/30/2005 | Last Modified: 09/20/2009
168Service(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
169Alternate benefit has been provided.
Start: 06/30/2005 | Last Modified: 09/30/2007
170Payment is denied when performed/billed by this type of provider. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
Start: 06/30/2005 | Last Modified: 09/20/2009
171Payment is denied when performed/billed by this type of provider in this type of facility. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
Start: 06/30/2005 | Last Modified: 09/20/2009
172Payment is adjusted when performed/billed by a provider of this specialty. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
Start: 06/30/2005 | Last Modified: 09/20/2009
173Service/equipment was not prescribed by a physician.
Start: 06/30/2005 | Last Modified: 07/01/2013
174Service was not prescribed prior to delivery.
Start: 06/30/2005 | Last Modified: 09/30/2007
175Prescription is incomplete.
Start: 06/30/2005 | Last Modified: 09/30/2007
176Prescription is not current.
Start: 06/30/2005 | Last Modified: 09/30/2007
177Patient has not met the required eligibility requirements.
Start: 06/30/2005 | Last Modified: 09/30/2007
178Patient has not met the required spend down requirements.
Start: 06/30/2005 | Last Modified: 09/30/2007
179Patient has not met the required waiting requirements. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
Start: 06/30/2005 | Last Modified: 09/20/2009
180Patient has not met the required residency requirements.
Start: 06/30/2005 | Last Modified: 09/30/2007
181Procedure code was invalid on the date of service.
Start: 06/30/2005 | Last Modified: 09/30/2007
182Procedure modifier was invalid on the date of service.
Start: 06/30/2005 | Last Modified: 09/30/2007
183The referring provider is not eligible to refer the service billed. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
Start: 06/30/2005 | Last Modified: 09/20/2009
184The prescribing/ordering provider is not eligible to prescribe/order the service billed. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
Start: 06/30/2005 | Last Modified: 09/20/2009
185The rendering provider is not eligible to perform the service billed. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
Start: 06/30/2005 | Last Modified: 09/20/2009
186Level of care change adjustment.
Start: 06/30/2005 | Last Modified: 09/30/2007
187Consumer Spending Account payments (includes but is not limited to Flexible Spending Account, Health Savings Account, Health Reimbursement Account, etc.)
Start: 06/30/2005 | Last Modified: 01/25/2009
188This 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
190Payment is included in the allowance for a Skilled Nursing Facility (SNF) qualified stay.
Start: 10/31/2005
191Not a work related injury/illness and thus not the liability of the workers' compensation carrier Note: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier 'IG') for the jurisdictional regulation. If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF)
Start: 10/31/2005 | Last Modified: 10/17/2010 | Stop: 07/01/2014
Notes: Use code P2
192Non 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
193Original 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
194Anesthesia performed by the operating physician, the assistant surgeon or the attending physician.
Start: 02/28/2006 | Last Modified: 09/30/2007
195Refund issued to an erroneous priority payer for this claim/service.
Start: 02/28/2006 | Last Modified: 09/30/2007
196Claim/service denied based on prior payer's coverage determination.
Start: 06/30/2006 | Stop: 02/01/2007
Notes: Use code 136.
197Precertification/authorization/notification absent.
Start: 10/31/2006 | Last Modified: 09/30/2007
198Precertification/authorization exceeded.
Start: 10/31/2006 | Last Modified: 09/30/2007
199Revenue code and Procedure code do not match.
Start: 10/31/2006
200Expenses incurred during lapse in coverage
Start: 10/31/2006
201Patient is responsible for amount of this claim/service through 'set aside arrangement' or other agreement. (Use only with Group Code PR) At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.)
Start: 10/31/2006 | Last Modified: 09/28/2014
Notes: Not for use by Workers' Compensation payers; use code P3 instead.
202Non-covered personal comfort or convenience services.
Start: 02/28/2007 | Last Modified: 09/30/2007
203Discontinued or reduced service.
