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Claim Adjustment Reason Codes

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Last Update 7/1/2010 - All

Claim Adjustment Reason Codes - All

Claim adjustment reason codes communicate an adjustment, meaning that they must communicate why a claim or service line was paid differently than it was billed. If there is no adjustment to a claim/line, then there is no adjustment reason code.

1Deductible Amount
Start: 01/01/1995
2Coinsurance Amount
Start: 01/01/1995
3Co-payment Amount
Start: 01/01/1995
4The 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.
Start: 01/01/1995 | Last Modified: 09/20/2009
5The 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.
Start: 01/01/1995 | Last Modified: 09/20/2009
6The 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.
Start: 01/01/1995 | Last Modified: 09/20/2009
7The 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.
Start: 01/01/1995 | Last Modified: 09/20/2009
8The 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.
Start: 01/01/1995 | Last Modified: 09/20/2009
9The 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.
Start: 01/01/1995 | Last Modified: 09/20/2009
10The 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.
Start: 01/01/1995 | Last Modified: 09/20/2009
11The diagnosis is inconsistent with the procedure. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
Start: 01/01/1995 | Last Modified: 09/20/2009
12The diagnosis is inconsistent with the provider type. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
Start: 01/01/1995 | Last Modified: 09/20/2009
13The date of death precedes the date of service.
Start: 01/01/1995
14The date of birth follows the date of service.
Start: 01/01/1995
15The authorization number is missing, invalid, or does not apply to the billed services or provider.
Start: 01/01/1995 | Last Modified: 09/30/2007
16Claim/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.)
Start: 01/01/1995 | Last Modified: 09/20/2009
17Requested 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.)
Start: 01/01/1995 | Last Modified: 09/21/2008 | Stop: 07/01/2009
18Duplicate claim/service.
Start: 01/01/1995
19This is a work-related injury/illness and thus the liability of the Worker's Compensation Carrier.
Start: 01/01/1995 | Last Modified: 09/30/2007
20This injury/illness is covered by the liability carrier.
Start: 01/01/1995 | Last Modified: 09/30/2007
21This injury/illness is the liability of the no-fault carrier.
Start: 01/01/1995 | Last Modified: 09/30/2007
22This care may be covered by another payer per coordination of benefits.
Start: 01/01/1995 | Last Modified: 09/30/2007
23The impact of prior payer(s) adjudication including payments and/or adjustments.
Start: 01/01/1995 | Last Modified: 09/30/2007
24Charges are covered under a capitation agreement/managed care plan.
Start: 01/01/1995 | Last Modified: 09/30/2007
25Payment denied. Your Stop loss deductible has not been met.
Start: 01/01/1995 | Stop: 04/01/2008
26Expenses incurred prior to coverage.
Start: 01/01/1995
27Expenses incurred after coverage terminated.
Start: 01/01/1995
28Coverage not in effect at the time the service was provided.
Start: 01/01/1995 | Stop: 10/16/2003
Notes: Redundant to codes 26&27.
29The time limit for filing has expired.
Start: 01/01/1995
30Payment adjusted because the patient has not met the required eligibility, spend down, waiting, or residency requirements.
Start: 01/01/1995 | Stop: 02/01/2006
31Patient cannot be identified as our insured.
Start: 01/01/1995 | Last Modified: 09/30/2007
32Our records indicate that this dependent is not an eligible dependent as defined.
Start: 01/01/1995
33Insured has no dependent coverage.
Start: 01/01/1995 | Last Modified: 09/30/2007
34Insured has no coverage for newborns.
Start: 01/01/1995 | Last Modified: 09/30/2007
35Lifetime benefit maximum has been reached.
Start: 01/01/1995 | Last Modified: 10/31/2002
36Balance does not exceed co-payment amount.
Start: 01/01/1995 | Stop: 10/16/2003
37Balance does not exceed deductible.
Start: 01/01/1995 | Stop: 10/16/2003
38Services not provided or authorized by designated (network/primary care) providers.
Start: 01/01/1995 | Last Modified: 06/30/2003
39Services denied at the time authorization/pre-certification was requested.
