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. Additional payment for Dental/Vision service utilization, Processed under Medicaid ACA Enhance Fee Schedule. Reason codes appear on an explanation of benefits (EOB) to communicate why a claim has been adjusted. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. 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). The diagnosis is inconsistent with the provider type. Did you receive a code from a health plan, such as: PR32 or CO286? 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. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. (Use only with Group Code OA). 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). 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. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. This injury/illness is the liability of the no-fault carrier. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Procedure code was incorrect. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. 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. 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. Reason Code 49: The referring/prescribing/rendering provider is not eligible to refer/prescribe/order/perform the service billed. Additional information will be sent following the conclusion of litigation. Adjustment for postage cost. Multiple physicians/assistants are not covered in this case. Per regulatory or other agreement. 2670. Services not provided by network/primary care providers. 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. Precertification/authorization/notification absent. An allowance has been made for a comparable service. Note: To be used for pharmaceuticals only. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. (Use only with Group Codes PR or CO depending upon liability). 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 Remark Code(s) Denial Denial Description; 16: M51 | N56: Missing/Incorrect Required Claim Information: Claim/service lacks information or has submission/billing error(s). Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Missing/incomplete/invalid procedure code(s). Reason Code 242: Provider performance program withhold. Submit these services to the patient's hearing plan for further consideration. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Claim spans eligible and ineligible periods of coverage. ), Requested information was not provided or was insufficient/incomplete. Reason Code 247: The attachment/other documentation that was received was the incorrect attachment/document. 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. Group codes include CO Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Reason Code 260: Adjustment for shipping cost. No current requests. Treatment was deemed by the payer to have been rendered in an inappropriate or invalid place of service. To be used for Workers' Compensation only, Based on subrogation of a third party settlement, Based on the findings of a review organization, Based on payer reasonable and customary fees. Reason Code 24: Expenses incurred after coverage terminated. Reason Code 8: The diagnosis is inconsistent with the procedure. To be used for Property & Casualty only. Services not authorized by network/primary care providers. Reason Code 126: 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. Additional information will be sent following the conclusion of litigation. Reason Code 147: Payer deems the information submitted does not support this level of service. Review X12's official interpretations based on submitted RFIs related to the meaning and use of X12 Standards, Guidelines, and Technical Reports, including Technical Report Type 3 (TR3) implementation guidelines. Low Income Subsidy (LIS) Co-payment Amount. The disposition of the claim/service is undetermined during the premium payment grace period, per Health Insurance SHOP Exchange requirements. Adjustment amount represents collection against receivable created in prior overpayment. Payment denied because service/procedure was provided outside the United States or as a result of war. Note: Refer to the835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. The charges were reduced because the service/care was partially furnished by another physician. Not a work related injury/illness and thus not the liability of the workers' compensation carrier Usage: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier 'IG') for the jurisdictional regulation. Reason Code 105: Rent/purchase guidelines were not met. Payment adjusted based on the Liability Coverage Benefits jurisdictional regulations and/or payment policies. This change effective 7/1/2013: Claim is under investigation. Processed based on multiple or concurrent procedure rules. CO should be sent if the adjustment is Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Reason Code 21: Charges are covered under a capitation agreement/managed care plan. Reason Code 36: Services denied at the time authorization/pre-certification was requested. Claim received by the medical plan, but benefits not available under this plan. This claim/service will be reversed and corrected when the grace period ends (due to premium payment or lace of premium payment). This service/equipment/drug is not covered under the patient's current benefit plan, National Provider identifier - Invalid format. N205 This injury/illness is covered by the liability carrier. Reason Code 22: Payment denied. Non-covered personal comfort or convenience services. 