Adjustment Group and Reason Codes List

Adjustment Group and Reason Codes List

What is a reason code used on an EOB/ERA?
Reason codes appear on an explanation of benefits (EOB) to communicate why a claim has been adjusted. If there is no adjustment to a claim/line, then there is no adjustment reason code.

The letters preceding the number codes identify: Contractual Obligation (CO), Correction or reversal to a prior decision (CR), and Patient Responsibility (PR).

Here is a comprehensive Adjustment Group and Reason Codes list*:
*Note: This list is just for your quick reference. The adjustment reason codes are revised from time to time and insurance companies add or deactivate a reason code. So, it is recommended to check the original source for the updates. The adjustment group and reason codes have been taken from the Official Portal for North Dakota State Government website: https://www.nd.gov/dhs/info/mmis.html

A. Adjustment Group Codes

Code
Description
Remarks
PR 
Patient Responsibility 
This indicates Patient Paid Amt ....COPAY,DED,COINSURANCE
CO
Contractual Obligations

This indicates Differences between Submitted Charge and Allowed Charges and final
Paid Amt, After Considering PR and other Adjustments
CR 
Correction and Reversals 
Submitted by Provider
OA
Other Adjustments


OA indicates , Member has TPL or Medicare Policy and Amount is Cut back from Submitted Charge
PI 
Payor Initiated Reductions 
Submitted by Provider

B. Adjustment Reason Codes

Reason Code

Description

   1


Deductible Amount


   2


Coinsurance Amount


    3


Co-payment Amount



4

The 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.


 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.

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.

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.

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.
9

The 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.


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.


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.

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.


13


The date of death precedes the date of service.


14


The date of birth follows the date of service.


15


The authorization number is missing, invalid, or does not apply to the billed services or provider.


16

Claim/service lacks information which is needed for adjudication. 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.)

17

Requested 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.)


18


Duplicate claim/service. This change effective 1/1/2013: Exact duplicate claim/service (Use only with Group Code OA)


19


This is a work-related injury/illness and thus the liability of the Worker's Compensation Carrier.


20


This injury/illness is covered by the liability carrier.


21


This injury/illness is the liability of the no-fault carrier.


22


This care may be covered by another payer per coordination of benefits.



 23
The impact of prior payer(s) adjudication including payments and/or adjustments. (Use only with Group Code OA)

24


Charges are covered under a capitation agreement/managed care plan.


25


Payment denied. Your Stop loss deductible has not been met.


26


Expenses incurred prior to coverage.


27


Expenses incurred after coverage terminated.


28


Coverage not in effect at the time the service was provided.


29


The time limit for filing has expired.


30

Payment adjusted because the patient has not met the required eligibility, spend down, waiting, or residency requirements.


31


Patient cannot be identified as our insured.


32


Our records indicate that this dependent is not an eligible dependent as defined.


33


Insured has no dependent coverage.


34


Insured has no coverage for newborns.


35


Lifetime benefit maximum has been reached.


36


Balance does not exceed co-payment amount.


37


Balance does not exceed deductible.


38


Services not provided or authorized by designated (network/primary care) providers.


39


Services denied at the time authorization/pre-certification was requested.



40


Charges 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.


41


Discount agreed to in Preferred Provider contract.


42


Charges exceed our fee schedule or maximum allowable amount. (Use CARC 45)


43


Gramm-Rudman reduction.


44


Prompt-pay discount.


45

Charge exceeds fee schedule/maximum allowable or contracted/legislated fee arrangement. (Use Group Codes PR or CO depending upon liability).


46


This (these) service(s) is (are) not covered.


47


This (these) diagnosis(es) is (are) not covered, missing, or are invalid.


48


This (these) procedure(s) is (are) not covered.


49


These are non-covered services because this is a routine exam or screening procedure done in conjunction with a routine exam. 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. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
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.

52

The referring/prescribing/rendering provider is not eligible to refer/prescribe/order/perform the service billed.
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. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

55

Procedure/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.

56
Procedure/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.
57

Payment 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.

58

Treatment 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.

59

Processed 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.


60


Charges for outpatient services are not covered when performed within a period of time prior to or after inpatient services.

61

Penalty for failure to obtain second surgical opinion. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

62

Payment denied/reduced for absence of, or exceeded, pre-certification/authorization.

63

Correction to a prior claim.


64


Denial reversed per Medical Review.