Start: 01/01/1995
40Charges 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.
Start: 01/01/1995 | Last Modified: 09/20/2009
41Discount agreed to in Preferred Provider contract.
Start: 01/01/1995 | Stop: 10/16/2003
42Charges exceed our fee schedule or maximum allowable amount. (Use CARC 45)
Start: 01/01/1995 | Last Modified: 10/31/2006 | Stop: 06/01/2007
43Gramm-Rudman reduction.
Start: 01/01/1995 | Stop: 07/01/2006
44Prompt-pay discount.
Start: 01/01/1995
45Charge exceeds fee schedule/maximum allowable or contracted/legislated fee arrangement. (Use Group Codes PR or CO depending upon liability).
Start: 01/01/1995 | Last Modified: 10/31/2006
46This (these) service(s) is (are) not covered.
Start: 01/01/1995 | Stop: 10/16/2003
Notes: Use code 96.
47This (these) diagnosis(es) is (are) not covered, missing, or are invalid.
Start: 01/01/1995 | Stop: 02/01/2006
48This (these) procedure(s) is (are) not covered.
Start: 01/01/1995 | Stop: 10/16/2003
Notes: Use code 96.
49These 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.
Start: 01/01/1995 | Last Modified: 09/20/2009
50These 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.
Start: 01/01/1995 | Last Modified: 09/20/2009
51These 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.
Start: 01/01/1995 | Last Modified: 09/20/2009
52The referring/prescribing/rendering provider is not eligible to refer/prescribe/order/perform the service billed.
Start: 01/01/1995 | Stop: 02/01/2006
53Services by an immediate relative or a member of the same household are not covered.
Start: 01/01/1995
54Multiple 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.
Start: 01/01/1995 | Last Modified: 09/20/2009
55Procedure/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.
Start: 01/01/1995 | Last Modified: 09/20/2009
56Procedure/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.
Start: 01/01/1995 | Last Modified: 09/20/2009
57Payment 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.
Start: 01/01/1995 | Stop: 06/30/2007
Notes: Split into codes 150, 151, 152, 153 and 154.
58Treatment 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.
Start: 01/01/1995 | Last Modified: 09/20/2009
59Processed 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.
Start: 01/01/1995 | Last Modified: 09/20/2009
60Charges for outpatient services are not covered when performed within a period of time prior to or after inpatient services.
Start: 01/01/1995 | Last Modified: 06/01/2008
61Penalty for failure to obtain second surgical opinion. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
Start: 01/01/1995 | Last Modified: 09/20/2009
62Payment denied/reduced for absence of, or exceeded, pre-certification/authorization.
Start: 01/01/1995 | Last Modified: 10/31/2006 | Stop: 04/01/2007
63Correction to a prior claim.
Start: 01/01/1995 | Stop: 10/16/2003
64Denial reversed per Medical Review.
Start: 01/01/1995 | Stop: 10/16/2003
65Procedure code was incorrect. This payment reflects the correct code.
Start: 01/01/1995 | Stop: 10/16/2003
66Blood Deductible.
Start: 01/01/1995
67Lifetime reserve days. (Handled in QTY, QTY01=LA)
Start: 01/01/1995 | Stop: 10/16/2003
68DRG weight. (Handled in CLP12)
Start: 01/01/1995 | Stop: 10/16/2003
69Day outlier amount.
Start: 01/01/1995
70Cost outlier - Adjustment to compensate for additional costs.
Start: 01/01/1995 | Last Modified: 06/30/2001
71Primary Payer amount.
Start: 01/01/1995 | Stop: 06/30/2000
Notes: Use code 23.
72Coinsurance day. (Handled in QTY, QTY01=CD)
Start: 01/01/1995 | Stop: 10/16/2003
73Administrative days.
Start: 01/01/1995 | Stop: 10/16/2003
74Indirect Medical Education Adjustment.
Start: 01/01/1995
75Direct Medical Education Adjustment.
Start: 01/01/1995
76Disproportionate Share Adjustment.
