{"aaData": [["4", "
\n
\n\n
\n", "
\n
\n\n
\n", "
File: 161.27, IEN: 4
\n", "
\nThe 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.\n
\n
\n", "
\n
\n\n
\n", "
Incorrect Claim Data
\n", "
\n
\n\n
\n"], ["B13", "
\n
\n\n
\n", "
\n
\n\n
\n", "
File: 161.27, IEN: 5
\n", "
\nPreviously paid. Payment for this claim/service may have been provided in a previous payment.\n
\n
\n", "
\n
\n\n
\n", "
Billed Service Not Covered
\n", "
\n
\n\n
\n"], ["100", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nCost outlier - Adjustment to compensate for additional costs.\n
\n
\n", "", "", ""], ["101", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nPrimary Payer amount.\n
\n
\n", "", "", ""], ["102", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nCoinsurance day.\n
\n
\n", "", "", ""], ["103", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nAdministrative days.\n
\n
\n", "", "", ""], ["104", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nIndirect Medical Education Adjustment.\n
\n
\n", "", "", ""], ["105", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nDirect Medical Education Adjustment.\n
\n
\n", "", "", ""], ["106", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nDisproportionate Share Adjustment.\n
\n
\n", "", "", ""], ["107", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nCovered days.\n
\n
\n", "", "", ""], ["78", "
\n
\n\n
\n", "
\n
\n\n
\n", "
File: 161.27, IEN: 4
\n", "
\nNon-Covered days/Room charge adjustment.\n
\n
\n", "", "
Billed Service Not Covered
\n", "
\n
\n\n
\n"], ["109", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nCost Report days.\n
\n
\n", "", "", ""], ["125", "
\n
\n\n
\n", "
\n
\n\n
\n", "
File: 161.27, IEN: 4
\n", "
\nSubmission/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.)\n
\n
\n", "", "", ""], ["110", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nOutlier days.\n
\n
\n", "", "", ""], ["111", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nDischarges.\n
\n
\n", "", "", ""], ["112", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nPIP days.\n
\n
\n", "", "", ""], ["113", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nTotal visits.\n
\n
\n", "", "", ""], ["114", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nCapital Adjustment.\n
\n
\n", "", "", ""], ["115", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nStatutory Adjustment.\n
\n
\n", "", "", ""], ["116", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nTransfer amount.\n
\n
\n", "", "", ""], ["117", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nIngredient cost adjustment. Note: To be used for pharmaceuticals only\n
\n
\n", "", "", ""], ["118", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nDispensing fee adjustment.\n
\n
\n", "", "", ""], ["119", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nClaim Paid in full.\n
\n
\n", "", "", ""], ["148", "
\n
\n\n
\n", "
\n
\n\n
\n", "
File: 161.27, IEN: 4
\n", "
\nInformation 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.)\n
\n
\n", "", "", ""], ["120", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nNo Claim level Adjustments.\n
\n
\n", "", "", ""], ["95", "
\n
\n\n
\n", "
\n
\n\n
\n", "
File: 161.27, IEN: 4
\n", "
\nPlan procedures not followed.\n
\n
\n", "
\n
\n\n
\n", "
Billed Service Not Covered
\n", "
\n
\n\n
\n"], ["122", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nThe hospital must file the Medicare claim for this inpatient non-physician service.\n
\n
\n", "", "", ""], ["123", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nMedicare Secondary Payer Adjustment Amount.\n
\n
\n", "", "", ""], ["124", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nPredetermination: anticipated payment upon completion of services or claim adjudication.\n
\n
\n", "", "", ""], ["125", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nMajor Medical Adjustment.\n
\n
\n", "", "", ""], ["126", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nProvider promotional discount (e.g., Senior citizen discount).\n
\n
\n", "", "", ""], ["127", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nManaged care withholding.\n
\n
\n", "", "", ""], ["128", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nTax withholding.\n
\n
\n", "", "", ""], ["129", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nPatient payment option/election not in effect.\n
\n
