Payment reduced or denied based on workers' compensation jurisdictional regulations or payment policies, use only if no other code is applicable. Reason Code 74: Covered days. State-mandated Requirement for Property and Casualty, see Claim Payment Remarks Code for specific explanation. Claim lacks invoice or statement certifying the actual cost of the lens, less discounts or the type of intraocular lens used. Low Income Subsidy (LIS) Co-payment Amount. Claim has been forwarded to the patient's vision plan for further consideration. Medicare Claim PPS Capital Day Outlier Amount. 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. Reason Code 104: The related or qualifying claim/service was not identified on this claim. Services by an immediate relative or a member of the same household are not covered. To be used for P&C Auto only. This is a work-related injury/illness and thus the liability of the Worker's Compensation Carrier. Reason Code 56: Processed based on multiple or concurrent procedure rules. Service/procedure was provided as a result of terrorism. (Use only with Group Code OA). Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Rebill as a separate claim/service. All Rights Reserved. Reason Code 85: Adjustment amount represents collection against receivable created in prior overpayment. Reason Code 64: Lifetime reserve days. This change effective 7/1/2013: Failure to follow prior payer's coverage rules. Lifetime benefit maximum has been reached for this service/benefit category. Refund to patient if collected. (Use only with Group Code OA). 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. (Use Group Code OA). Reason Code 97: Payment made to patient/insured/responsible party/employer. To access a denial description, select the applicable Reason/Remark code found on Noridian's Remittance Based on industry feedback, X12 is using a phased approach for the recommendations rather than presenting the entire catalog of adopted and mandated transactions at once. The Claim spans two calendar years. 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. Reason Code 254: The disposition of the claim/service is undetermined during the premium payment grace period, per Health Insurance Exchange requirements. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. This is not patient specific. Adjustment for shipping cost. Non-standard adjustment code from paper remittance. WebThe following document contains common EOB codes that may appear on your MassHealth remittance advice. Claim/service denied. The disposition of the related Property & Casualty claim (injury or illness) is pending due to litigation. Reason Code 146: Lifetime benefit maximum has been reached for this service/benefit category. 119/120. Expenses incurred after coverage terminated. However, this amount may be billed to subsequent payer. X12's diverse membership includes technologists and business process experts in health care, insurance, transportation, finance, government, supply chain and other industries. This provider was not certified/eligible to be paid for this procedure/service on this date of service. Rent/purchase guidelines were not met. Deductible for Professional service rendered in an Institutional setting and billed on an Institutional claim. The related or qualifying claim/service was not identified on this claim. 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 43: This (these) service(s) is (are) not covered. Medical Payments Coverage (MPC) or Personal Injury Protection (PIP) Benefits jurisdictional fee schedule adjustment. This care may be covered by another payer per coordination of benefits. Reason Code 31: Insured has no coverage for new borns. Consumer Spending Account payments (includes but is not limited to Flexible Spending Account, Health Savings Account, Health Reimbursement Account, etc.). Claim lacks indication that service was supervised or evaluated by a physician. The procedure or service is inconsistent with the patient's history. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Refund to patient if collected. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. co 256 denial code descriptions . Usage: This adjustment amount cannot equal the total service or claim charge amount; and must not duplicate provider adjustment amounts (payments and contractual reductions) that have resulted from prior payer(s) adjudication. Note: To be used for pharmaceuticals only. Service not payable per managed care contract. Reason Code 71: Indirect Medical Education Adjustment. Reason Code 217: The applicable fee schedule/fee database does not contain the billed code. CODES Reason Code 126: Prior processing information appears incorrect. (Use Group Codes PR or CO depending upon liability). Another code to be established and/or for 06/2008 meeting for a revised code to replace or strategy to use another existing code, This dual eligible patient is covered by Medicare Part D per Medicare Retro-Eligibility. NULL CO A1 M62, N612 028 Patient has not met the required residency requirements. 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. Payment reduced to zero due to litigation. This (these) service(s) is (are) not covered. co 256 denial code descriptions To be used for Property and Casualty Auto only. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. (Handled in QTY, QTY01=CD). Payer deems the information submitted does not support this length of service. (For example, multiple surgery or diagnostic imaging, concurrent anesthesia.) Reason Code 111: Procedure/product not approved by the Food and Drug Administration. 50. Reason Code 218: Workers' Compensation claim is under investigation. Discount agreed to in Preferred Provider contract. 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: 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). Claim lacks prior payer payment information. Internal liaisons coordinate between two X12 groups. Medicare Claim PPS Capital Cost Outlier Amount. Payment for this claim/service may have been provided in a previous payment. 