Start: 01/01/1995
77Covered days. (Handled in QTY, QTY01=CA)
Start: 01/01/1995 | Stop: 10/16/2003
78Non-Covered days/Room charge adjustment.
Start: 01/01/1995
79Cost Report days. (Handled in MIA15)
Start: 01/01/1995 | Stop: 10/16/2003
80Outlier days. (Handled in QTY, QTY01=OU)
Start: 01/01/1995 | Stop: 10/16/2003
81Discharges.
Start: 01/01/1995 | Stop: 10/16/2003
82PIP days.
Start: 01/01/1995 | Stop: 10/16/2003
83Total visits.
Start: 01/01/1995 | Stop: 10/16/2003
84Capital Adjustment. (Handled in MIA)
Start: 01/01/1995 | Stop: 10/16/2003
85Patient Interest Adjustment (Use Only Group code PR)
Start: 01/01/1995 | Last Modified: 07/09/2007
Notes: Only use when the payment of interest is the responsibility of the patient.
86Statutory Adjustment.
Start: 01/01/1995 | Stop: 10/16/2003
Notes: Duplicative of code 45.
87Transfer amount.
Start: 01/01/1995 | Last Modified: 09/20/2009 | Stop: 01/01/2012
88Adjustment amount represents collection against receivable created in prior overpayment.
Start: 01/01/1995 | Stop: 06/30/2007
89Professional fees removed from charges.
Start: 01/01/1995
90Ingredient cost adjustment. Note: To be used for pharmaceuticals only.
Start: 01/01/1995 | Last Modified: 07/01/2009
91Dispensing fee adjustment.
Start: 01/01/1995
92Claim Paid in full.
Start: 01/01/1995 | Stop: 10/16/2003
93No Claim level Adjustments.
Start: 01/01/1995 | Stop: 10/16/2003
Notes: As of 004010, CAS at the claim level is optional.
94Processed in Excess of charges.
Start: 01/01/1995
95Plan procedures not followed.
Start: 01/01/1995 | Last Modified: 09/30/2007
96Non-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.
Start: 01/01/1995 | Last Modified: 09/20/2009
97The 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.
Start: 01/01/1995 | Last Modified: 09/20/2009
98The hospital must file the Medicare claim for this inpatient non-physician service.
Start: 01/01/1995 | Stop: 10/16/2003
99Medicare Secondary Payer Adjustment Amount.
Start: 01/01/1995 | Stop: 10/16/2003
100Payment made to patient/insured/responsible party/employer.
Start: 01/01/1995 | Last Modified: 01/27/2008
101Predetermination: anticipated payment upon completion of services or claim adjudication.
Start: 01/01/1995 | Last Modified: 02/28/1999
102Major Medical Adjustment.
Start: 01/01/1995
103Provider promotional discount (e.g., Senior citizen discount).
Start: 01/01/1995 | Last Modified: 06/30/2001
104Managed care withholding.
Start: 01/01/1995
105Tax withholding.
Start: 01/01/1995
106Patient payment option/election not in effect.
Start: 01/01/1995
107The 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.
Start: 01/01/1995 | Last Modified: 09/20/2009
108Rent/purchase guidelines were not met. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
Start: 01/01/1995 | Last Modified: 09/20/2009
109Claim not covered by this payer/contractor. You must send the claim to the correct payer/contractor.
Start: 01/01/1995
110Billing date predates service date.
Start: 01/01/1995
111Not covered unless the provider accepts assignment.
Start: 01/01/1995
112Service not furnished directly to the patient and/or not documented.
Start: 01/01/1995 | Last Modified: 09/30/2007
113Payment denied because service/procedure was provided outside the United States or as a result of war.
Start: 01/01/1995 | Last Modified: 02/28/2001 | Stop: 06/30/2007
Notes: Use Codes 157, 158 or 159.
114Procedure/product not approved by the Food and Drug Administration.
Start: 01/01/1995
115Procedure postponed, canceled, or delayed.
Start: 01/01/1995 | Last Modified: 09/30/2007
116The advance indemnification notice signed by the patient did not comply with requirements.