\n", "", "", ""], ["8", "
\n
\n\n
\n", "
\n
\n\n
\n", "
File: 161.27, IEN: 4
\n", "
\nThe 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.\n
\n
\n", "
\n
\n\n
\n", "
Billed Service Not Covered
\n", "
\n
\n\n
\n"], ["107", "
\n
\n\n
\n", "
\n
\n\n
\n", "
File: 161.27, IEN: 4
\n", "
\nThe 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.\n
\n
\n", "
\n
\n\n
\n", "
Incorrect Claim Data
\n", "
\n
\n\n
\n"], ["108", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nRent/purchase guidelines were not met. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.\n
\n
\n", "
\n
\n\n
\n", "
Billed Service Not Covered
\n", "
\n
\n\n
\n"], ["110", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nBilling date predates service date.\n
\n
\n", "
\n
\n\n
\n", "
Incorrect Claim Data
\n", "
\n
\n\n
\n"], ["111", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nNot covered unless the provider accepts assignment.\n
\n
\n", "", "
Billed Service Not Covered
\n", "
\n
\n\n
\n"], ["112", "
\n
\n\n
\n", "
\n
\n\n
\n", "
File: 161.27, IEN: 4
\n", "
\nService not furnished directly to the patient and/or not documented.\n
\n
\n", "", "", ""], ["135", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nPayment denied because service/procedure was provided outside the United States or as a result of war.\n
\n
\n", "", "", ""], ["115", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nProcedure postponed, canceled, or delayed.\n
\n
\n", "", "
Billed Service Not Covered
\n", "
\n
\n\n
\n"], ["116", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nThe advance indemnification notice signed by the patient did not comply with requirements.\n
\n
\n", "", "
Incorrect Documentation
\n", "
\n
\n\n
\n"], ["117", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nTransportation is only covered to the closest facility that can provide the necessary care.\n
\n
\n", "
\n
\n\n
\n", "
Billed Service Not Covered
\n", "
\n
\n\n
\n"], ["139", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nESRD network support adjustment.\n
\n
\n", "", "", ""], ["13", "
\n
\n\n
\n", "
\n
\n\n
\n", "
File: 161.27, IEN: 4
\n", "
\nThe date of death precedes the date of service.\n
\n
\n", "", "
Incorrect Claim Data
\n", "
\n
\n\n
\n"], ["140", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nPatient is covered by a managed care plan.\n
\n
\n", "", "", ""], ["141", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nIndemnification adjustment - compensation for outstanding member responsibility.\n
\n
\n", "", "", ""], ["142", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nPayer refund due to overpayment.\n
\n
\n", "", "", ""], ["143", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nPayer refund amount - not our patient.\n
\n
\n", "", "", ""], ["144", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nDeductible -- Major Medical\n
\n
\n", "", "", ""], ["145", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nCoinsurance -- Major Medical\n
\n
\n", "", "", ""], ["128", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nNewborn's services are covered in the mother's Allowance.\n
\n
\n", "", "
Billed Service Not Covered
\n", "
\n
\n\n
\n"], ["129", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nPrior 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.)\n
\n
\n", "
\n
\n\n
\n", "
Incorrect Claim Data
\n", "
\n
\n\n
\n"], ["148", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nClaim submission fee.\n
\n
\n", "", "", ""], ["133", "
\n
\n\n
\n", "
\n
\n\n
\n", "
File: 161.27, IEN: 4
\n", "
\nsegment of the 835 or Loop 2430 of the 837).\n
\n
\n", "", "", ""], ["16", "
\n
\n\n
\n", "
\n
\n\n
\n", "
File: 161.27, IEN: 4
\n", "
\nprovided (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.\n
\n
\n", "
\n
\n\n
\n", "
Incorrect Claim Data
\n", "
\n
\n\n
\n"], ["134", "
\n
\n\n
\n", "
\n
\n\n
\n", "
File: 161.27, IEN: 4
\n", "
\nTechnical fees removed from charges.\n
\n
\n", "", "", ""], ["151", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nFailure to follow prior payer's coverage rules. (Use only with Group Code OA)\n
\n
\n", "", "", ""], ["152", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nRegulatory Surcharges, Assessments, Allowances or Health Related Taxes.\n
\n
\n", "", "", ""], ["139", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nContracted funding agreement - Subscriber is employed by the provider of services.\n