Start: 02/28/2007 | Last Modified: 09/30/2007
204This service/equipment/drug is not covered under the patient’s current benefit plan
Start: 02/28/2007
205Pharmacy discount card processing fee
Start: 07/09/2007
206National Provider Identifier - missing.
Start: 07/09/2007 | Last Modified: 09/30/2007
207National Provider identifier - Invalid format
Start: 07/09/2007 | Last Modified: 06/01/2008
208National Provider Identifier - Not matched.
Start: 07/09/2007 | Last Modified: 09/30/2007
209Per 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 only with Group code OA)
Start: 07/09/2007 | Last Modified: 07/01/2013
210Payment adjusted because pre-certification/authorization not received in a timely fashion
Start: 07/09/2007
211National Drug Codes (NDC) not eligible for rebate, are not covered.
Start: 07/09/2007
212Administrative surcharges are not covered
Start: 11/05/2007
213Non-compliance with the physician self referral prohibition legislation or payer policy.
Start: 01/27/2008
214Workers' Compensation claim adjudicated as non-compensable. This Payer not liable for claim or service/treatment. Note: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier 'IG') for the jurisdictional regulation. If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF). To be used for Workers' Compensation only
Start: 01/27/2008 | Last Modified: 10/17/2010 | Stop: 07/01/2014
Notes: Use code P4
215Based on subrogation of a third party settlement
Start: 01/27/2008
216Based on the findings of a review organization
Start: 01/27/2008
217Based on payer reasonable and customary fees. No maximum allowable defined by legislated fee arrangement. (Note: To be used for Property and Casualty only)
Start: 01/27/2008 | Last Modified: 09/30/2012 | Stop: 07/01/2014
Notes: Use code P5
218Based on entitlement to benefits. Note: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier 'IG') for the jurisdictional regulation. If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF). To be used for Workers' Compensation only
Start: 01/27/2008 | Last Modified: 10/17/2010 | Stop: 07/01/2014
Notes: Use code P6
219Based on extent of injury. Note: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier 'IG') for the jurisdictional regulation. If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF).
Start: 01/27/2008 | Last Modified: 10/17/2010
220The applicable fee schedule/fee database does not contain the billed code. Please resubmit a bill with the appropriate fee schedule/fee database code(s) that best describe the service(s) provided and supporting documentation if required. (Note: To be used for Property and Casualty only)
Start: 01/27/2008 | Last Modified: 09/30/2012 | Stop: 07/01/2014
Notes: Use code P7
221Claim is under investigation. Note: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier 'IG') for the jurisdictional regulation. If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF). (Note: To be used by Property & Casualty only)
Start: 01/27/2008 | Last Modified: 07/01/2013 | Stop: 07/01/2014
Notes: Use code P8
222Exceeds the contracted maximum number of hours/days/units by this provider for this period. This is not patient specific. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
Start: 06/01/2008 | Last Modified: 09/20/2009
223Adjustment code for mandated federal, state or local law/regulation that is not already covered by another code and is mandated before a new code can be created.
Start: 06/01/2008
224Patient identification compromised by identity theft. Identity verification required for processing this and future claims.
Start: 06/01/2008
225Penalty or Interest Payment by Payer (Only used for plan to plan encounter reporting within the 837)
Start: 06/01/2008
226Information requested from the Billing/Rendering Provider was not provided or not provided timely or was insufficient/incomplete. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.)
Start: 09/21/2008 | Last Modified: 07/01/2013
227Information requested from the patient/insured/responsible party was not provided or was insufficient/incomplete. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.)
Start: 09/21/2008 | Last Modified: 09/20/2009
228Denied for failure of this provider, another provider or the subscriber to supply requested information to a previous payer for their adjudication
Start: 09/21/2008
229Partial charge amount not considered by Medicare due to the initial claim Type of Bill being 12X. Note: This code can only be used in the 837 transaction to convey Coordination of Benefits information when the secondary payer's cost avoidance policy allows providers to bypass claim submission to a prior payer. (Use only with Group Code PR)
Start: 01/25/2009 | Last Modified: 07/01/2013
230No available or correlating CPT/HCPCS code to describe this service. Note: Used only by Property and Casualty.
