This is a current list of claims adjustment codes and descriptions. Check back now and then to get the latest version.
Code |
Description |
## |
SYSTEM-MORE ADJUSTMENTS |
#C |
SYSTEM-CAPITATED SERVICE |
10 |
The diagnosis is inconsistent with the patient's gender. |
10 |
The 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. |
100 |
Payment made to patient/insured/responsible party/employer. |
104 |
Managed care withholding. |
105 |
Tax withholding. |
107 |
The related or qualifying claim/service was not identified on this claim. |
108 |
Rent/purchase guidelines were not met. |
109 |
Claim/service not covered by this payer/contractor. You must send the claim/service to the correct payer/contractor. |
11 |
The diagnosis is inconsistent with the procedure. |
11 |
The diagnosis is inconsistent with the procedure. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. |
110 |
Billing date predates service date. |
111 |
Not covered unless the provider accepts assignment. |
114 |
Procedure/product not approved by the Food and Drug Administration. |
115 |
Procedure postponed, canceled, or delayed. |
116 |
The advance indemnification notice signed by the patient did not comply with requirements. |
117 |
Transportation is only covered to the closest facility that can provide the necessary care. |
118 |
ESRD network support adjustment. |
119 |
Benefit maximum for this time period or occurrence has been reached. |
12 |
The diagnosis is inconsistent with the provider type. |
12 |
The diagnosis is inconsistent with the provider type. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. |
128 |
Newborn's services are covered in the mother's Allowance. |
129 |
PRIOR PROCESSING INFORMATION APPEARS INCORRECT. AT LEAST ONE REMARK CODE MUST BE PROVIDED |
13 |
The date of death precedes the date of service. |
131 |
Claim specific negotiated discount. |
136 |
Failure to follow prior payer's coverage rules. |
138 |
Appeal procedures not followed or time limits not met. |
14 |
The date of birth follows the date of service. |
140 |
Patient/Insured health identification number and name do not match. |
143 |
Portion of payment deferred. |
146 |
Diagnosis was invalid for the date(s) of service reported. |
148 |
Information from another provider was not provided or was insufficient/incomplete. At least one Remark Code must be provided |
148 |
Information 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.) |
149 |
Lifetime benefit maximum has been reached for this service/benefit category. |
15 |
THE AUTHORIZATION NUMBER IS MISSING, INVALID, OR DOES NOT APPLY TO THE BILLED SERVICES OR PROVIDER. |
150 |
PAYER DEEMS THE INFORMATION SUBMITTED DOES NOT SUPPORT THIS LEVEL OF SERVICE. |
151 |
Payment adjusted because the payer deems the information submitted does not support this many/frequency of services. |
152 |
Payer deems the information submitted does not support this length of service. |
152 |
Payer 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. |
157 |
Service/procedure was provided as a result of an act of war. |
158 |
Service/procedure was provided outside of the United States. |
159 |
Service/procedure was provided as a result of terrorism. |
16 |
Claim/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 |
160 |
Injury/illness was the result of an activity that is a benefit exclusion. |
163 |
Attachment/other documentation referenced on the claim was not received. |
164 |
Attachment/other documentation referenced on the claim was not received in a timely fashion. |
165 |
REFERRAL ABSENT OR EXCEEDED |
167 |
This (these) diagnosis(es) is (are) not covered. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. |
168 |
Service(s) have been considered under the patient's medical plan. Benefits are not available under this dental plan. |
170 |
Payment 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. |
171 |
Payment 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. |
172 |
Payment is adjusted when performed/billed by a provider of this specialty. |
173 |
Service/equipment was not prescribed by a physician. |
174 |
Service was not prescribed prior to delivery. |
175 |
Prescription is incomplete. |
176 |
Prescription is not current. |
18 |
Exact duplicate claim/service |
181 |
Procedure code was invalid on the date of service. |
182 |
Procedure modifier was invalid on the date of service. |
183 |
The referring provider is not eligible to refer the service billed. |
184 |
The 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. |
185 |
The 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. |
186 |
LEVEL OF CARE CHANGE ADJUSTMENT. |
188 |
This product/procedure is only covered when used according to FDA recommendations. |
189 |
Not otherwise classified' or 'unlisted' procedure code (CPT/HCPCS) was billed when there is a specific procedure code for this procedure/service |
19 |
This is a work-related injury/illness and thus the liability of the Worker's Compensation Carrier. |
193 |
Original payment decision is being maintained. Upon review, it was determined that this claim was processed properly. |
194 |
Anesthesia performed by the operating physician, the assistant surgeon or the attending physician. |
198 |
Precertification/authorization exceeded. |