\n
\n", "", "
Billed Service Not Covered
\n", ""], ["154", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nIncentive adjustment, e.g. preferred product/service.\n
\n
\n", "", "", ""], ["155", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nPremium payment withholding\n
\n
\n", "", "", ""], ["149", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nLifetime benefit maximum has been reached for this service/benefit category.\n
\n
\n", "
\n
\n\n
\n", "
Billed Service Not Covered
\n", "
\n
\n\n
\n"], ["150", "
\n
\n\n
\n", "
\n
\n\n
\n", "
File: 161.27, IEN: 4
\n", "
\nPayer deems the information submitted does not support this level of service.\n
\n
\n", "
\n
\n\n
\n", "
Billed Service Not Covered
\n", "
\n
\n\n
\n"], ["151", "
\n
\n\n
\n", "
\n
\n\n
\n", "
File: 161.27, IEN: 4
\n", "
\nPayment adjusted because the payer deems the information submitted does not support this many/frequency of services.\n
\n
\n", "
\n
\n\n
\n", "
Billed Service Not Covered
\n", "
\n
\n\n
\n"], ["152", "
\n
\n\n
\n", "
\n
\n\n
\n", "
File: 161.27, IEN: 4
\n", "
\nPayer 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.\n
\n
\n", "
\n
\n\n
\n", "
Billed Service Not Covered
\n", "
\n
\n\n
\n"], ["18", "
\n
\n\n
\n", "
\n
\n\n
\n", "
File: 161.27, IEN: 4
\n", "
\nExact duplicate claim/service (Use only with Group Code OA except where state workers' compensation regulations requires CO)\n
\n
\n", "
\n
\n\n
\n", "
Incorrect Claim Data
\n", "
\n
\n\n
\n"], ["153", "
\n
\n\n
\n", "
\n
\n\n
\n", "
File: 161.27, IEN: 4
\n", "
\nPayer deems the information submitted does not support this dosage.\n
\n
\n", "", "
Billed Service Not Covered
\n", "
\n
\n\n
\n"], ["154", "
\n
\n\n
\n", "
\n
\n\n
\n", "
File: 161.27, IEN: 4
\n", "
\nPayer deems the information submitted does not support this day's supply.\n
\n
\n", "", "
Billed Service Not Covered
\n", "
\n
\n\n
\n"], ["155", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nPatient refused the service/procedure.\n
\n
\n", "", "
Billed Service Not Covered
\n", "
\n
\n\n
\n"], ["163", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nFlexible spending account payments\n
\n
\n", "", "", ""], ["157", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nService/procedure was provided as a result of an act of war.\n
\n
\n", "", "
Billed Service Not Covered
\n", "
\n
\n\n
\n"], ["158", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nService/procedure was provided outside of the United States.\n
\n
\n", "
\n
\n\n
\n", "
Billed Service Not Covered
\n", "
\n
\n\n
\n"], ["159", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nService/procedure was provided as a result of terrorism.\n
\n
\n", "", "
Billed Service Not Covered
\n", "
\n
\n\n
\n"], ["160", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nInjury/illness was the result of an activity that is a benefit exclusion.\n
\n
\n", "
\n
\n\n
\n", "
Billed Service Not Covered
\n", "
\n
\n\n
\n"], ["168", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nProvider performance bonus\n
\n
\n", "", "", ""], ["169", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nState-mandated Requirement for Property and Casualty, see Claim Payment Remarks Code for specific explanation.\n
\n
\n", "", "", ""], ["19", "
\n
\n\n
\n", "
\n
\n\n
\n", "
File: 161.27, IEN: 4
\n", "
\nThis is a work-related injury/illness and thus the liability of the Worker's Compensation Carrier.\n
\n
\n", "
\n
\n\n
\n", "
Billed Service Not Covered
\n", "
\n
\n\n
\n"], ["163", "
\n
\n\n
\n", "
\n
\n\n
\n", "
File: 161.27, IEN: 4
\n", "
\nAttachment/other documentation referenced on the claim was not received.\n
\n
\n", "
\n
\n\n
\n", "
Incorrect Documentation
\n", "
\n
\n\n
\n"], ["164", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nAttachment/other documentation referenced on the claim was not received in a timely fashion.\n
\n
\n", "
\n
\n\n
\n", "
Incorrect Documentation
\n", "
\n
\n\n
\n"], ["165", "
\n
\n\n
\n", "
\n
\n\n
\n", "
File: 161.27, IEN: 4
\n", "
\nReferral absent or exceeded\n
\n
\n", "
\n
\n\n
\n", "
Billed Service Not Covered
\n", "
\n
\n\n
\n"], ["166", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nThese services were submitted after this payers responsibility for processing claims under this plan ended.\n
\n
\n", "", "
Billed Service Not Covered
\n", "
\n
\n\n
\n"], ["167", "
\n