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. *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. 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 75: Non-Covered days/Room charge adjustment. Each request will be in one of the following statuses: Fields marked with an asterisk (*) are required, consensus-based, interoperable, syntaxneutral data exchange standards, X12 Member Announcement: Recommendations to NCVHS - Set 2. The date of death precedes the date of service. Payment denied based on the Medical Payments Coverage (MPC) and/or Personal Injury Protection (PIP) Benefits jurisdictional regulations, or payment policies. Reason Code 149: Payer deems the information submitted does not support this length of service. These are non-covered services because this is a routine exam or screening procedure done in conjunction with a routine exam. Usage: To be used for pharmaceuticals only. Claim lacks the name, strength, or dosage of the drug furnished. ), This change effective 7/1/2013: Information requested from the Billing/Rendering Provider was not provided or not provided timely or was insufficient/incomplete. Legislated/Regulatory Penalty. Adjustment for compound preparation cost. The procedure/revenue code is inconsistent with the patient's age. No current requests. Note: To be used for pharmaceuticals only. Reason Code 32: Lifetime benefit maximum has been reached. Please resubmit on claim per calendar year. Reason Code 20: The impact of prior payer(s) adjudication including payments and/or adjustments. Reason Code 234: Legislated/Regulatory Penalty. Reason Code 38: Discount agreed to in Preferred Provider contract. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. This claim has been identified as a resubmission. Information about the X12 organization, its activities, committees & subcommittees, tools, products, and processes. Penalty or Interest Payment by Payer (Only used for plan to plan encounter reporting within the 837), Information requested from the Billing/Rendering Provider was not provided or not provided timely or was insufficient/incomplete. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Reason Code 243: This non-payable code is for required reporting only. codes Services denied by the prior payer(s) are not covered by this payer. Service not paid under jurisdiction allowed outpatient facility fee schedule. We are receiving a denial with the claim adjustment reason code (CARC) PR B9. No available or correlating CPT/HCPCS code to describe this service. Reason Code 2: The procedure code/bill type is inconsistent with the place of service. These codes describe why a claim or service line was paid differently than it was billed. The diagnosis is inconsistent with the patient's gender. Payment adjusted based on Preferred Provider Organization (PPO). (Use only with Group code OA), Reason Code 207: Payment adjusted because pre-certification/authorization not received in a timely fashion. Payment is adjusted when performed/billed by a provider of this specialty. Fee/Service not payable per patient Care Coordination arrangement. 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. Expenses incurred after coverage terminated. 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. The beneficiary is not liable for more than the charge limit for the basic procedure/test. Reason Code 59: Payment denied/reduced for absence of, or exceeded, pre-certification/authorization. Reason Code 203: National Provider Identifier - missing. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Reason Code 208: National Drug Codes (NDC) not eligible for rebate, are not covered. Exceeds the contracted maximum number of hours/days/units by this provider for this period. Additional information will be sent following the conclusion of litigation. X12 B2X Supply Chain Survey - What X12 EDI transactions do you support? Reason Code 171: Service was not prescribed prior to delivery. Your Stop loss deductible has not been met. X12 is well-positioned to continue to serve its members and the large install base by continuing to support the existing metadata, standards, and implementation tools while also focusing on several key collaborative initiatives. (Use CARC 45). (Use with Group Code CO or OA). Reason Code 247: The attachment/other documentation that was received was the incorrect attachment/document. Coinsurance for Professional service rendered in an Institutional setting and billed on an Institutional claim. Reason Code 51: Multiple physicians/assistants are not covered in this case. Payment denied for exacerbation when supporting documentation was not complete. Reason Code 185: This product/procedure is only covered when used according to FDA recommendations. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. (Note: To be used for Property and Casualty only), Based on entitlement to benefits. Webco 256 denial code descriptions co 256 denial code descriptions on November 29, 2022 on November 29, 2022 Claim received by the medical plan, but benefits not available under this plan. The letters preceding the number codes identify: Contractual Obligation (CO), Correction or reversal to a prior decision (CR), and Patient Responsibility (PR). The applicable fee schedule/fee database does not contain the billed code. Are you looking for more than one billing quotes? The "PR" is a Claim Adjustment Group Code and the description for "32" is below. Based on extent of injury. This change effective 7/1/2013: Service/equipment was not prescribed by a physician. Discount agreed to in Preferred Provider contract. Join other member organizations in continuously adapting the expansive vocabulary and languageused by millions of organizationswhileleveraging more than 40 years of cross-industry standards development knowledge. This service/equipment/drug is not covered under the patient's current benefit plan. Bridge: Standardized Syntax Neutral X12 Metadata. Reason Code 48: These are non-covered services because this is a pre-existing condition. Payment is denied when performed/billed by this type of provider. Five Claim Denials and Resolutions Medical Necessity 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 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. Medicare Secondary Payer Adjustment Amount. Did you receive a code from a health plan, such as: PR32 or CO286? (Use Group code OA) This change effective 7/1/2013: Per regulatory or other agreement. Identity verification required for processing this and future claims. Reason Code 197: Expenses incurred during lapse in coverage, Reason Code 198: Patient is responsible for amount of this claim/service through 'set aside arrangement' or other agreement. 