Start: 01/25/2009 | Stop: 07/01/2014
Notes: Use code P9
231Mutually exclusive procedures cannot be done in the same day/setting. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
Start: 07/01/2009 | Last Modified: 09/20/2009
232Institutional Transfer Amount. Note - Applies to institutional claims only and explains the DRG amount difference when the patient care crosses multiple institutions.
Start: 11/01/2009
233Services/charges related to the treatment of a hospital-acquired condition or preventable medical error.
Start: 01/24/2010
234This procedure is not paid separately. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.)
Start: 01/24/2010
235Sales Tax
Start: 06/06/2010
236This procedure or procedure/modifier combination is not compatible with another procedure or procedure/modifier combination provided on the same day according to the National Correct Coding Initiative or workers compensation state regulations/ fee schedule requirements.
Start: 01/30/2011 | Last Modified: 07/01/2013
237Legislated/Regulatory Penalty. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.)
Start: 06/05/2011
238Claim spans eligible and ineligible periods of coverage, this is the reduction for the ineligible period. (Use only with Group Code PR)
Start: 03/01/2012 | Last Modified: 07/01/2013
239Claim spans eligible and ineligible periods of coverage. Rebill separate claims.
Start: 03/01/2012 | Last Modified: 01/29/2012
240The diagnosis is inconsistent with the patient's birth weight. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
Start: 06/03/2012
241Low Income Subsidy (LIS) Co-payment Amount
Start: 06/03/2012
242Services not provided by network/primary care providers.
Start: 06/03/2012 | Last Modified: 06/02/2013
Notes: This code replaces deactivated code 38
243Services not authorized by network/primary care providers.
Start: 06/03/2012 | Last Modified: 06/02/2013
Notes: This code replaces deactivated code 38
244Payment reduced to zero due to litigation. Additional information will be sent following the conclusion of litigation. To be used for Property & Casualty only.
Start: 09/30/2012 | Stop: 07/01/2014
Notes: Use code P10
245Provider performance program withhold.
Start: 09/30/2012
246This non-payable code is for required reporting only.
Start: 09/30/2012
247Deductible for Professional service rendered in an Institutional setting and billed on an Institutional claim.
Start: 09/30/2012
Notes: For Medicare Bundled Payment use only, under the Patient Protection and Affordable Care Act (PPACA).
248Coinsurance for Professional service rendered in an Institutional setting and billed on an Institutional claim.
Start: 09/30/2012
Notes: For Medicare Bundled Payment use only, under the Patient Protection and Affordable Care Act (PPACA).
249This claim has been identified as a readmission. (Use only with Group Code CO)
Start: 09/30/2012
250The attachment/other documentation that was received was the incorrect attachment/document. The expected attachment/document is still missing. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT).
Start: 09/30/2012 | Last Modified: 06/01/2014
251The attachment/other documentation that was received was incomplete or deficient. The necessary information is still needed to process the claim. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT).
Start: 09/30/2012 | Last Modified: 06/01/2014
252An attachment/other documentation is required to adjudicate this claim/service. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT).
Start: 09/30/2012 | Last Modified: 06/02/2013
253Sequestration - reduction in federal payment
Start: 06/02/2013 | Last Modified: 11/01/2013
254Claim received by the dental plan, but benefits not available under this plan. Submit these services to the patient's medical plan for further consideration.
Start: 06/02/2013
255The disposition of the related Property & Casualty claim (injury or illness) is pending due to litigation. (Use only with Group Code OA)
Start: 06/02/2013 | Stop: 07/01/2014
Notes: Use code P11
256Service not payable per managed care contract.
Start: 06/02/2013
257The disposition of the claim/service is undetermined during the premium payment grace period, per Health Insurance Exchange requirements. This claim/service will be reversed and corrected when the grace period ends (due to premium payment or lack of premium payment). (Use only with Group Code OA)
Start: 11/01/2013 | Last Modified: 06/01/2014
Notes: To be used after the first month of the grace period.