\n\n
\n", "
\n
\n\n
\n", "
File: 161.27, IEN: 4
\n", "
\nThis (these) diagnosis(es) is (are) not covered. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.\n
\n
\n", "
\n
\n\n
\n", "
Billed Service Not Covered
\n", "
\n
\n\n
\n"], ["168", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nService(s) have been considered under the patient's medical plan. Benefits are not available under this dental plan\n
\n
\n", "
\n
\n\n
\n", "
Billed Service Not Covered
\n", "
\n
\n\n
\n"], ["169", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nAlternate benefit has been provided.\n
\n
\n", "
\n
\n\n
\n", "
Billed Service Not Covered
\n", "
\n
\n\n
\n"], ["170", "
\n
\n\n
\n", "
\n
\n\n
\n", "
File: 161.27, IEN: 4
\n", "
\nPayment 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.\n
\n
\n", "
\n
\n\n
\n", "
Billed Service Not Covered
\n", "
\n
\n\n
\n"], ["171", "
\n
\n\n
\n", "
\n
\n\n
\n", "
File: 161.27, IEN: 4
\n", "
\nPayment 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.\n
\n
\n", "
\n
\n\n
\n", "
Billed Service Not Covered
\n", "
\n
\n\n
\n"], ["172", "
\n
\n\n
\n", "
\n
\n\n
\n", "
File: 161.27, IEN: 4
\n", "
\nPayment 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.\n
\n
\n", "
\n
\n\n
\n", "
Billed Service Not Covered
\n", "
\n
\n\n
\n"], ["20", "
\n
\n\n
\n", "
\n
\n\n
\n", "
File: 161.27, IEN: 4
\n", "
\nThis injury/illness is covered by the liability carrier.\n
\n
\n", "
\n
\n\n
\n", "
Billed Service Not Covered
\n", "
\n
\n\n
\n"], ["173", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nService/equipment was not prescribed by a physician.\n
\n
\n", "
\n
\n\n
\n", "
Billed Service Not Covered
\n", "
\n
\n\n
\n"], ["174", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nService was not prescribed prior to delivery\n
\n
\n", "
\n
\n\n
\n", "
Billed Service Not Covered
\n", "
\n
\n\n
\n"], ["175", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nPrescription is incomplete\n
\n
\n", "
\n
\n\n
\n", "
Incorrect Claim Data
\n", "
\n
\n\n
\n"], ["176", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nPrescription is not current\n
\n
\n", "
\n
\n\n
\n", "
Billed Service Not Covered
\n", "
\n
\n\n
\n"], ["177", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nPatient has not met the required eligibility requirements\n
\n
\n", "
\n
\n\n
\n", "
Billed Service Not Covered
\n", "
\n
\n\n
\n"], ["178", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nPatient has not met the required spend down requirements.\n
\n
\n", "", "
Billed Service Not Covered
\n", "
\n
\n\n
\n"], ["179", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nPatient has not met the required waiting requirements. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.\n
\n
\n", "", "
Billed Service Not Covered
\n", "
\n
\n\n
\n"], ["180", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nPatient has not met the required residency requirements\n
\n
\n", "", "
Billed Service Not Covered
\n", "
\n
\n\n
\n"], ["181", "
\n
\n\n
\n", "
\n
\n\n
\n", "
File: 161.27, IEN: 4
\n", "
\nProcedure code was invalid on the date of service\n
\n
\n", "
\n
\n\n
\n", "
Incorrect Claim Data
\n", "
\n
\n\n
\n"], ["182", "
\n
\n\n
\n", "
\n
\n\n
\n", "
File: 161.27, IEN: 4
\n", "
\nProcedure modifier was invalid on the date of service.\n
\n
\n", "
\n
\n\n
\n", "
Incorrect Claim Data
\n", "
\n
\n\n
\n"], ["26", "
\n
\n\n
\n", "
\n
\n\n
\n", "
File: 161.27, IEN: 4
\n", "
\nExpenses incurred prior to coverage.\n
\n
\n", "
\n
\n\n
\n", "
Billed Service Not Covered
\n", "
\n
\n\n
\n"], ["183", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nThe 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.\n
\n
\n", "
\n
\n\n
\n", "
Billed Service Not Covered
\n", "
\n
\n\n
\n"], ["184", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nThe 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.\n
\n
\n", "
\n
\n\n
\n", "
Billed Service Not Covered
\n", "
\n
\n\n
\n"], ["185", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nThe 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.\n
\n
\n", "
\n
\n\n
\n", "
Billed Service Not Covered
\n", "
\n
\n\n
\n"], ["193", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nLevel of care change adjustment.\n
\n
\n", "", "", ""], ["194", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nConsumer Spending Account payments (includes but is not limited to Flexible Spending Account, Health Savings Account, Health Reimbursement Account, etc.)\n