199 |
Revenue code and Procedure code do not match. |
20 |
This injury/illness is covered by the liability carrier. |
200 |
Expenses incurred during lapse in coverage |
201 |
WORKERS' COMPENSATION CASE SETTLED. PATIENT IS RESPONSIBLE FOR AMOUNT OF THIS CLAIM/SERVICE THROUGH WC 'MEDICARE SET ASIDE ARRANGEMENT' OR OTHER AGREEMENT. |
202 |
Non-covered personal comfort or convenience services. |
204 |
This service/equipment/drug is not covered under the patient's current benefit plan. |
204 |
This service/equipment/drug is not covered under the patient’s current benefit plan |
206 |
National Provider Identifier - missing. |
207 |
National Provider identifier - Invalid format |
208 |
National Provider Identifier - Not matched. |
21 |
This injury/illness is the liability of the no-fault carrier. |
211 |
National Drug Codes (NDC) not eligible for rebate, are not covered. |
212 |
Administrative surcharges are not covered. |
216 |
Based on the findings of a review organization |
217 |
BASED ON PAYER REASONABLE AND CUSTOMARY FEES. NO MAXIMUM ALLOWABLE DEFINED BY LEGISLATED FEE ARRANGEMENT. |
22 |
This care may be covered by another payer per coordination of benefits. |
222 |
Exceeds 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. |
224 |
Patient identification compromised by identity theft. Identity verification required for processing this and future claims. |
225 |
Penalty or Interest Payment by Payer |
228 |
Denied for failure of this provider, another provider or the subscriber to supply requested information to a previous payer for their adjudication. |
23 |
The impact of prior payer(s) adjudication including payments and/or adjustments. |
231 |
Mutually 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. |
232 |
Institutional Transfer Amount. Note - Applies to institutional claims only and explains the DRG amount difference when the patient care crosses multiple institutions. |
233 |
Services/charges related to the treatment of a hospital-acquired condition or preventable medical error. |
234 |
This procedure is not paid separately. At least one Remark Code must be provided |
234 |
This 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.) |
236 |
This 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. |
237 |
Legislated/Regulatory Penalty. At least one Remark Code must be provided |
238 |
Claim spans eligible and ineligible periods of coverage, this is the reduction for the ineligible period. |
239 |
Claim spans eligible and ineligible periods of coverage. Rebill separate claims. |
24 |
CHARGES ARE COVERED UNDER A CAPITATION AGREEMENT/MANAGED CARE PLAN. |
240 |
The diagnosis is inconsistent with the patient's birth weight. |
240 |
The 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. |
242 |
Services not provided by network/primary care providers. |
242 |
Services not provided by network/primary care providers. Notes: This code replaces deactivated code 38 |
243 |
Services not authorized by network/primary care providers. |
243 |
Services not authorized by network/primary care providers. Notes: This code replaces deactivated code 38 |
246 |
This non-payable code is for required reporting only. |
247 |
Deductible for Professional service rendered in an Institutional setting and billed on an Institutional claim. |
248 |
Coinsurance for Professional service rendered in an Institutional setting and billed on an Institutional claim. |
249 |
This claim has been identified as a readmission. |
250 |
The attachment/other documentation content received is inconsistent with the expected content. |
251 |
THE ATTACHMENT/OTHER DOCUMENTATION THAT WAS RECEIVED WAS INCOMPLETE OR DEFICIENT. THE NECESSARY INFORMATION IS STILL NEEDED TO PROCESS THE CLAIM. |
252 |
An attachment/other documentation is required to adjudicate this claim/service. At least one Remark Code must be provided |
253 |
Sequestration - reduction in federal payment |
254 |
Claim received by the dental plan, but benefits not available under this plan. Submit these services to the patient's medical plan for further consideration. |
256 |
Service not payable per managed care contract. |
257 |
THE 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). |
258 |
Claim/service not covered when patient is in custody/incarcerated. Applicable federal, state or local authority may cover the claim/service. |
259 |
ADDITIONAL PAYMENT FOR DENTAL/VISION SERVICE UTILIZATION. |
26 |
Expenses incurred prior to coverage. |
260 |
PROCESSED UNDER MEDICAID ACA ENHANCED FEE SCHEDULE |
261 |
THE PROCEDURE OR SERVICE IS INCONSISTENT WITH THE PATIENT'S HISTORY. |
27 |
Expenses incurred after coverage terminated. |
29 |
The time limit for filing has expired. |
31 |
Patient cannot be identified as our insured. |
32 |
Our records indicate that this dependent is not an eligible dependent as defined. |
34 |
Insured has no coverage for newborns. |
35 |
Lifetime benefit maximum has been reached. |
39 |
Services denied at the time authorization/pre-certification was requested. |
4 |
The procedure code is inconsistent with the modifier used or a required modifier is missing. |
40 |
Charges do not meet qualifications for emergent/urgent care. |
45 |
Charge exceeds fee schedule/maximum allowable or contracted/legislated fee arrangement. |
