No maximum allowable defined by legislated fee arrangement. The claim/service has been transferred to the proper payer/processor for processing. This injury/illness is the liability of the no-fault carrier. 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. Provider contracted/negotiated rate expired or not on file. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Service/procedure was provided as a result of terrorism. Payment adjusted based on Preferred Provider Organization (PPO). Reason Code 228: Mutually exclusive procedures cannot be done in the same day/setting. Patient/Insured health identification number and name do not match. Reason Code 120: Payer refund due to overpayment. The provider cannot collect this amount from the patient. Charges are covered under a capitation agreement/managed care plan. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Applicable federal, state or local authority may cover the claim/service. Payment denied/reduced because the payer deems the information submitted does not support this level of service, this many service, this length of service, this dosage, or this day's supply. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Payment adjusted because the payer deems the information submitted does not support this many/frequency of services. (Use CARC 45), Charge exceeds fee schedule/maximum allowable or contracted/legislated fee arrangement. Additional information will be sent following the conclusion of litigation. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. To be used for Workers' Compensation only. Reason Code 247: The attachment/other documentation that was received was the incorrect attachment/document. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. preferred product/service. Procedure has a relative value of zero in the jurisdiction fee schedule, therefore no payment is due. (Use only with Group Codes CO or PI) Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. (Use only with Group Code OA). Claim spans eligible and ineligible periods of coverage. B10 and click the NEXT button in the Search Box to locate the Adjustment Reason code you are inquiring on. Browse and download meeting minutes by committee. Ingredient cost adjustment. Adjustment for postage cost. *Explain the business scenario or use case when the requested new code would be used, the reason an existing code is no longer appropriate for the code lists business purpose, or reason the current description needs to be revised. (Use Group code OA) This change effective 7/1/2013: Per regulatory or other agreement. Reason Code 141: Incentive adjustment, e.g. Denial Code (Remarks): CO 96. Late claim denial. Adjustment for administrative cost. All of our contact information is here. To be used for Property and Casualty Auto only. The rendering provider is not eligible to perform the service billed. (Use only with Group Code OA). An attachment/other documentation is required to adjudicate this claim/service. Treatment was deemed by the payer to have been rendered in an inappropriate or invalid place of service. 04 The procedure code is inconsistent with the modifier used, or a required modifier is missing. The disposition of the claim/service is undetermined during the premium payment grace period, per Health Insurance Exchange requirements. Reason Code 112: Procedure postponed, canceled, or delayed. denial Procedure code was incorrect. Rent/purchase guidelines were not met. 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.) Payment is denied when performed/billed by this type of provider in this type of facility. WebANSI Reason & Remark Codes The Washington Publishing Company maintains a standard code set used industry wide to provide information regarding claim processing.. Service/procedure was provided outside of the United States. codes 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). Benefit maximum for this time period or occurrence has been reached. Services not authorized by network/primary care providers. The attachment/other documentation that was received was the incorrect attachment/document. Each group has specific responsibilities and the groups cooperatively handle items or issues that span the responsibilities of both groups. Deductible for Professional service rendered in an Institutional setting and billed on an Institutional claim. Note: To be used for pharmaceuticals only. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. 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. Reason Code 240: Services not authorized by network/primary care providers. However, this amount may be billed to subsequent payer. Reason Code 233: 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. (Use only with Group Code PR). WebCompare physician performance within organization. Claim received by the medical plan, but benefits not available under this plan. Usage: To be used for pharmaceuticals only. Reason Code 159: State-mandated Requirement for Property and Casualty, see Claim Payment Remarks Code for specific explanation. These are non-covered services because this is not deemed a 'medical necessity' by the payer. Non-compliance with the physician self referral prohibition legislation or payer policy. Procedure/treatment/drug is deemed experimental/investigational by the payer. Claim/service spans multiple months. Reason Code 128: Claim specific negotiated discount. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Adjustment for delivery cost. Newborn's services are covered in the mother's Allowance. This claim has been identified as a resubmission. Usage: 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). Reason Code 147: Payer deems the information submitted does not support this level of service. EOB Description Rejection Group Reason Remark Code Claim Adjustment Reason Codes | X12 (Handled in MIA), Reason Code 82: Patient Interest Adjustment (Use Only Group code PR). This payment reflects the correct code. Reason Code 161: Attachment referenced on the claim was not received in a timely fashion. The list below shows the status of change requests which are in process. These services were submitted after this payers responsibility for processing claims under this plan ended. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. This change effective 7/1/2013: Service/equipment was not prescribed by a physician. (Handled in QTY, QTY01=LA). Reason Code 259: Adjustment for delivery cost. Treatment was deemed by the payer to have been rendered in an inappropriate or invalid place of service. Reason Code 206: Per regulatory or other agreement. Reason Code 229: Institutional Transfer Amount. Charges for outpatient services are not covered when performed within a period of time prior to orafter inpatient services. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Payment denied. Remark Code: N130. Payment is denied when performed/billed by this type of provider. The benefit for this service is included in the payment/allowance for another service/procedure that has already been adjudicated. This (these) diagnosis(es) is (are) missing or are invalid, Reimbursement was adjusted for the reasons to be provided in separate correspondence. Reason Code 148: Payment adjusted because the payer deems the information submitted does not support this many/frequency of services. Refund to patient if collected. Procedure/service was partially or fully furnished by another provider. To be used for Workers' Compensation only. This claim has been identified as a readmission. The authorization number is missing, invalid, or does not apply to the billed services or provider. To apply for an X12 membership, complete and submit an application form which will be reviewed and verified, then you will be notified of the next steps. The applicable fee schedule/fee database does not contain the billed code. The motion passed on a vote of 3-2. 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. Reason Code 1: The procedure code is inconsistent with the modifier used or a required modifier is missing. The diagnosis is inconsistent with the patient's gender. 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. Explanation of Benefit Codes Appearing on the Remittance Advice Reason Code 46: These are non-covered services because this is a routine exam or screening procedure done in conjunction with a routine exam. The referring provider is not eligible to refer the service billed. Administrative surcharges are not covered. Alphabetized listing of current X12 members organizations. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. 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. No available or correlating CPT/HCPCS code to describe this service. Usage: To be used for pharmaceuticals only. Reason Code 253: Service not payable per managed care contract. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. 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. Based on subrogation of a third-party settlement, Based on the findings of a review organization, Based on payer reasonable and customary fees. Claim/service denied. Exceeds the contracted maximum number of hours/days/units by this provider for this period. Medical Payments Coverage (MPC) or Personal Injury Protection (PIP) Benefits jurisdictional fee schedule adjustment. To be used for Workers' Compensation only. This injury/illness is the liability of the no-fault carrier. Reason Code 95: The hospital must file the Medicare claim for this inpatient non-physician service. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. The beneficiary is not liable for more than the charge limit for the basic procedure/test. 0. The diagnosis is inconsistent with the patient's gender. Flexible spending account payments. ), Reason Code 14: Requested information was not provided or was insufficient/incomplete. Usage: 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. Revenue code and Procedure code do not match. Payer deems the information submitted does not support this day's supply. Reason Code 172: Prescription is incomplete. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. 06 The procedure/revenue code is inconsistent with the patients age. The diagnosis is inconsistent with the patient's age. 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). Basically, its a code that signifies a denial and it The diagnosis is inconsistent with the provider type. Patient identification compromised by identity theft. This change effective 7/1/2013: Failure to follow prior payer's coverage rules. The necessary information is still needed to process the claim. 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). Reason Code 73: Disproportionate Share Adjustment. (Use only with Group Codes PR or CO depending upon liability). Medical provider not authorized/certified to provide treatment to injured workers in this jurisdiction. 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. 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. WebDescription. Usage: Do not use this code for claims attachment(s)/other documentation. Claim received by the dental plan, but benefits not available under this plan. Webco 256 denial code descriptions. Reason Code 264: Claim/service spans multiple months. Reason Code 69: Coinsurance day. Reason Code 185: This product/procedure is only covered when used according to FDA recommendations. Monthly Medicaid patient liability amount. ), Claim spans eligible and ineligible periods of coverage, this is the reduction for the ineligible period (use 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). (Use only with Group code OA), Reason Code 207: Payment adjusted because pre-certification/authorization not received in a timely fashion. Denial Codes in Medical Billing - Remit Codes List with solutions Claim/Service has missing diagnosis information. (Use Group code OA) This change effective 7/1/2013: Per regulatory or other agreement. 