'New Patient' qualifications were not met. (Use only with Group Code CO). Claim Adjustment Reason Codes | X12 Reason Code 212: Based on subrogation of a third-party settlement, Reason Code 213: Based on the findings of a review organization, Reason Code 214: Based on payer reasonable and customary fees. The procedure/revenue code is inconsistent with the patient's gender. Medicare denial codes - OA : Other adjustments, CARC and RARC list The information provided does not support the need for this service or item. Reason Code 88: Dispensing fee adjustment. Injury/illness was the result of an activity that is a benefit exclusion. Reason Code 159: State-mandated Requirement for Property and Casualty, see Claim Payment Remarks Code for specific explanation. Adjustment amount represents collection against receivable created in prior overpayment. Reason Code 216: Based on extent of injury. To be used for Workers' Compensation only. Procedure postponed, canceled, or delayed. OA Group Reason code applies when other Group reason code cant be applied. Claim received by the dental plan, but benefits not available under this plan. ), Information requested from the patient/insured/responsible party was not provided or was insufficient/incomplete. Claim has been forwarded to the patient's pharmacy plan for further consideration. Reason Code 175: Patient has not met the required spend down requirements. Reason Code 33: Balance does not exceed co-payment amount. The billing provider is not eligible to receive payment for the service billed. Reason Code 256: Additional payment for Dental/Vision service utilization, Reason Code 257: Processed under Medicaid ACA Enhance Fee Schedule. Reason Code 142: Premium payment withholding. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. The attachment/other documentation that was received was the incorrect attachment/document. Reason Code 154: Service/procedure was provided as a result of an act of war. 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. Other RCM Tools. Note: To be used for pharmaceuticals only. The authorization number is missing, invalid, or does not apply to the billed services or provider. (Handled in QTY, QTY01=LA). Adjustment for administrative cost. At least one Remark Code must be provided (may be comprised of either the Remittance Advice Remark Code or NCPDP Reject Reason Code. Procedure/treatment has not been deemed 'proven to be effective' by the payer. For use by Property and Casualty only. X12 standards are the workhorse of business to business exchanges proven by the billions of daily transactions within and across many industries including: X12 has developed standards and associated products to facilitate the transmission of electronic business messages for over 40 years. Medical provider not authorized/certified to provide treatment to injured workers in this jurisdiction. Coverage not in effect at the time the service was provided. WebAdjustment Reason Codes* Description Note 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. The applicable fee schedule/fee database does not contain the billed code. Reason Code 253: Service not payable per managed care contract. The diagnosis is inconsistent with the patient's birth weight. 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. (Use only with Group Code OA). Reason Code 205: National Provider Identifier - Not matched. Reason Code 170: Service was not prescribed by a physician. To be used for Workers' Compensation only. Service/procedure was provided as a result of an act of war. The diagnosis is inconsistent with the provider type. Payment is denied when performed/billed by this type of provider. Reason Code 160: Attachment referenced on the claim was not received. Payer deems the information submitted does not support this day's supply. Reason Code 9: The diagnosis is inconsistent with the provider type. Denial CO-252 | Medical Billing and Coding Forum - AAPC Services considered under the dental and medical plans, benefits not available. Non standard adjustment code from paper remittance. Original payment decision is being maintained. The disposition of the related Property & Casualty claim (injury or illness) is pending due to litigation. Precertification/notification/authorization/pre-treatment exceeded. (Use only with Group Code OA). CO-50, CO-57, CO-151, N-115 - Medical Necessity: An ICD-9 code (s) was submitted that is not covered under a LCD/NCD. What is CO 24 Denial Code? Reason Code 129: Prearranged demonstration project adjustment. Legislated/Regulatory Penalty. 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. Service was not prescribed prior to delivery. These services were submitted after this payers responsibility for processing claims under this plan ended. CMS contractors medically review some claims (and prior authorizations) to ensure that payment is billed (or authorization Aid code invalid for . Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. 073. Payment reduced to zero due to litigation. 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. Original payment decision is being maintained. 