258Claim/service not covered when patient is in custody/incarcerated. Applicable federal, state or local authority may cover the claim/service.
Start: 11/01/2013
259Additional payment for Dental/Vision service utilization.
Start: 01/26/2014
260Processed under Medicaid ACA Enhanced Fee Schedule
Start: 01/26/2014
261The procedure or service is inconsistent with the patient's history.
Start: 06/01/2014
262Adjustment for delivery cost. Note: To be used for pharmaceuticals only.
Start: 11/01/2014
263Adjustment for shipping cost. Note: To be used for pharmaceuticals only.
Start: 11/01/2014
264Adjustment for postage cost. Note: To be used for pharmaceuticals only.
Start: 11/01/2014
265Adjustment for administrative cost. Note: To be used for pharmaceuticals only.
Start: 11/01/2014
266Adjustment for compound preparation cost. Note: To be used for pharmaceuticals only.
Start: 11/01/2014
267Claim/service spans multiple months. Rebill as separate claim/service.
Start: 11/01/2014
268The Claim spans two calendar years. Please resubmit one claim per calendar year.
Start: 11/01/2014
A0Patient refund amount.
Start: 01/01/1995
A1Claim/Service denied. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.)
Start: 01/01/1995 | Last Modified: 09/20/2009
A2Contractual adjustment.
Start: 01/01/1995 | Last Modified: 02/28/2007 | Stop: 01/01/2008
Notes: Use Code 45 with Group Code 'CO' or use another appropriate specific adjustment code.
A3Medicare Secondary Payer liability met.
Start: 01/01/1995 | Stop: 10/16/2003
A4Medicare Claim PPS Capital Day Outlier Amount.
Start: 01/01/1995 | Last Modified: 09/30/2007 | Stop: 04/01/2008
A5Medicare Claim PPS Capital Cost Outlier Amount.
Start: 01/01/1995
A6Prior hospitalization or 30 day transfer requirement not met.
Start: 01/01/1995
A7Presumptive Payment Adjustment
Start: 01/01/1995 | Stop: 07/01/2015
A8Ungroupable DRG.
Start: 01/01/1995 | Last Modified: 09/30/2007
B1Non-covered visits.
Start: 01/01/1995
B2Covered visits.
Start: 01/01/1995 | Stop: 10/16/2003
B3Covered charges.
Start: 01/01/1995 | Stop: 10/16/2003
B4Late filing penalty.
Start: 01/01/1995
B5Coverage/program guidelines were not met or were exceeded.
Start: 01/01/1995 | Last Modified: 09/30/2007
B6This 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
B7This provider was not certified/eligible to be paid for this procedure/service on this date of service. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
Start: 01/01/1995 | Last Modified: 09/20/2009
B8Alternative services were available, and should have been utilized. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
Start: 01/01/1995 | Last Modified: 09/20/2009
B9Patient is enrolled in a Hospice.
Start: 01/01/1995 | Last Modified: 09/30/2007
B10Allowed 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
B11The claim/service has been transferred to the proper payer/processor for processing. Claim/service not covered by this payer/processor.
Start: 01/01/1995
B12Services not documented in patients' medical records.
Start: 01/01/1995
B13Previously paid. Payment for this claim/service may have been provided in a previous payment.
Start: 01/01/1995
B14Only one visit or consultation per physician per day is covered.
Start: 01/01/1995 | Last Modified: 09/30/2007
B15This service/procedure requires that a qualifying service/procedure be received and covered. The qualifying other service/procedure has not been received/adjudicated. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
Start: 01/01/1995 | Last Modified: 09/20/2009
B16'New Patient' qualifications were not met.
Start: 01/01/1995 | Last Modified: 09/30/2007
B17Payment 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
B18This procedure code and modifier were invalid on the date of service.
