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