Start: 01/01/1995 | Last Modified: 09/30/2007
117Transportation is only covered to the closest facility that can provide the necessary care.
Start: 01/01/1995 | Last Modified: 09/30/2007
118ESRD network support adjustment.
Start: 01/01/1995 | Last Modified: 09/30/2007
119Benefit maximum for this time period or occurrence has been reached.
Start: 01/01/1995 | Last Modified: 02/29/2004
120Patient is covered by a managed care plan.
Start: 01/01/1995 | Stop: 06/30/2007
Notes: Use code 24.
121Indemnification adjustment - compensation for outstanding member responsibility.
Start: 01/01/1995 | Last Modified: 09/30/2007
122Psychiatric reduction.
Start: 01/01/1995
123Payer refund due to overpayment.
Start: 01/01/1995 | Stop: 06/30/2007
Notes: Refer to implementation guide for proper handling of reversals.
124Payer refund amount - not our patient.
Start: 01/01/1995 | Last Modified: 06/30/1999 | Stop: 06/30/2007
Notes: Refer to implementation guide for proper handling of reversals.
125Submission/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.)
Start: 01/01/1995 | Last Modified: 09/20/2009
126Deductible -- Major Medical
Start: 02/28/1997 | Last Modified: 09/30/2007 | Stop: 04/01/2008
Notes: Use Group Code PR and code 1.
127Coinsurance -- Major Medical
Start: 02/28/1997 | Last Modified: 09/30/2007 | Stop: 04/01/2008
Notes: Use Group Code PR and code 2.
128Newborn's services are covered in the mother's Allowance.
Start: 02/28/1997
129Prior processing information appears incorrect. This change to be effective 4-1-2011: 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.)
Start: 02/28/1997 | Last Modified: 09/30/2007
130Claim submission fee.
Start: 02/28/1997 | Last Modified: 06/30/2001
131Claim specific negotiated discount.
Start: 02/28/1997
132Prearranged demonstration project adjustment.
Start: 02/28/1997
133The disposition of this claim/service is pending further review.
Start: 02/28/1997 | Last Modified: 10/31/1999
134Technical fees removed from charges.
Start: 10/31/1998
135Interim bills cannot be processed.
Start: 10/31/1998 | Last Modified: 09/30/2007
136Failure to follow prior payer's coverage rules. (Use Group Code OA).
Start: 10/31/1998 | Last Modified: 09/30/2007
137Regulatory Surcharges, Assessments, Allowances or Health Related Taxes.
Start: 02/28/1999 | Last Modified: 09/30/2007
138Appeal procedures not followed or time limits not met.
Start: 06/30/1999 | Last Modified: 09/30/2007
139Contracted funding agreement - Subscriber is employed by the provider of services.
Start: 06/30/1999
140Patient/Insured health identification number and name do not match.
Start: 06/30/1999
141Claim spans eligible and ineligible periods of coverage.
Start: 06/30/1999 | Last Modified: 09/30/2007
142Monthly Medicaid patient liability amount.
Start: 06/30/2000 | Last Modified: 09/30/2007
143Portion of payment deferred.
Start: 02/28/2001
144Incentive adjustment, e.g. preferred product/service.
Start: 06/30/2001
145Premium payment withholding
Start: 06/30/2002 | Last Modified: 09/30/2007 | Stop: 04/01/2008
Notes: Use Group Code CO and code 45.
146Diagnosis was invalid for the date(s) of service reported.
Start: 06/30/2002 | Last Modified: 09/30/2007
147Provider contracted/negotiated rate expired or not on file.
Start: 06/30/2002
148Information 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.)
Start: 06/30/2002 | Last Modified: 09/20/2009
149Lifetime benefit maximum has been reached for this service/benefit category.
Start: 10/31/2002
150Payer deems the information submitted does not support this level of service.
Start: 10/31/2002 | Last Modified: 09/30/2007
151Payment adjusted because the payer deems the information submitted does not support this many/frequency of services.
Start: 10/31/2002 | Last Modified: 01/27/2008
152Payer 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.