65


Procedure code was incorrect. This payment reflects the correct code.


66


Blood Deductible.


67


Lifetime reserve days. (Handled in QTY, QTY01=LA)


68


DRG weight. (Handled in CLP12)


69


Day outlier amount.


70


Cost outlier - Adjustment to compensate for additional costs.


71


Primary Payer amount.


72


Coinsurance day. (Handled in QTY, QTY01=CD)


73


Administrative days.


74


Indirect Medical Education Adjustment.


75


Direct Medical Education Adjustment.


76


Disproportionate Share Adjustment.


77


Covered days. (Handled in QTY, QTY01=CA)


78


Non-Covered days/Room charge adjustment.


79


Cost Report days. (Handled in MIA15)


80


Outlier days. (Handled in QTY, QTY01=OU)


81


Discharges.


82


PIP days.


83


Total visits.


84


Capital Adjustment. (Handled in MIA)


85


Patient Interest Adjustment (Use Only Group code PR)


86


Statutory Adjustment.


87


Transfer amount.


88


Adjustment amount represents collection against receivable created in prior overpayment.


89


Professional fees removed from charges.


90


Ingredient cost adjustment. Note: To be used for pharmaceuticals only.


91


Dispensing fee adjustment.


92


Claim Paid in full.


93


No Claim level Adjustments.


 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.) Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.


97

The 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.

98


The hospital must file the Medicare claim for this inpatient non-physician service.


99


Medicare Secondary Payer Adjustment Amount.


100


Payment made to patient/insured/responsible party/employer.


101


Predetermination: anticipated payment upon completion of services or claim adjudication.


102


Major Medical Adjustment.


103


Provider promotional discount (e.g., Senior citizen discount).


104


Managed care withholding.


105


Tax withholding.


106


Patient payment option/election not in effect.




107


The 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.

108


Rent/purchase guidelines were not met. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.


109


Claim/service not covered by this payer/contractor. You must send the claim/service to the correct payer/contractor.


110


Billing date predates service date.


111


Not covered unless the provider accepts assignment.


112


Service not furnished directly to the patient and/or not documented.


113


Payment denied because service/procedure was provided outside the United States or as a result of
war.


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.


120


Patient is covered by a managed care plan.


121


Indemnification adjustment - compensation for outstanding member responsibility.


122


Psychiatric reduction.


123


Payer refund due to overpayment.


124


Payer refund amount - not our patient.


125


Submission/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.)


126


Deductible -- Major Medical


127


Coinsurance -- Major Medical


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 (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.)

130


Claim submission fee.


131


Claim specific negotiated discount.


132


Prearranged demonstration project adjustment.


133

The disposition of the claim/service 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).

134


Technical fees removed from charges.


135


Interim bills cannot be processed.


136


Failure to follow prior payer's coverage rules. (Use Group Code OA). This change effective 7/1/2013: Failure to follow prior payer's coverage rules. (Use only with Group Code OA)


137


Regulatory Surcharges, Assessments, Allowances or Health Related Taxes.


138


Appeal procedures not followed or time limits not met.


139


Contracted funding agreement - Subscriber is employed by the provider of services.


140


Patient/Insured health identification number and name do not match.


141


Claim spans eligible and ineligible periods of coverage.


142


Monthly Medicaid patient liability amount.


143


Portion of payment deferred.


144


Incentive adjustment, e.g. preferred product/service.


145


Premium payment withholding


146


Diagnosis was invalid for the date(s) of service reported.


147


Provider contracted/negotiated rate expired or not on file.

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.


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. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.


153


Payer deems the information submitted does not support this dosage.


154


Payer deems the information submitted does not support this day's supply.


155


Patient refused the service/procedure.


156


Flexible spending account payments. Note: Use code 187.


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.


160


Injury/illness was the result of an activity that is a benefit exclusion.


161


Provider performance bonus


162


State-mandated Requirement for Property and Casualty, see Claim Payment Remarks Code for specific explanation.


163


Attachment referenced on the claim was not received.


164


Attachment referenced on the claim was not received in a timely fashion.


165

Referral absent or exceeded.

 166
These services were submitted after this payers responsibility for processing claims under this plan ended.


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.


169


Alternate benefit has been provided.

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. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
173

Service was not prescribed by a physician. This change effective 7/1/2013: 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.


177


Patient has not met the required eligibility requirements.