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. The beneficiary is not liable for more than the charge limit for the basic procedure/test. The X12 Board and the Accredited Standards Committees Steering group (Steering) collaborate to ensure the best interests of X12 are served. The benefit for this service is included in the payment/allowance for another service/procedure that has already been adjudicated. EOB: Claims Adjustment Reason Codes List X12 produces three types of documents tofacilitate consistency across implementations of its work. Reason Code 256: Additional payment for Dental/Vision service utilization. Reason Code 257: Processed under Medicaid ACA Enhance Fee Schedule. Reason Code 258: The procedure or service is inconsistent with the patient's history. Reason Code 259: Adjustment for delivery cost. Note: to be used for pharmaceuticals only. Reason Code 22: Payment denied. Denial reason: Non-covered charge (s). Charges are covered under a capitation agreement/managed care plan. Everything You Need to Know About Denial Code CO 4 Payer deems the information submitted does not support this day's supply. National Provider Identifier - Not matched. State-mandated Requirement for Property and Casualty, see Claim Payment Remarks Code for specific explanation. Did you receive a code from a health plan, such as: PR32 or CO286? Please resubmit on claim per calendar year. This Payer not liable for claim or service/treatment. Procedure/treatment has not been deemed 'proven to be effective' by the payer. This (these) service(s) is (are) not covered. The attachment/other documentation that was received was the incorrect attachment/document. State-mandated Requirement for Property and Casualty, see Claim Payment Remarks Code for specific explanation. Claim spans eligible and ineligible periods of coverage. This change effective 7/1/2013: Partial charge amount not considered by Medicare due to the initial claim Type of Bill being 12X. Reason Code A7: Allowed amount has been reduced because a component of the basic procedure/test was paid. Reason Code 109: Service not furnished directly to the patient and/or not documented. Note: Used only by Property and Casualty. Procedure code was incorrect. Coverage not in effect at the time the service was provided. The following changes to the RARC , Group Credentialing Services, Re-Credentialing Services. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Non-covered charge(s). Reason Code 251: Claim received by the dental plan, but benefits not available under this plan. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Reason Code 7: The diagnosis is inconsistent with the patient's gender. Usage: 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). Adjustment for delivery cost. What is CO 24 Denial Code? Reason Code 35: Services not provided or authorized by designated (network/primary care) providers. (Use only with Group code OA), Payment adjusted because pre-certification/authorization not received in a timely fashion. 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. Pharmacy Direct/Indirect Remuneration (DIR). Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. X12 appoints various types of liaisons, including external and internal liaisons. Note: Used only by Property and Casualty. Service(s) have been considered under the patient's medical plan. (Use only with Group Code CO). Next step verify the application to see any authorization number available or not for the services rendered. The disposition of the related Property & Casualty claim (injury or illness) is pending due to litigation. Reason Code 98: Predetermination: anticipated payment upon completion of services or claim adjudication. Chartered by the American National Standards Institute for more than 40 years, X12 develops and maintains EDI standards and XML schemas which drive business processes globally. 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. Payment denied for exacerbation when supporting documentation was not complete. Reason Code 255: Claim/service not covered when patient is in custody/incarcerated. 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). Claim/Service denied. PIL02b1 Publishing and Maintaining Externally Developed Implementation Guides, PIL02b2 Publishing and Maintaining Externally Developed Implementation Guides. Reason Code 201: This service/equipment/drug is not covered under the patients current benefit plan, Reason Code 202: Pharmacy discount card processing fee. Each recommendation will cover a set of logically grouped transactions and will include supporting information that will assist reviewers as they look at the functionality enhancements and other revisions. At least one Remark Code must be provided (may be comprised of either the Service not paid under jurisdiction allowed outpatient facility fee schedule. No available or correlating CPT/HCPCS code to describe this service. Reason Code 72: Direct Medical Education Adjustment. Reason Code 142: Premium payment withholding. Any use of any X12 work product must be compliant with US Copyright laws and X12 Intellectual Property policies. 05 The procedure code/bill type is inconsistent with the place of service. Precertification/notification/authorization/pre-treatment exceeded. Reason Code 32: Lifetime benefit maximum has been reached. 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.