Start: 10/31/2002 | Last Modified: 09/20/2009
153Payer deems the information submitted does not support this dosage.
Start: 10/31/2002 | Last Modified: 09/30/2007
154Payer deems the information submitted does not support this day's supply.
Start: 10/31/2002 | Last Modified: 09/30/2007
155Patient refused the service/procedure.
Start: 06/30/2003 | Last Modified: 09/30/2007
156Flexible spending account payments. Note: Use code 187.
Start: 09/30/2003 | Last Modified: 01/25/2009 | Stop: 10/01/2009
157Service/procedure was provided as a result of an act of war.
Start: 09/30/2003 | Last Modified: 09/30/2007
158Service/procedure was provided outside of the United States.
Start: 09/30/2003 | Last Modified: 09/30/2007
159Service/procedure was provided as a result of terrorism.
Start: 09/30/2003 | Last Modified: 09/30/2007
160Injury/illness was the result of an activity that is a benefit exclusion.
Start: 09/30/2003 | Last Modified: 09/30/2007
161Provider performance bonus
Start: 02/29/2004
162State-mandated Requirement for Property and Casualty, see Claim Payment Remarks Code for specific explanation.
Start: 02/29/2004
163Attachment referenced on the claim was not received.
Start: 06/30/2004 | Last Modified: 09/30/2007
164Attachment referenced on the claim was not received in a timely fashion.
Start: 06/30/2004 | Last Modified: 09/30/2007
165Referral absent or exceeded.
Start: 10/31/2004 | Last Modified: 09/30/2007
166These services were submitted after this payers responsibility for processing claims under this plan ended.
Start: 02/28/2005
167This (these) diagnosis(es) is (are) not covered. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
Start: 06/30/2005 | Last Modified: 09/20/2009
168Service(s) have been considered under the patient's medical plan. Benefits are not available under this dental plan.
Start: 06/30/2005 | Last Modified: 09/30/2007
169Alternate benefit has been provided.
Start: 06/30/2005 | Last Modified: 09/30/2007
170Payment 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.
Start: 06/30/2005 | Last Modified: 09/20/2009
171Payment 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.
Start: 06/30/2005 | Last Modified: 09/20/2009
172Payment 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.
Start: 06/30/2005 | Last Modified: 09/20/2009
173Service was not prescribed by a physician.
Start: 06/30/2005 | Last Modified: 09/30/2007
174Service was not prescribed prior to delivery.
Start: 06/30/2005 | Last Modified: 09/30/2007
175Prescription is incomplete.
Start: 06/30/2005 | Last Modified: 09/30/2007
176Prescription is not current.
Start: 06/30/2005 | Last Modified: 09/30/2007
177Patient has not met the required eligibility requirements.
Start: 06/30/2005 | Last Modified: 09/30/2007
178Patient has not met the required spend down requirements.
Start: 06/30/2005 | Last Modified: 09/30/2007
179Patient has not met the required waiting requirements. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
Start: 06/30/2005 | Last Modified: 09/20/2009
180Patient has not met the required residency requirements.
Start: 06/30/2005 | Last Modified: 09/30/2007
181Procedure code was invalid on the date of service.
Start: 06/30/2005 | Last Modified: 09/30/2007
182Procedure modifier was invalid on the date of service.
Start: 06/30/2005 | Last Modified: 09/30/2007
183The 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.
Start: 06/30/2005 | Last Modified: 09/20/2009
184The 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.
Start: 06/30/2005 | Last Modified: 09/20/2009
185The 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.
Start: 06/30/2005 | Last Modified: 09/20/2009
186Level of care change adjustment.
Start: 06/30/2005 | Last Modified: 09/30/2007
187Consumer Spending Account payments (includes but is not limited to Flexible Spending Account, Health Savings Account, Health Reimbursement Account, etc.)
Start: 06/30/2005 | Last Modified: 01/25/2009
188This product/procedure is only covered when used according to FDA recommendations.
Start: 06/30/2005
189'Not otherwise classified' or 'unlisted' procedure code (CPT/HCPCS) was billed when there is a specific procedure code for this procedure/service
Start: 06/30/2005
190Payment is included in the allowance for a Skilled Nursing Facility (SNF) qualified stay.