\n
\n", "", "", ""], ["188", "
\n
\n\n
\n", "
\n
\n\n
\n", "
File: 161.27, IEN: 4
\n", "
\nThis product/procedure is only covered when used according to FDA recommendations.\n
\n
\n", "
\n
\n\n
\n", "
Billed Service Not Covered
\n", "
\n
\n\n
\n"], ["189", "
\n
\n\n
\n", "
\n
\n\n
\n", "
File: 161.27, IEN: 4
\n", "
\n'Not otherwise classified' or 'unlisted' procedure code (CPT/HCPCS) was billed when there is a specific procedure code for this procedure/service\n
\n
\n", "
\n
\n\n
\n", "
Incorrect Claim Data
\n", "
\n
\n\n
\n"], ["190", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nPayment is included in the allowance for a Skilled Nursing Facility (SNF) qualified stay.\n
\n
\n", "
\n
\n\n
\n", "
Benefit for Service Not Payable
\n", "
\n
\n\n
\n"], ["198", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nNot a work related injury/illness and thus not the liability of the workers compensation carrier.  Note: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier 'IG') for the jurisdictional regulation. If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF)\n
\n
\n", "", "", ""], ["199", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nnon-standard code cannot be reasonably mapped to an existing Claims Adjustment Reason Code, specifically Deductible, Coinsurance and Co-payment.\n
\n
\n", "", "", ""], ["2", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nDeductible Amount\n
\n
\n", "", "", ""], ["30", "
\n
\n\n
\n", "
\n
\n\n
\n", "
File: 161.27, IEN: 4
\n", "
\nPayment adjusted because the patient has not met the required eligibility, spend down, waiting, or residency requirements.\n
\n
\n", "", "", ""], ["200", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nOriginal payment decision is being maintained. Upon review, it was determined that this claim was processed properly.\n
\n
\n", "", "", ""], ["194", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nAnesthesia performed by the operating physician, the assistant surgeon or the attending physician.\n
\n
\n", "
\n
\n\n
\n", "
Billed Service Not Covered
\n", "
\n
\n\n
\n"], ["202", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nRefund issued to an erroneous priority payer for this claim/service\n
\n
\n", "", "", ""], ["203", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nClaim/service denied based on prior payer's coverage determination.\n
\n
\n", "", "", ""], ["197", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nPrecertification/ authorization/notification absent.\n
\n
\n", "
\n
\n\n
\n", "
Billed Service Not Covered
\n", "
\n
\n\n
\n"], ["198", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nPrecertification/authorization exceeded.\n
\n
\n", "
\n
\n\n
\n", "
Billed Service Not Covered
\n", "
\n
\n\n
\n"], ["199", "
\n
\n\n
\n", "
\n
\n\n
\n", "
File: 161.27, IEN: 4
\n", "
\nRevenue code and Procedure code do not match.\n
\n
\n", "
\n
\n\n
\n", "
Incorrect Claim Data
\n", "
\n
\n\n
\n"], ["200", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nExpenses incurred during lapse in coverage\n
\n
\n", "
\n
\n\n
\n", "
Billed Service Not Covered
\n", "
\n
\n\n
\n"], ["201", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nor Remittance Advice Remark Code that is not an ALERT.)\n
\n
\n", "
\n
\n\n
\n", "
Billed Service Not Covered
\n", "
\n
\n\n
\n"], ["202", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nNon-covered personal comfort or convenience services.\n
\n
\n", "
\n
\n\n
\n", "
Billed Service Not Covered
\n", "
\n
\n\n
\n"], ["31", "
\n
\n\n
\n", "
\n
\n\n
\n", "
File: 161.27, IEN: 4
\n", "
\nPatient cannot be identified as our insured.\n
\n
\n", "
\n
\n\n
\n", "
Billed Service Not Covered
\n", "
\n
\n\n
\n"], ["203", "
\n
\n\n
\n", "
\n
\n\n
\n", "
File: 161.27, IEN: 4
\n", "
\nDiscontinued or reduced service.\n
\n
\n", "", "", ""], ["204", "
\n
\n\n
\n", "
\n
\n\n
\n", "
File: 161.27, IEN: 4
\n", "
\nThis service/equipment/drug is not covered under the patient's current benefit plan\n
\n
\n", "
\n
\n\n
\n", "
Billed Service Not Covered
\n", "
\n
\n\n
\n"], ["212", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nPharmacy discount card processing fee\n
\n
\n", "", "", ""], ["206", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nNational Provider Identifier - missing.\n
\n
\n", "
\n
\n\n
\n", "