Start: 01/01/1995 | Last Modified: 09/21/2008 | Stop: 03/01/2009
B19Claim/service adjusted because of the finding of a Review Organization.
Start: 01/01/1995 | Stop: 10/16/2003
B20Procedure/service was partially or fully furnished by another provider.
Start: 01/01/1995 | Last Modified: 09/30/2007
B21The charges were reduced because the service/care was partially furnished by another physician.
Start: 01/01/1995 | Stop: 10/16/2003
B22This payment is adjusted based on the diagnosis.
Start: 01/01/1995 | Last Modified: 02/28/2001
B23Procedure billed is not authorized per your Clinical Laboratory Improvement Amendment (CLIA) proficiency test.
Start: 01/01/1995 | Last Modified: 09/30/2007
D1Claim/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.
D2Claim 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.
D3Claim/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.
D4Claim/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.
D5Claim/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.
D6Claim/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.
D7Claim/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.
D8Claim/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.
D9Claim/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.
D10Claim/service denied. Completed physician financial relationship form not on file.
Start: 01/01/1995 | Stop: 10/16/2003
Notes: Use code 17.
D11Claim lacks completed pacemaker registration form.
Start: 01/01/1995 | Stop: 10/16/2003
Notes: Use code 17.
D12Claim/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.
D13Claim/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.
D14Claim lacks indication that plan of treatment is on file.
Start: 01/01/1995 | Stop: 10/16/2003
Notes: Use code 17.
D15Claim lacks indication that service was supervised or evaluated by a physician.
Start: 01/01/1995 | Stop: 10/16/2003
Notes: Use code 17.
D16Claim lacks prior payer payment information.
Start: 01/01/1995 | Stop: 06/30/2007
Notes: Use code 16 with appropriate claim payment remark code [N4].
D17Claim/Service has invalid non-covered days.
Start: 01/01/1995 | Stop: 06/30/2007
Notes: Use code 16 with appropriate claim payment remark code.
D18Claim/Service has missing diagnosis information.
Start: 01/01/1995 | Stop: 06/30/2007
Notes: Use code 16 with appropriate claim payment remark code.
D19Claim/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.
D20Claim/Service missing service/product information.
Start: 01/01/1995 | Stop: 06/30/2007
Notes: Use code 16 with appropriate claim payment remark code.
D21This (these) diagnosis(es) is (are) missing or are invalid
Start: 01/01/1995 | Stop: 06/30/2007
D22Reimbursement 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
D23This dual eligible patient is covered by Medicare Part D per Medicare Retro-Eligibility. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.)
Start: 11/01/2009 | Stop: 01/01/2012
P1State-mandated Requirement for Property and Casualty, see Claim Payment Remarks Code for specific explanation. To be used for Property and Casualty only.
Start: 11/01/2013
Notes: This code replaces deactivated code 162
P2Not a work related injury/illness and thus not the liability of the workers' compensation carrier Note: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier 'IG') for the jurisdictional regulation. If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF). To be used for Workers' Compensation only.
Start: 11/01/2013
Notes: This code replaces deactivated code 191
P3Workers' Compensation case settled. Patient is responsible for amount of this claim/service through WC 'Medicare set aside arrangement' or other agreement. To be used for Workers' Compensation only. (Use only with Group Code PR)
Start: 11/01/2013
Notes: This code replaces deactivated code 201
P4Workers' Compensation claim adjudicated as non-compensable. This Payer not liable for claim or service/treatment. Note: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier 'IG') for the jurisdictional regulation. If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF). To be used for Workers' Compensation only
Start: 11/01/2013
Notes: This code replaces deactivated code 214
P5Based on payer reasonable and customary fees. No maximum allowable defined by legislated fee arrangement. To be used for Property and Casualty only.
Start: 11/01/2013
Notes: This code replaces deactivated code 217
P6Based on entitlement to benefits. Note: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier 'IG') for the jurisdictional regulation. If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF). To be used for Property and Casualty only.