Start: 10/31/2005
191Not a work related injury/illness and thus not the liability of the workers' compensation carrier.
Start: 10/31/2005 | Last Modified: 09/30/2007
192Non 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.
Start: 10/31/2005 | Last Modified: 09/30/2007
193Original payment decision is being maintained. Upon review, it was determined that this claim was processed properly.
Start: 02/28/2006 | Last Modified: 01/27/2008
194Anesthesia performed by the operating physician, the assistant surgeon or the attending physician.
Start: 02/28/2006 | Last Modified: 09/30/2007
195Refund issued to an erroneous priority payer for this claim/service.
Start: 02/28/2006 | Last Modified: 09/30/2007
196Claim/service denied based on prior payer's coverage determination.
Start: 06/30/2006 | Stop: 02/01/2007
Notes: Use code 136.
197Precertification/authorization/notification absent.
Start: 10/31/2006 | Last Modified: 09/30/2007
198Precertification/authorization exceeded.
Start: 10/31/2006 | Last Modified: 09/30/2007
199Revenue code and Procedure code do not match.
Start: 10/31/2006
200Expenses incurred during lapse in coverage
Start: 10/31/2006
201Workers Compensation case settled. Patient is responsible for amount of this claim/service through WC 'Medicare set aside arrangement' or other agreement. (Use group code PR).
Start: 10/31/2006
202Non-covered personal comfort or convenience services.
Start: 02/28/2007 | Last Modified: 09/30/2007
203Discontinued or reduced service.
Start: 02/28/2007 | Last Modified: 09/30/2007
204This service/equipment/drug is not covered under the patient's current benefit plan
Start: 02/28/2007
205Pharmacy discount card processing fee
Start: 07/09/2007
206National Provider Identifier - missing.
Start: 07/09/2007 | Last Modified: 09/30/2007
207National Provider identifier - Invalid format
Start: 07/09/2007 | Last Modified: 06/01/2008
208National Provider Identifier - Not matched.
Start: 07/09/2007 | Last Modified: 09/30/2007
209Per 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)
Start: 07/09/2007
210Payment adjusted because pre-certification/authorization not received in a timely fashion
Start: 07/09/2007
211National Drug Codes (NDC) not eligible for rebate, are not covered.
Start: 07/09/2007
212Administrative surcharges are not covered
Start: 11/05/2007
213Non-compliance with the physician self referral prohibition legislation or payer policy.
Start: 01/27/2008
214Workers' Compensation claim adjudicated as non-compensable. This Payer not liable for claim or service/treatment. (Note: To be used for Workers' Compensation only)
Start: 01/27/2008
215Based on subrogation of a third party settlement
Start: 01/27/2008
216Based on the findings of a review organization
Start: 01/27/2008
217Based on payer reasonable and customary fees. No maximum allowable defined by legislated fee arrangement. (Note: To be used for Workers' Compensation only)
Start: 01/27/2008
218Based on entitlement to benefits (Note: To be used for Workers' Compensation only)
Start: 01/27/2008
219Based on extent of injury (Note: To be used for Workers' Compensation only)
Start: 01/27/2008
220The applicable fee schedule does not contain the billed code. Please resubmit a bill with the appropriate fee schedule code(s) that best describe the service(s) provided and supporting documentation if required. (Note: To be used for Workers' Compensation only)
Start: 01/27/2008
221Workers' Compensation claim is under investigation. (Note: To be used for Workers' Compensation only. Claim pending final resolution)
Start: 01/27/2008
222Exceeds 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.
Start: 06/01/2008 | Last Modified: 09/20/2009
223Adjustment 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.
Start: 06/01/2008
224Patient identification compromised by identity theft. Identity verification required for processing this and future claims.
Start: 06/01/2008
225Penalty or Interest Payment by Payer (Only used for plan to plan encounter reporting within the 837)
Start: 06/01/2008
226Information 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.)
Start: 09/21/2008 | Last Modified: 09/20/2009
227Information 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.)