178


Patient has not met the required spend down requirements.

179

Patient has not met the required waiting requirements. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

180


Patient has not met the required residency requirements.


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. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.


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.


187

Consumer Spending Account payments (includes but is not limited to Flexible Spending Account, Health Savings Account, Health Reimbursement Account, etc.)

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

190


Payment is included in the allowance for a Skilled Nursing Facility (SNF) qualified stay.




.   191


Not 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)


192
Non 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.
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.


195


Refund issued to an erroneous priority payer for this claim/service.


196


Claim/service denied based on prior payer's coverage determination.


197


Precertification/authorization/notification absent.


198


Precertification/authorization exceeded.


199


Revenue code and Procedure code do not match.


200


Expenses incurred during lapse in coverage


201

Patient is responsible for amount of this claim/service through 'set aside arrangement' or other agreement. ( Use only with Group Code PR) At least on remark code must be provider (may be comprised of either the NCPDP Reject Reason Code or Remittance Advice Remark Code that is not an alert.)

202


Non-covered personal comfort or convenience services.


203


Discontinued or reduced service.


204


This service/equipment/drug is not covered under the patients current benefit plan


205


Pharmacy discount card processing fee


206


National Provider Identifier - missing.


207


National Provider identifier - Invalid format


208


National Provider Identifier - Not matched.


209

Per 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 Group code OA) This change effective 7/1/2013: Per 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)

210


Payment adjusted because pre-certification/authorization not received in a timely fashion


211


National Drug Codes (NDC) not eligible for rebate, are not covered.


212


Administrative surcharges are not covered


213


Non-compliance with the physician self referral prohibition legislation or payer policy.


214


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


215


Based on subrogation of a third party settlement


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. (Note: To be used for Property and Casualty only)


218
Based 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

219

Based 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).

220

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. (Note: To be used for Property and Casualty only)






221


Workers' Compensation claim 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). This change effective 7/1/2013: Claim 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)


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.

223


Adjustment 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.


224


Patient identification compromised by identity theft. Identity verification required for processing
this and future claims.


225

Penalty or Interest Payment by Payer (Only used for plan to plan encounter reporting within the 837)


226


Information requested from the Billing/Rendering 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.) This change effective 7/1/2013: Information 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.)

227
Information 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.)

228


Denied for failure of this provider, another provider or the subscriber to supply requested
information to a previous payer for their adjudication


229
Partial 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 Group Code PR. This change effective 7/1/2013: Partial 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)

230


No available or correlating CPT/HCPCS code to describe this service. Note: Used only by Property and Casualty.


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 (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.)

235


Sales Tax


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. This change effective 7/1/2013: 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 (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.)

238

Claim spans eligible and ineligible periods of coverage, this is the reduction for the ineligible period (use Group Code PR). This change effective 7/1/2013: Claim spans eligible and ineligible periods of coverage, this is the reduction for the ineligible period. (Use only with Group Code PR)

239


Claim spans eligible and ineligible periods of coverage. Rebill separate claims.


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.

241


Low Income Subsidy (LIS) Co-payment Amount


242


Services not provided by network/primary care providers.


243


Services not authorized by network/primary care providers.


244


Payment reduced to zero due to litigation. Additional information will be sent following the conclusion of litigation. To be used for Property & Casualty only.


245


Provider performance program withhold.


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 resubmission. (Use only with Group Code CO)


250
The 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.

251

The 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).

252

An attachment 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).

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.


255

The disposition of the related Property & Casualty claim (injury or illness) is pending due to litigation (Use only with Group Code OA)

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 lace of premium payment). (Use only with Group Code OA).

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


260


Processed under Medicaid ACA Enhance Fee Schedule


261


The procedure or service is inconsistent with the patient's history.


262


Adjustment for delivery cost. Note: to be used for pharmaceuticals only.


263


Adjustment for shipping cost. Note: To be used for pharmaceuticals only.


264


Adjustment for postage cost. Note: To be used for pharmaceuticals only.


265


Adjustment for administrative cost. Note: To be used for pharmaceuticals only.


266


Adjustment for compound preparation cost. Note: To be used for pharmaceuticals only.


267


Claim/service spans multiple months. Rebill as a separate claim/service.


268


The Claim spans two calendar years. Please resubmit on claim per calendar year.


A0


Patient refund amount.


A1


Claim/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.)