Incorrect Claim Data
\n", "
\n
\n\n
\n"], ["207", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nNational Provider identifier - Invalid format\n
\n
\n", "
\n
\n\n
\n", "
Incorrect Claim Data
\n", "
\n
\n\n
\n"], ["208", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nNational Provider Identifier - Not matched\n
\n
\n", "
\n
\n\n
\n", "
Incorrect Claim Data
\n", "
\n
\n\n
\n"], ["216", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nPer regulatory or other agreement. The provider cannot collect this amount from the patient. However, this amount may be billed to subsequent payer. Refund to patient if collected. (Use only with Group code OA)\n
\n
\n", "", "", ""], ["210", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nPayment adjusted because pre-certification/authorization not received in a timely fashion\n
\n
\n", "", "
Billed Service Not Covered
\n", "
\n
\n\n
\n"], ["218", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nNational Drug Codes (NDC) not eligible for rebate, are not covered\n
\n
\n", "", "", ""], ["212", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nAdministrative surcharges are not covered\n
\n
\n", "
\n
\n\n
\n", "
Billed Service Not Covered
\n", "
\n
\n\n
\n"], ["34", "
\n
\n\n
\n", "
\n
\n\n
\n", "
File: 161.27, IEN: 4
\n", "
\nInsured has no coverage for newborns.\n
\n
\n", "", "
Billed Service Not Covered
\n", "
\n
\n\n
\n"], ["213", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nNon-compliance with the physician self referral prohibition legislation or payer policy\n
\n
\n", "", "
Billed Service Not Covered
\n", ""], ["221", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nWorkers' Compensation claim adjudicated as non-compensable. This Payer not liable for claim or service/treatment. Note: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier 'IG') for the jurisdictional regulation. If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF). To be used for Workers' Compensation only\n
\n
\n", "", "", ""], ["222", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nBased on subrogation of a third party settlement\n
\n
\n", "", "", ""], ["223", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nBased on the findings of a review organization\n
\n
\n", "", "", ""], ["224", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nBased on payer reasonable and customary fees. No maximum allowable defined by legislated fee arrangement. (Note: To be used for Property and Casualty only)\n
\n
\n", "", "", ""], ["225", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nBased on entitlement to benefits. Note: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier 'IG') for the jurisdictional regulation. If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF). To be used for Workers' Compensation only\n
\n
\n", "", "", ""], ["226", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nBased on extent of injury. Note: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier 'IG') for the jurisdictional regulation. If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF).\n
\n
\n", "", "", ""], ["227", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nTo be used for Property and Casualty only)\n
\n
\n", "", "", ""], ["228", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nProperty & Casualty only)\n
\n
\n", "", "", ""], ["222", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nExceeds 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.\n
\n
\n", "
\n
\n\n
\n", "
Billed Service Not Covered
\n", "
\n
\n\n
\n"], ["35", "
\n
\n\n
\n", "
\n
\n\n
\n", "
File: 161.27, IEN: 4
\n", "
\nLifetime benefit maximum has been reached.\n
\n
\n", "
\n
\n\n
\n", "
Billed Service Not Covered
\n", "
\n
\n\n
\n"], ["230", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nAdjustment 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.\n
\n
\n", "", "", ""], ["224", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nPatient identification compromised by identity theft. Identity verification required for processing this and future claims.\n
\n
\n", "", "
Billed Service Not Covered
\n", "
\n
\n\n
\n"], ["232", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nPenalty or Interest Payment by Payer (Only used for plan to plan encounter reporting within the 837)\n
\n
\n", "", "", ""], ["233", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nor Remittance Advice Remark Code that is not an ALERT.)\n