Start: 09/21/2008 | Last Modified: 09/20/2009
228Denied for failure of this provider, another provider or the subscriber to supply requested information to a previous payer for their adjudication
Start: 09/21/2008
229Partial 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.
Start: 01/25/2009
230No available or correlating CPT/HCPCS code to describe this service. Note: Used only by Property and Casualty.
Start: 01/25/2009
231Mutually 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.
Start: 07/01/2009 | Last Modified: 09/20/2009
232Institutional Transfer Amount. Note - Applies to institutional claims only and explains the DRG amount difference when the patient care crosses multiple institutions.
Start: 11/01/2009
233Services/charges related to the treatment of a hospital-acquired condition or preventable medical error.
Start: 01/24/2010
234This 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.)
Start: 01/24/2010
235Sales Tax
Start: 06/06/2010
A0Patient refund amount.
Start: 01/01/1995
A1Claim/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.)
Start: 01/01/1995 | Last Modified: 09/20/2009
A2Contractual adjustment.
Start: 01/01/1995 | Last Modified: 02/28/2007 | Stop: 01/01/2008
Notes: Use Code 45 with Group Code 'CO' or use another appropriate specific adjustment code.
A3Medicare Secondary Payer liability met.
Start: 01/01/1995 | Stop: 10/16/2003
A4Medicare Claim PPS Capital Day Outlier Amount.
Start: 01/01/1995 | Last Modified: 09/30/2007 | Stop: 04/01/2008
A5Medicare Claim PPS Capital Cost Outlier Amount.
Start: 01/01/1995
A6Prior hospitalization or 30 day transfer requirement not met.
Start: 01/01/1995
A7Presumptive Payment Adjustment
Start: 01/01/1995
A8Ungroupable DRG.
Start: 01/01/1995 | Last Modified: 09/30/2007
B1Non-covered visits.
Start: 01/01/1995
B2Covered visits.
Start: 01/01/1995 | Stop: 10/16/2003
B3Covered charges.
Start: 01/01/1995 | Stop: 10/16/2003
B4Late filing penalty.
Start: 01/01/1995
B5Coverage/program guidelines were not met or were exceeded.
Start: 01/01/1995 | Last Modified: 09/30/2007
B6This 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.
Start: 01/01/1995 | Stop: 02/01/2006
B7This 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.
Start: 01/01/1995 | Last Modified: 09/20/2009
B8Alternative 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.
Start: 01/01/1995 | Last Modified: 09/20/2009
B9Patient is enrolled in a Hospice.
Start: 01/01/1995 | Last Modified: 09/30/2007
B10Allowed 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.
Start: 01/01/1995
B11The claim/service has been transferred to the proper payer/processor for processing. Claim/service not covered by this payer/processor.
Start: 01/01/1995
B12Services not documented in patients' medical records.
Start: 01/01/1995
B13Previously paid. Payment for this claim/service may have been provided in a previous payment.
Start: 01/01/1995
B14Only one visit or consultation per physician per day is covered.
Start: 01/01/1995 | Last Modified: 09/30/2007
B15This 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.
Start: 01/01/1995 | Last Modified: 09/20/2009
B16'New Patient' qualifications were not met.
Start: 01/01/1995 | Last Modified: 09/30/2007
B17Payment 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.
Start: 01/01/1995 | Stop: 02/01/2006
B18This procedure code and modifier were invalid on the date of service.
Start: 01/01/1995 | Last Modified: 09/21/2008 | Stop: 03/01/2009
B19Claim/service adjusted because of the finding of a Review Organization.
Start: 01/01/1995 | Stop: 10/16/2003
B20Procedure/service was partially or fully furnished by another provider.
Start: 01/01/1995 | Last Modified: 09/30/2007
B21The charges were reduced because the service/care was partially furnished by another physician.
Start: 01/01/1995 | Stop: 10/16/2003
B22This payment is adjusted based on the diagnosis.
Start: 01/01/1995 | Last Modified: 02/28/2001
B23Procedure billed is not authorized per your Clinical Laboratory Improvement Amendment (CLIA) proficiency test.