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 195: Precertification/authorization exceeded. Reason Code 205: National Provider Identifier - Not matched. CALL : 1- (877)-394-5567. Usage: To be used for pharmaceuticals only. The motion passed on a vote of 3-2. Reason Code 200: Discontinued or reduced service. You must send the claim/service to the correct payer/contractor. Appeal procedures not followed or time limits not met. Reason Code 262: Adjustment for administrative cost. Discount agreed to in Preferred Provider contract. co 256 denial code descriptions . To be used for Property and Casualty Auto only. Based on entitlement to benefits. Procedure modifier was invalid on the date of service. Non-standard adjustment code from paper remittance. If so read About Claim Adjustment Group Codes below. (Use only with Group Code OA). To be used for P&C Auto only. Reason Code 114: Transportation is only covered to the closest facility that can provide the necessary care. Coverage/program guidelines were not met or were exceeded. ), Reason Code 225: Denied for failure of this provider, another provider or the subscriber to supply requested information to a previous payer for their adjudication. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. This Payer not liable for claim or service/treatment. Exceeds the contracted maximum number of hours/days/units by this provider for this period. This feedback is used to inform X12's decision-making processes, policies, and question and answer resources. Alphabetized listing of current X12 members organizations. Submission/billing error(s). (Handled in QTY, QTY01=LA). If any error on the claim that caused it to deny can be corrected, the corrected claim can be resubmitted to MassHealth. 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.). Coverage/program guidelines were exceeded. (Use only with Group Code OA). Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Coverage not in effect at the time the service was provided. Anesthesia not covered for this service/procedure. Remark Code: N130. An attachment is required to adjudicate this claim/service. 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. This change effective 7/1/2013: Failure to follow prior payer's coverage rules. The Claim spans two calendar years. Claim received by the medical plan, but benefits not available under this plan. 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). Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Reason Code 185: This product/procedure is only covered when used according to FDA recommendations. Upon review, it was determined that this claim was processed properly. Late claim denial. Based on payer reasonable and customary fees. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. To be used for Property and Casualty only. The procedure code/bill type is inconsistent with the place of service. Identity verification required for processing this and future claims. Charges for outpatient services are not covered when performed within a period of time prior to or after inpatient services. Services not authorized by network/primary care providers. Reason Code 227: No available or correlating CPT/HCPCS code to describe this service. (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. The rendering provider is not eligible to perform the service billed. Precertification/authorization/notification/pre-treatment number may be valid but does not apply to the provider. Reason Code 246: This claim has been identified as a resubmission. (Use only with Group Code PR) At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.). 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. Whenever claim denied with CO 197 denial code, we need to follow the steps to resolve and reimburse the claim from insurance company: First step is to verify the denial reason and get the denial date. Claim received by the dental plan, but benefits not available under this plan. The procedure code is inconsistent with the modifier used or a required modifier is missing. OA Group Reason code applies when other Group reason code cant be applied. Benefits are not available under this dental plan. The necessary information is still needed to process the claim. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. More information is available in X12 Liaisons (CAP17). Reason Code 128: Claim specific negotiated discount. These codes generally assign responsibility for the adjustment amounts. Procedure has a relative value of zero in the jurisdiction fee schedule, therefore no payment is due. 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 procedure code and modifier were invalid on the date of service. CO 24 Charges are covered under a capitation agreement or managed care plan . (Use only with Group Code CO). Payment is denied when performed/billed by this type of provider in this type of facility. Incentive adjustment, e.g. (Use only with Group Code PR). 'New Patient' qualifications were not met. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Refund issued to an erroneous priority payer for this claim/service. Reason Code 209: Administrative surcharges are not covered. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. State-mandated Requirement for Property and Casualty, see Claim Payment Remarks Code for specific explanation. 