Start: 11/01/2013
Notes: This code replaces deactivated code 218
P7The applicable fee schedule/fee database does not contain the billed code. Please resubmit a bill with the appropriate fee schedule/fee database code(s) that best describe the service(s) provided and supporting documentation if required. To be used for Property and Casualty only.
Start: 11/01/2013
Notes: This code replaces deactivated code 220
P8Claim is under investigation. Note: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier 'IG') for the jurisdictional regulation. If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF). To be used for Property and Casualty only.
Start: 11/01/2013
Notes: This code replaces deactivated code 221
P9No available or correlating CPT/HCPCS code to describe this service. To be used for Property and Casualty only.
Start: 11/01/2013
Notes: This code replaces deactivated code 230
P10Payment reduced to zero due to litigation. Additional information will be sent following the conclusion of litigation. To be used for Property and Casualty only.
Start: 11/01/2013
Notes: This code replaces deactivated code 244
P11The disposition of the related Property & Casualty claim (injury or illness) is pending due to litigation. To be used for Property and Casualty only. (Use only with Group Code OA)
Start: 11/01/2013
Notes: This code replaces deactivated code 255
P12Workers' compensation jurisdictional fee schedule adjustment. Note: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Class of Contract Code Identification Segment (Loop 2100 Other Claim Related Information REF). If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF) if the regulations apply. To be used for Workers' Compensation only.
Start: 11/01/2013
Notes: This code replaces deactivated code W1
P13Payment reduced or denied based on workers' compensation jurisdictional regulations or payment policies, use only if no other code is applicable. Note: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier 'IG') if the jurisdictional regulation applies. If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF) if the regulations apply. To be used for Workers' Compensation only.
Start: 11/01/2013
Notes: This code replaces deactivated code W2
P14The Benefit for this Service is included in the payment/allowance for another service/procedure that has been performed on the same day. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. To be used for Property and Casualty only.
Start: 11/01/2013
Notes: This code replaces deactivated code W3
P15Workers' Compensation Medical Treatment Guideline Adjustment. To be used for Workers' Compensation only.
Start: 11/01/2013
Notes: This code replaces deactivated code W4
P16Medical provider not authorized/certified to provide treatment to injured workers in this jurisdiction. To be used for Workers' Compensation only. (Use with Group Code CO or OA)
Start: 11/01/2013
Notes: This code replaces deactivated code W5
P17Referral not authorized by attending physician per regulatory requirement. To be used for Property and Casualty only.
Start: 11/01/2013
Notes: This code replaces deactivated code W6
P18Procedure is not listed in the jurisdiction fee schedule. An allowance has been made for a comparable service. To be used for Property and Casualty only.
Start: 11/01/2013
Notes: This code replaces deactivated code W7
P19Procedure has a relative value of zero in the jurisdiction fee schedule, therefore no payment is due. To be used for Property and Casualty only.
Start: 11/01/2013
Notes: This code replaces deactivated code W8
P20Service not paid under jurisdiction allowed outpatient facility fee schedule. To be used for Property and Casualty only.
Start: 11/01/2013
Notes: This code replaces deactivated code W9
P21Payment denied based on Medical Payments Coverage (MPC) or Personal Injury Protection (PIP) Benefits jurisdictional regulations or payment policies, use only if no other code is applicable. Note: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier 'IG') if the jurisdictional regulation applies. If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF) if the regulations apply. To be used for Property and Casualty Auto only.
Start: 11/01/2013
Notes: This code replaces deactivated code Y1
P22Payment adjusted based on Medical Payments Coverage (MPC) or Personal Injury Protection (PIP) Benefits jurisdictional regulations or payment policies, use only if no other code is applicable. Note: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier 'IG') if the jurisdictional regulation applies. If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF) if the regulations apply. To be used for Property and Casualty Auto only.
Start: 11/01/2013
Notes: This code replaces deactivated code Y2
P23Medical Payments Coverage (MPC) or Personal Injury Protection (PIP) Benefits jurisdictional fee schedule adjustment. Note: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Class of Contract Code Identification Segment (Loop 2100 Other Claim Related Information REF). If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF) if the regulations apply. To be used for Property and Casualty Auto only.