Start: 01/01/1995 | Last Modified: 09/30/2007
D1Claim/service denied. Level of subluxation is missing or inadequate.
Start: 01/01/1995 | Stop: 10/16/2003
Notes: Use code 16 and remark codes if necessary.
D2Claim lacks the name, strength, or dosage of the drug furnished.
Start: 01/01/1995 | Stop: 10/16/2003
Notes: Use code 16 and remark codes if necessary.
D3Claim/service denied because information to indicate if the patient owns the equipment that requires the part or supply was missing.
Start: 01/01/1995 | Stop: 10/16/2003
Notes: Use code 16 and remark codes if necessary.
D4Claim/service does not indicate the period of time for which this will be needed.
Start: 01/01/1995 | Stop: 10/16/2003
Notes: Use code 16 and remark codes if necessary.
D5Claim/service denied. Claim lacks individual lab codes included in the test.
Start: 01/01/1995 | Stop: 10/16/2003
Notes: Use code 16 and remark codes if necessary.
D6Claim/service denied. Claim did not include patient's medical record for the service.
Start: 01/01/1995 | Stop: 10/16/2003
Notes: Use code 16 and remark codes if necessary.
D7Claim/service denied. Claim lacks date of patient's most recent physician visit.
Start: 01/01/1995 | Stop: 10/16/2003
Notes: Use code 16 and remark codes if necessary.
D8Claim/service denied. Claim lacks indicator that 'x-ray is available for review.'
Start: 01/01/1995 | Stop: 10/16/2003
Notes: Use code 16 and remark codes if necessary.
D9Claim/service denied. Claim lacks invoice or statement certifying the actual cost of the lens, less discounts or the type of intraocular lens used.
Start: 01/01/1995 | Stop: 10/16/2003
Notes: Use code 16 and remark codes if necessary.
D10Claim/service denied. Completed physician financial relationship form not on file.
Start: 01/01/1995 | Stop: 10/16/2003
Notes: Use code 17.
D11Claim lacks completed pacemaker registration form.
Start: 01/01/1995 | Stop: 10/16/2003
Notes: Use code 17.
D12Claim/service denied. Claim does not identify who performed the purchased diagnostic test or the amount you were charged for the test.
Start: 01/01/1995 | Stop: 10/16/2003
Notes: Use code 17.
D13Claim/service denied. Performed by a facility/supplier in which the ordering/referring physician has a financial interest.
Start: 01/01/1995 | Stop: 10/16/2003
Notes: Use code 17.
D14Claim lacks indication that plan of treatment is on file.
Start: 01/01/1995 | Stop: 10/16/2003
Notes: Use code 17.
D15Claim lacks indication that service was supervised or evaluated by a physician.
Start: 01/01/1995 | Stop: 10/16/2003
Notes: Use code 17.
D16Claim lacks prior payer payment information.
Start: 01/01/1995 | Stop: 06/30/2007
Notes: Use code 16 with appropriate claim payment remark code [N4].
D17Claim/Service has invalid non-covered days.
Start: 01/01/1995 | Stop: 06/30/2007
Notes: Use code 16 with appropriate claim payment remark code.
D18Claim/Service has missing diagnosis information.
Start: 01/01/1995 | Stop: 06/30/2007
Notes: Use code 16 with appropriate claim payment remark code.
D19Claim/Service lacks Physician/Operative or other supporting documentation
Start: 01/01/1995 | Stop: 06/30/2007
Notes: Use code 16 with appropriate claim payment remark code.
D20Claim/Service missing service/product information.
Start: 01/01/1995 | Stop: 06/30/2007
Notes: Use code 16 with appropriate claim payment remark code.
D21This (these) diagnosis(es) is (are) missing or are invalid
Start: 01/01/1995 | Stop: 06/30/2007
D22Reimbursement 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
Start: 01/27/2008 | Stop: 01/01/2009
D23This 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.)
Start: 11/01/2009 | Stop: 01/01/2012
W1Workers Compensation State Fee Schedule Adjustment
Start: 02/29/2000
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