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 only. Patient is covered by a managed care plan. Prior contractual reductions related to a current periodic payment as part of a contractual payment schedule when deferred amounts have been previously reported. (Handled in QTY, QTY01=CA). What is CO 24 Denial Code? The expected attachment/document is still missing. This care may be covered by another payer per coordination of benefits. X12 defines and maintains transaction sets that establish the data content exchanged for specific business purposes and, in some cases, implementation guides that describe the use of one or more transaction sets related to a single business purpose or use case. Patient has not met the required spend down requirements. Claim lacks prior payer payment information. If there is no adjustment to a claim/line, then there is no adjustment reason code. To be used for Property & Casualty only. Code. 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 74: Covered days. Usage: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier 'IG') for the jurisdictional regulation. Denial was received because the provider did not respond to the development request; therefore, the services billed to Medicare could not be validated. Claim/service spans multiple months. The referring/prescribing/rendering provider is not eligible to refer/prescribe/order/perform the service billed. Reason Code 239: Services not provided by network/primary care providers. 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.). Service/procedure was provided as a result of an act of war. Payment is adjusted when performed/billed by a provider of this specialty. The necessary information is still needed to process the claim. Usage: Applies to institutional claims only and explains the DRG amount difference when the patient care crosses multiple institutions. This change effective 1/1/2013: Exact duplicate claim/service. Usage: 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). Attachment referenced on the claim was not received. Procedure/treatment/drug is deemed experimental/investigational by the payer. Procedure/treatment has not been deemed 'proven to be effective' by the payer. The format is always two alpha characters. Submit these services to the patient's Pharmacy plan for further consideration. (Handled in QTY, QTY01=CD). Reason Code 86: Professional fees removed from charges. Reason Code 93: Non-covered charge(s). Procedure/treatment is deemed experimental/investigational by the payer. Reason Code 25: Coverage not in effect at the time the service was provided. CO/29/ CO/29/N30. Procedure/service was partially or fully furnished by another provider. (Use only with Group Code PR). Medical Payments Coverage (MPC) or Personal Injury Protection (PIP) Benefits jurisdictional fee schedule adjustment. The billing provider is not eligible to receive payment for the service billed. Reason Code 228: Mutually exclusive procedures cannot be done in the same day/setting. Webco 256 denial code descriptions. Reason Code A3: Prior hospitalization or 30-day transfer requirement not met. 073. Reason Code 156: Service/procedure was provided as a result of terrorism. Reason Code 184: Consumer Spending Account payments (includes but is not limited to Flexible Spending Account, Health Savings Account, Health Reimbursement Account, etc.). Medical provider not authorized/certified to provide treatment to injured workers in this jurisdiction. If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF) if the regulations apply. The disposition of the claim/service is pending further review. To be used for Property and Casualty only. 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. Reason Code 19: This care may be covered by another payer per coordination of benefits. Reason Code 88: Dispensing fee adjustment. Patient has not met the required waiting requirements. Adjustment for delivery cost. The attachment/other documentation that was received was incomplete or deficient. Payment denied/reduced because the payer deems the information submitted does not support this level of service, this many service, this length of service, this dosage, or this day's supply. Patient identification compromised by identity theft. Reason Code 218: Workers' Compensation claim is under investigation. Reason Code 10: The date of death precedes the date of service. Newborn's services are covered in the mother's Allowance. The disposition of the related Property & Casualty claim (injury or illness) is pending due to litigation. This injury/illness is covered by the liability carrier. To be used for Property and Casualty only. Payment reduced or denied based on workers' compensation jurisdictional regulations or payment policies, use only if no other code is applicable. Claim/Service lacks Physician/Operative or other supporting documentation. Reason Code 69: Coinsurance day. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Medicare Claim PPS Capital Day Outlier Amount. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Payment made to patient/insured/responsible party. Reason Code 64: Lifetime reserve days. 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). Additional information will be sent following the conclusion of litigation. Service/procedure was provided outside of the United States. Reason Code 251: Claim received by the dental plan, but benefits not available under this plan. Reason Code 90: No Claim level Adjustments. B10 and click the NEXT button in the Search Box to locate the Adjustment Reason code you are inquiring on. Procedure code was incorrect. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Reason Code 11: The date of birth follows the date of service. To be used for Workers' Compensation only. Reason Code 46: These are non-covered services because this is a routine exam or screening procedure done in conjunction with a routine exam. This (these) procedure(s) is (are) not covered. Reason Code 192: Refund issued to an erroneous priority payer for this claim/service. Services not provided or authorized by designated (network/primary care) providers. Reason Code 3: The procedure/revenue code is inconsistent with the patient's age. Reason Code 204: National Provider identifier - Invalid format. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Reason Code 134: Regulatory Surcharges, Assessments, Allowances or Health Related Taxes. To apply for an X12 membership, complete and submit an application form which will be reviewed and verified, then you will be notified of the next steps. Procedure modifier was invalid on the date of service. Reason Code 233: This procedure or procedure/modifier combination is not compatible with another procedure or procedure/modifier combination provided on the same day according to the National Correct Coding Initiative. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. X12 manages the exclusive copyright to all standards, publications, and products, and such works do not constitute joint works of authorship eligible for joint copyright. X12 B2X Supply Chain Survey - What X12 EDI transactions do you support? Summer 2023 X12 Standing Meeting On-Site in San Antonio, TX, Continuation of Summer X12J Technical Assessment meeting, 3:00 - 5:00 ET, Summer Procedures Review Board meeting, 3:00 - 5:00 ET, Deadline for submitting code maintenance requests for member review of Batch 121, Insurance Business Process Application Error Codes, Accredited Standards Committees Steering group, X12-03 External Code List Oversight (ECO), Member Representative Request for Workspace Access, 270/271 Health Care Eligibility Benefit Inquiry and Response, 276/277 Health Care Claim Status Request and Response, 277 Health Care Information Status Notification, 278 Health Care Services Review - Request for Review and Response, 278 Health Care Services Review - Inquiry and Response, 278 Health Care Services Review Notification and Acknowledgment, 278 Request for Review and Response Examples, 820 Payroll Deducted and Other Group Premium Payment For Insurance Products Examples, 820 Health Insurance Exchange Related Payments. Reason Code 135: Appeal procedures not followed or time limits not met. Catering to more than 40 specialties, Medical Billers and Coders (MBC) is proficient in handling services that range from revenue cycle management to ICD-10 testing solutions. 03 Co-payment 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). Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. HIPAA Compliant. Millions of entities around the world have an established infrastructure that supports X12 transactions. Coinsurance day. It also happens to be super easy to correct, resubmit and overturn. 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. 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.) Services/charges related to the treatment of a hospital-acquired condition or preventable medical error. To be used for Workers' Compensation only. Please resubmit on claim per calendar year. Reason Code 48: These are non-covered services because this is a pre-existing condition. 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. Lifetime reserve days. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Precertification/notification/authorization/pre-treatment exceeded. Services not documented in patient's medical records. X12 produces three types of documents tofacilitate consistency across implementations of its work. The diagnosis is inconsistent with the patient's gender. 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). The expected attachment/document is still missing. Diagnosis was invalid for the date(s) of service reported. Submission/billing error(s). Reason Code 141: Incentive adjustment, e.g. Reason Code 91: Processed in Excess of charges. The disposition of the claim/service is undetermined during the premium payment grace period, per Health Insurance Exchange requirements. ), Duplicate claim/service. We are receiving a denial with the claim adjustment reason code (CARC) PR B9. The authorization number is missing, invalid, or does not apply to the billed services or provider. 04 The procedure code is inconsistent with the modifier used, or a required modifier is missing. Claim/service lacks information or has submission/billing error(s). WebCompare physician performance within organization. Charges do not meet qualifications for emergent/urgent care. The procedure code is inconsistent with the modifier used. Reason Code 5: The procedure code is inconsistent with the provider type/specialty (taxonomy). Usage: 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 254: The disposition of the claim/service is undetermined during the premium payment grace period, per Health Insurance Exchange requirements. Claim/Service has invalid non-covered days. The date of birth follows the date of service. PIL02b1 Publishing and Maintaining Externally Developed Implementation Guides, PIL02b2 Publishing and Maintaining Externally Developed Implementation Guides. Procedure postponed, canceled, or delayed. Reason Code 120: Payer refund due to overpayment. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. The attachment/other documentation that was received was incomplete or deficient. (Note: To be used by Property & Casualty only). This service/procedure requires that a qualifying service/procedure be received and covered. Claim has been forwarded to the patient's dental plan for further consideration. 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 adjusted because the patient has not met the required eligibility, spend down, waiting, or residency requirements. 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.