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. Claim received by the dental plan, but benefits not available under this plan. Payer deems the information submitted does not support this level of service. Reason Code 128: Claim specific negotiated discount. Reason Code 1: The procedure code is inconsistent with the modifier used or a required modifier is missing. Patient is covered by a managed care plan. The X12 Board and the Accredited Standards Committees Steering group (Steering) collaborate to ensure the best interests of X12 are served. Prearranged demonstration project adjustment. WebCode Description 01 Deductible amount. 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). Submit these services to the patient's medical plan for further consideration. 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). The provider cannot collect this amount from the patient. Reason Code 219: Exceeds the contracted maximum number of hours/days/units by this provider for this period. Contact us through email, mail, or over the phone. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Referral not authorized by attending physician per regulatory requirement. Denial Code CO 16: Claim or Service Lacks Information which is needed for adjudication. Contact work hardening reviewer at (360)902-4480. To be used for Property & Casualty only. To be used for Property and Casualty only. Payment is denied when performed/billed by this type of provider in this type of facility. Reason Code: 204. co 256 denial code descriptions. 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: to be used for pharmaceuticals only. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Reason Code 131: Technical fees removed from charges. Reason Code 17: This injury/illness is covered by the liability carrier. Provider contracted/negotiated rate expired or not on file. Reason Code 94: The benefit for this service is included in the payment/allowance for another service/procedure that has already been adjudicated. Reason Code 194: Precertification/authorization/notification absent. Consult plan benefit documents/guidelines for information about restrictions for this service. Explanation of Benefit Codes Appearing on the Remittance Advice Reason Code 209: Administrative surcharges are not covered. What does that sentence mean? Deductible for Professional service rendered in an Institutional setting and billed on an Institutional claim. This (these) diagnosis(es) is (are) not covered, missing, or are invalid. 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. Claim lacks indicator that 'x-ray is available for review.'. Reason Code 18: This injury/illness is the liability of the no-fault carrier. Submit these services to the patient's Pharmacy plan for further consideration. Reason Code 87: Ingredient cost adjustment. Reason Code 21: Charges are covered under a capitation agreement/managed care plan. CO should be sent if the adjustment is Charges do not meet qualifications for emergent/urgent care. This page lists X12 Pilots that are currently in progress. 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. (Use only with Group Code PR). The tables on this page depict the key dates for various steps in a normal modification/publication cycle. Reason Code 189: Non-standard adjustment code from paper remittance. Reason Code 138: Claim spans eligible and ineligible periods of coverage. Payment denied based on the Liability Coverage Benefits jurisdictional regulations and/or payment policies. Processed under Medicaid ACA Enhanced Fee Schedule. Late claim denial. Applicable federal, state or local authority may cover the claim/service. Claim spans eligible and ineligible periods of coverage. Lifetime benefit maximum has been reached for this service/benefit category. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Membership categories and associated dues are based on the size and type of organization or individual, as well as the committee you intend to participate with. Coverage/program guidelines were exceeded. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Remark Code: N130. Lifetime benefit maximum has been reached. This injury/illness is the liability of the no-fault carrier. Reason Code A4: Presumptive Payment Adjustment. Local Regulation Of Firearms | Colorado General Assembly Reason Code 136: Contracted funding agreement - Subscriber is employed by the provider of services. Note: To be used for pharmaceuticals only. This procedure code and modifier were invalid on the date of service. Sequestration - reduction in federal payment. This change effective 7/1/2013: Claim is under investigation. Copyright 2023 Medical Billers and Coders. 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. Missing patient medical record for this service. No maximum allowable defined by legislated fee arrangement. WebRefer Senate Bill 21-256, as amended, to the Committee of the Whole. Services not authorized by network/primary care providers. Reason Code 108: Not covered unless the provider accepts assignment. Reason Code 76: Cost Report days. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Procedure/treatment has not been deemed 'proven to be effective' by the payer. Additional information will be sent following the conclusion of litigation. (Note: To be used for Property and Casualty only). Medicare Claim PPS Capital Cost Outlier Amount. Reason Code A1: Medicare Claim PPS Capital Day Outlier Amount. Administrative surcharges are not covered. To be used for P&C Auto only. X12 appoints various types of liaisons, including external and internal liaisons. Procedure code was incorrect. Denial was received because the provider did not respond to the development request; therefore, the services billed to Medicare could not be validated. 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. (For example multiple surgery or diagnostic imaging, concurrent anesthesia.) Reason Code 30: Insured has no dependent coverage.