Start: 11/01/2013
Notes: This code replaces deactivated code Y3
W1Workers' compensation jurisdictional fee schedule adjustment. Note: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Class of Contract Code Identification Segment (Loop 2100 Other Claim Related Information REF). If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF) if the regulations apply.
Start: 02/29/2000 | Last Modified: 06/02/2013 | Stop: 07/01/2014
Notes: Use code P12
W2Payment reduced or denied based on workers' compensation jurisdictional regulations or payment policies, use only if no other code is applicable. Note: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier 'IG') if the jurisdictional regulation applies. If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF) if the regulations apply. To be used for Workers' Compensation only.
Start: 10/17/2010 | Last Modified: 06/02/2013 | Stop: 07/01/2014
Notes: Use code P13
W3The Benefit for this Service is included in the payment/allowance for another service/procedure that has been performed on the same day. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. For use by Property and Casualty only.
Start: 09/30/2012 | Stop: 07/01/2014
Notes: Use code P14
W4Workers' Compensation Medical Treatment Guideline Adjustment.
Start: 09/30/2012 | Stop: 07/01/2014
Notes: Use code P15
W5Medical provider not authorized/certified to provide treatment to injured workers in this jurisdiction. (Use with Group Code CO or OA)
Start: 06/02/2013 | Stop: 07/01/2014
Notes: Use code P16
W6Referral not authorized by attending physician per regulatory requirement.
Start: 06/02/2013 | Stop: 07/01/2014
Notes: Use code P17
W7Procedure is not listed in the jurisdiction fee schedule. An allowance has been made for a comparable service.
Start: 06/02/2013 | Stop: 07/01/2014
Notes: Use code P18
W8Procedure has a relative value of zero in the jurisdiction fee schedule, therefore no payment is due.
Start: 06/02/2013 | Stop: 07/01/2014
Notes: Use code P19
W9Service not paid under jurisdiction allowed outpatient facility fee schedule.
Start: 06/02/2013 | Stop: 07/01/2014
Notes: Use code P20
Y1Payment denied based on Medical Payments Coverage (MPC) or Personal Injury Protection (PIP) Benefits jurisdictional regulations or payment policies, use only if no other code is applicable. Note: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier 'IG') if the jurisdictional regulation applies. If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF) if the regulations apply. To be used for P&C Auto only.
Start: 09/30/2012 | Last Modified: 06/02/2013 | Stop: 07/01/2014
Notes: Use code P21
Y2Payment adjusted based on Medical Payments Coverage (MPC) or Personal Injury Protection (PIP) Benefits jurisdictional regulations or payment policies, use only if no other code is applicable. Note: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier 'IG') if the jurisdictional regulation applies. If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF) if the regulations apply. To be used for P&C Auto only.
Start: 09/30/2012 | Last Modified: 06/02/2013 | Stop: 07/01/2014
Notes: Use code P22
Y3Medical Payments Coverage (MPC) or Personal Injury Protection (PIP) Benefits jurisdictional fee schedule adjustment. Note: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Class of Contract Code Identification Segment (Loop 2100 Other Claim Related Information REF). If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF) if the regulations apply. To be used for P&C Auto only.
Start: 09/30/2012 | Last Modified: 06/02/2013 | Stop: 07/01/2014
Notes: Use code P23
 

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Claim Adjustment Group Codes

Did you receive a code from a health plan, such as: PR32? The "PR" is a Claim Adjustment Group Code and the description for "32" is to the left. The Claim Adjustment Group Codes are internal to the X12 standard. These codes generally assign responsibility for the adjustment amounts. The format is always two alpha characters. For convenience, the values and explanations are below:

CO Contractual Obligation
CR Corrections and Reversal
Note: This value is not to be used with 005010 and up.
OA Other Adjustment
PI Payer Initiated Reductions
PR Patient Responsibility