A2


Contractual adjustment.


A3


Medicare Secondary Payer liability met.


A4


Medicare Claim PPS Capital Day Outlier Amount.


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.


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. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.


B16


'New Patient' qualifications were not met.


B17

Payment 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.


B18


This procedure code and modifier were invalid on the date of service.


B19


Claim/service adjusted because of the finding of a Review Organization.


B2


Covered visits.


B20


Procedure/service was partially or fully furnished by another provider.


B21


The charges were reduced because the service/care was partially furnished by another physician.


B22


This payment is adjusted based on the diagnosis.


B23


Procedure billed is not authorized per your Clinical Laboratory Improvement Amendment (CLIA) proficiency test.


B3


Covered charges.


B4


Late filing penalty.


B5


Coverage/program guidelines were not met or were exceeded.


B6


This 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.


B7

This 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.


B8

Alternative 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.


B9


Patient is enrolled in a Hospice.


D1


Claim/service denied. Level of subluxation is missing or inadequate.


D10


Claim/service denied. Completed physician financial relationship form not on file.


D11


Claim lacks completed pacemaker registration form.


D12


Claim/service denied. Claim does not identify who performed the purchased diagnostic test or the amount you were charged for the test.


D13


Claim/service denied. Performed by a facility/supplier in which the ordering/referring physician has a financial interest.


D14


Claim lacks indication that plan of treatment is on file.


D15


Claim lacks indication that service was supervised or evaluated by a physician.


D16


Claim lacks prior payer payment information.


D17


Claim/Service has invalid non-covered days.


D18


Claim/Service has missing diagnosis information.


D19


Claim/Service lacks Physician/Operative or other supporting documentation


D2


Claim lacks the name, strength, or dosage of the drug furnished.


D20


Claim/Service missing service/product information.


D21


This (these) diagnosis(es) is (are) missing or are invalid


D22
Reimbursement 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.

D23

This 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.)


D3


Claim/service denied because information to indicate if the patient owns the equipment that requires the part or supply was missing.


D4


Claim/service does not indicate the period of time for which this will be needed.


D5


Claim/service denied. Claim lacks individual lab codes included in the test.


D6


Claim/service denied. Claim did not include patient's medical record for the service.


D7


Claim/service denied. Claim lacks date of patient's most recent physician visit.


D8


Claim/service denied. Claim lacks indicator that 'x-ray is available for review.'


D9


Claim/service denied. Claim lacks invoice or statement certifying the actual cost of the lens, less discounts or the type of intraocular lens used.


P1


State-mandated Requirement for Property and Casualty, see Claim Payment Remarks Code for specific explanation. To be used for Property and Casualty only.


P10


Payment reduced to zero due to litigation. Additional information will be sent following the conclusion of litigation. To be used for Property and Casualty only.


P11


The 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)




P12


Workers' 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.


P13


Payment 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.


   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.


P15


Workers' Compensation Medical Treatment Guideline Adjustment. To be used for Workers' Compensation only.


P16


Medical 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)


P17


Referral not authorized by attending physician per regulatory requirement. To be used for Property and Casualty only.


P18


Procedure 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.


P19


Procedure has a relative value of zero in the jurisdiction fee schedule, therefore no payment is due. To be used for Property and Casualty only.


P2
Not 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.

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.


P22

Payment 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.

P23

Medical 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 provide 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.

P3


Workers' 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)



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. To be used for Property and Casualty only.



P6


Based 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.


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.


P8
Claim 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.

P9


No available or correlating CPT/HCPCS code to describe this service. To be used for Property and Casualty only.



W1


Workers' 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).



W2


Payment 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') 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.


W3

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. For use by Property and Casualty only.

W4


Workers' Compensation Medical Treatment Guideline Adjustment.


W5


Medical provider not authorized/certified to provide treatment to injured workers in this jurisdiction (Use with Group Code CO or OA)


W6


Referral not authorized by attending physician per regulatory requirement


W7


Procedure is not listed in the jurisdiction fee schedule. A allowance has been made for a comparable service.


W8


Procedure has a relative value of zero in the jurisdiction fee schedule, therefore no payment is due.


W9


Service not paid under jurisdiction allowed outpatient facility fee schedule.



Y1


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') 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 P&C Auto only.


Y2


Payment 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') 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 P&C Auto only.

Y3
Medical 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). To be used for P&C Auto only.


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