\n
\n", "", "", ""], ["234", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nInformation 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.)\n
\n
\n", "", "", ""], ["228", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nDenied for failure of this provider, another provider or the subscriber to supply requested information to a previous payer for their adjudication\n
\n
\n", "
\n
\n\n
\n", "
Billed Service Not Covered
\n", "
\n
\n\n
\n"], ["236", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\npolicy allows providers to bypass claim submission to a prior payer. (Use only with Group Code PR)\n
\n
\n", "", "", ""], ["237", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nNo available or correlating CPT/HCPCS code to describe this service. Note: Used only by Property and Casualty.\n
\n
\n", "", "", ""], ["231", "
\n
\n\n
\n", "
\n
\n\n
\n", "
File: 161.27, IEN: 4
\n", "
\nMutually 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.\n
\n
\n", "
\n
\n\n
\n", "
Billed Service Not Covered
\n", "
\n
\n\n
\n"], ["239", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nInstitutional Transfer Amount. Note - Applies to institutional claims only and explains the DRG amount difference when the patient care crosses multiple institutions.\n
\n
\n", "", "", ""], ["40", "
\n
\n\n
\n", "
\n
\n\n
\n", "
File: 161.27, IEN: 4
\n", "
\nCharges 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\n
\n
\n", "
\n
\n\n
\n", "
Billed Service Not Covered
\n", "
\n
\n\n
\n"], ["233", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nServices/charges related to the treatment of a hospital-acquired condition or preventable medical error.\n
\n
\n", "", "
Billed Service Not Covered
\n", "
\n
\n\n
\n"], ["234", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nThis 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.)\n
\n
\n", "
\n
\n\n
\n", "
Benefit for Service Not Payable
\n", "
\n
\n\n
\n"], ["A0", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nPatient refund amount.\n
\n
\n", "", "", ""], ["A3", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nMedicare Secondary Payer liability met.\n
\n
\n", "", "", ""], ["A4", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nMedicare Claim PPS Capital Day Outlier Amount.\n
\n
\n", "", "", ""], ["A5", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nMedicare Claim PPS Capital Cost Outlier Amount.\n
\n
\n", "", "", ""], ["A6", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nPrior hospitalization or 30 day transfer requirement not met.\n
\n
\n", "", "
Billed Service Not Covered
\n", "
\n
\n\n
\n"], ["A7", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nPresumptive Payment Adjustment\n
\n
\n", "", "", ""], ["A8", "
\n
\n\n
\n", "
\n
\n\n
\n", "
File: 161.27, IEN: 4
\n", "
\nUngroupable DRG\n
\n
\n", "
\n
\n\n
\n", "
Incorrect Claim Data
\n", "
\n
\n\n
\n"], ["B10", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nAllowed 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.\n
\n
\n", "
\n
\n\n
\n", "
Benefit for Service Not Payable
\n", "
\n
\n\n
\n"], ["42", "
\n
\n\n
\n", "
\n
\n\n
\n", "
File: 161.27, IEN: 4
\n", "
\nCharges exceed our fee schedule or maximum allowable amount.\n
\n
\n", "", "", ""], ["B2", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nCovered visits.\n
\n
\n", "", "", ""], ["B3", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nCovered charges.\n
\n
\n", "", "", ""], ["B4", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nLate filing penalty.\n
\n
\n", "", "", ""], ["B5", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nCoverage/program guidelines were not met or were exceeded.\n
\n
\n", "", "", ""], ["B6", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nThis 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.\n
\n
\n", "", "", ""], ["B9", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nPatient is enrolled in a Hospice.\n
\n
\n", "
\n
\n\n
\n", "
Billed Service Not Covered
\n", "
\n
\n\n
\n"], ["B11", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nThe claim/service has been transferred to the proper payer/processor for processing. Claim/service not covered by this payer/processor.\n
\n
\n", "
\n
\n\n
\n", "
Billed Service Not Covered
\n", "
\n
\n\n
