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Health Care Services Decision Reason Codes • ASC X12 External Code Source 886LAST UPDATED 7/1/2015

Health Care Services Decision Reason Codes are used to indicate the primary reason for the certification action code assigned as part of a health care services review.

Minutes from the June 2016 Meeting. Minutes from previous meetings can be found in the FAQs.

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

01Price Authorization Expired
Start: 01/10/2001
02Price authorization no longer required
Start: 01/10/2001
03Product not on the price authorization
Start: 01/10/2001
04Authorized Quantity Exceeded
Start: 01/10/2001
05Special Cost Incorrect
Start: 01/10/2001
06No Credit Allowed
Start: 01/10/2001
07Administrative Cancellation
Start: 01/10/2001
08Unit resale higher than authorized
Start: 01/10/2001
09Out of Network
Start: 01/10/2001
0ATesting not Included
Start: 01/10/2001
0BRequest Forwarded To and Decision Response Forthcoming From an External Review Organization
Start: 01/10/2001
0CAuthorization/Access Restrictions
Start: 01/10/2001
0DRequires PCP authorization
Start: 01/10/2001
0EProvider is Not Primary Care Physician
Start: 01/10/2001
0FNot Medically Necessary
Start: 01/10/2001
0GLevel of Care Not Appropriate
Start: 01/10/2001
0HCertification Not Required for this Service
Start: 01/10/2001
0JCertification Responsibility of External Review Organization
Start: 01/10/2001
0KPrimary Care Service
Start: 01/10/2001
0LExceeds Plan Maximums
Start: 01/10/2001
0MNon-covered Service
Start: 01/10/2001
0NNo Prior Approval
Start: 01/10/2001
0PRequested Information Not Received
Start: 01/10/2001
0QDuplicate Request
Start: 01/10/2001
0RService Inconsistent with Diagnosis
Start: 01/10/2001
0SPre-existing Condition
Start: 01/10/2001
0TExperimental Service or Procedure
Start: 01/10/2001
0UAdditional Patient Information required
Start: 01/10/2001
0VRequires Medical Review
Start: 01/10/2001
0WDisposition pending review
Start: 01/10/2001
0XService Inconsistent with Provider Type
Start: 01/10/2001
0YService inconsistent with Patient's Age
Start: 01/10/2001
0ZService inconsistent with Patient's Gender
Start: 01/10/2001
10Product/service/procedure delivery pattern (e.g., units, days, visits, weeks, hours, months)
Start: 01/10/2001
11Pricing
Start: 01/10/2001
12Patient is restricted to specific provider
Start: 01/10/2001
13Service authorized for another provider
Start: 01/10/2001
14Plan/contractual guidelines not followed
Start: 01/10/2001
15Plan/contractual geographic restriction
Start: 01/10/2001
16Inappropriate facility type
Start: 01/10/2001
17Time limits not met
Start: 02/01/2002
18Notification received
Start: 06/01/2002
19Cosmetic
Start: 06/01/2002
20Once in a lifetime restriction applies
Start: 02/01/2004
21Transport Request Denied
Start: 06/01/2004
22Ambulance Certification Segment information doesn't correspond to Transport Address Segment
Start: 06/01/2004
23Mileage cannot be computed based on data submitted
Start: 06/01/2004
24Computed mileage is inconsistent with transport information or service units submitted
Start: 06/01/2004
25Services were not considered due to other errors in the request.
Start: 06/06/2010
26Missing Provider Role
Start: 06/05/2011
27Patient is currently in a Health Insurance Exchange premium payment grace period -- first month. Note: Use only for Individual Market Qualified Health Plans.
Start: 06/01/2014
28Patient is currently in a Health Insurance Exchange premium payment grace period -- second month. Note: Use only for Individual Market Qualified Health Plans.
Start: 06/01/2014
29Patient is currently in a Health Insurance Exchange premium payment grace period -- third month. Note: Use only for Individual Market Qualified Health Plans.
Start: 06/01/2014