49 |
This 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. |
5 |
The procedure code/bill type is inconsistent with the place of service. |
5 |
The 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. |
50 |
These are non-covered services because this is not deemed a 'medical necessity' by the payer. |
51 |
These are non-covered services because this is a pre-existing condition. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. |
53 |
Services by an immediate relative or a member of the same household are not covered. |
54 |
Multiple physicians/assistants are not covered in this case. |
55 |
Procedure/treatment is deemed experimental/investigational by the payer. |
56 |
Procedure/treatment has not been deemed 'proven to be effective' by the payer. |
58 |
Treatment was deemed by the payer to have been rendered in an inappropriate or invalid place of service. |
59 |
Processed based on multiple or concurrent procedure rules. (For example multiple surgery or diagnostic imaging, concurrent anesthesia.) |
6 |
The procedure/revenue code is inconsistent with the patient's age. |
6 |
The 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. |
60 |
Charges for outpatient services are not covered when performed within a period of time prior to or after inpatient services. |
66 |
Blood Deductible. |
69 |
Day outlier amount. |
7 |
The procedure/revenue code is inconsistent with the patient's gender. |
7 |
The 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. |
70 |
Cost outlier - Adjustment to compensate for additional costs. |
78 |
Non-Covered days/Room charge adjustment. |
8 |
The procedure code is inconsistent with the provider type/specialty (taxonomy). |
8 |
The 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. |
89 |
Professional fees removed from charges. |
9 |
The diagnosis is inconsistent with the patient's age. |
94 |
Processed in Excess of charges. |
95 |
Plan procedures not followed. |
96 |
Non-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.) |
97 |
The benefit for this service is included in the payment/allowance for another service/procedure that has already been adjudicated. |
A1 |
Claim/Service denied. At least one Remark Code must be provided |
A5 |
Medicare Claim PPS Capital Cost Outlier Amount. |
A6 |
Prior hospitalization or 30 day transfer requirement not met. |
A7 |
PRESUMPTIVE PAYMENT ADJUSTMENT |
A8 |
Ungroupable DRG. |
APPR |
BILL W/CORRECT CPT/HCPCS CODE |
B1 |
Non-covered visits. |
B10 |
Allowed amount has been reduced because a component of the basic procedure/test was paid. The beneficiary is not liable for more than the charge limit for the basic procedure/test. |
B11 |
THE CLAIM/SERVICE HAS BEEN TRANSFERRED TO THE PROPER PAYER/PROCESSOR FOR PROCESSING. CLAIM/SERVICE NOT COVERED BY THIS PAYER/PROCESSOR. |
B12 |
Services not documented in patients' medical records. |
B13 |
Previously paid. Payment for this claim/service may have been provided in a previous payment. |
B14 |
Only one visit or consultation per physician per day is covered. |
B15 |
This service/procedure requires that a qualifying service/procedure be received and covered. The qualifying other service/procedure has not been received/adjudicated. |
B15 |
This 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. |
B16 |
New Patient' qualifications were not met. |
B20 |
Procedure/service was partially or fully furnished by another provider. |
B23 |
Procedure billed is not authorized per your Clinical Laboratory Improvement Amendment (CLIA) proficiency test. |
B4 |
Late filing penalty. |
B5 |
Coverage/program guidelines were not met or were exceeded. |
B7 |
This provider was not certified/eligible to be paid for this procedure/service on this date of service. |
B8 |
Alternative services were available, and should have been utilized. |
B9 |
Patient is enrolled in a Hospice. |
B9 |
SERVICES NOT COVERED BECAUSE THE PATIENT IS ENROLLED IN A HOSPICE |
BCCTF |
BREAST AND CERVICAL CANCER TREATMENT PROGRAM RESPONSIBILITY |
BCCTP |
BREAST AND CERVICAL CANCER TREATMENT PROGRAM RESPONSIBILITY |
CARVE |
CARVEOUT-SENT BILL TO H. PLAN |
CARVO |
CARVE OUT |
FWABVR |
FWD TO AFFINITY BAY VALLEY REGION |
FWHAP |
FWD TO HOAG AFFILIATED PHYSICIANS |
FWHI |
FWD TO HANKOOK IPA |
FWKP |
FWD TO KAISER PERMANENTE |
NONCON |
PD AT NON CONTRACTED RATES |
P14 |
The 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. |
P17 |
Referral not authorized by attending physician per regulatory requirement. To be used for Property and Casualty only. |
P20 |
Service not paid under jurisdiction allowed outpatient facility fee schedule. To be used for Property and Casualty only. |
P21 |
Payment 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. |
P4 |
Workers' 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 |
P5 |
BASED ON PAYER REASONABLE AND CUSTOMARY FEES. NO MAXIMUM ALLOWABLE DEFINED BY LEGISLATED FEE ARRANGEMENT. |
P7 |
The 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. |
PENDCON |
CMSP PENDING CONTRACT |
REVIEW |
PLEASE REVIEW QTY TO PAY CORRECT AMOUNT |
UDSOCAD |
SHARE OF COST ADJUSTMENT |
UDSOCM |
SHARE OF COST EXCEEDS CONTRACT VALUE |
UDSOCNA |
SHARE OF COST MET - NO ADJUSTMENT |
UDSOCNM |
SHARE OF COST NOT MET |