\n"], ["B14", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nOnly one visit or consultation per physician per day is covered.\n
\n
\n", "
\n
\n\n
\n", "
Billed Service Not Covered
\n", "
\n
\n\n
\n"], ["B15", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nThis 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\n
\n
\n", "
\n
\n\n
\n", "
Billed Service Not Covered
\n", "
\n
\n\n
\n"], ["B16", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\n'New Patient' qualifications were not met.\n
\n
\n", "
\n
\n\n
\n", "
Billed Service Not Covered
\n", "
\n
\n\n
\n"], ["45", "
\n
\n\n
\n", "
\n
\n\n
\n", "
File: 161.27, IEN: 4
\n", "
\ndepending upon liability)\n
\n
\n", "", "", ""], ["B17", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nPayment 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.\n
\n
\n", "", "", ""], ["B18", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nPayment adjusted because this procedure code and modifier were invalid on the date of service\n
\n
\n", "", "", ""], ["B19", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nClaim/service adjusted because of the finding of a Review Organization.\n
\n
\n", "", "", ""], ["B20", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nProcedure/service was partially or fully furnished by another provider.\n
\n
\n", "
\n
\n\n
\n", "
Billed Service Not Covered
\n", "
\n
\n\n
\n"], ["B21", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nThe charges were reduced because the service/care was partially furnished by another physician.\n
\n
\n", "", "", ""], ["B22", "
\n
\n\n
\n", "
\n
\n\n
\n", "
File: 161.27, IEN: 4
\n", "
\nThis payment is adjusted based on the diagnosis.\n
\n
\n", "", "", ""], ["B23", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nProcedure billed is not authorized per your Clinical Laboratory Improvement Amendment (CLIA) proficiency test.\n
\n
\n", "", "
Billed Service Not Covered
\n", "
\n
\n\n
\n"], ["D1", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nClaim/service denied. Level of subluxation is missing or inadequate.\n
\n
\n", "", "", ""], ["D2", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nClaim lacks the name, strength, or dosage of the drug furnished.\n
\n
\n", "", "", ""], ["D3", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nClaim/service denied because information to indicate if the patient owns the equipment that requires the part or supply was missing.\n
\n
\n", "", "", ""], ["47", "
\n
\n\n
\n", "
\n
\n\n
\n", "
File: 161.27, IEN: 4
\n", "
\nThis (these) diagnosis(es) is (are) not covered, missing, or are invalid.\n
\n
\n", "", "", ""], ["D4", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nClaim/service does not indicate the period of time for which this will be needed.\n
\n
\n", "", "", ""], ["D5", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nClaim/service denied. Claim lacks individual lab codes included in the test.\n
\n
\n", "", "", ""], ["D6", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nClaim/service denied. Claim did not include patient's medical record for the service.\n
\n
\n", "", "", ""], ["D7", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nClaim/service denied. Claim lacks date of patient's most recent physician visit.\n
\n
\n", "", "", ""], ["D8", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nClaim/service denied. Claim lacks indicator that `x-ray is available for review.'\n
\n
\n", "", "", ""], ["D9", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nClaim/service denied. Claim lacks invoice or statement certifying the actual cost of the lens, less discounts or the type of intraocular lens used.\n
\n
\n", "", "", ""], ["D10", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nClaim/service denied. Completed physician financial relationship form not on file.\n
\n
\n", "", "", ""], ["D11", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nClaim lacks completed pacemaker registration form.\n
\n
\n", "", "", ""], ["D12", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nClaim/service denied. Claim does not identify who performed the purchased diagnostic test or the amount you were charged for the test.\n
\n
\n", "", "", ""], ["D13", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nClaim/service denied. Performed by a facility/supplier in which the ordering/referring physician has a financial interest.\n
\n
\n", "", "", ""], ["49", "
\n
\n\n
\n", "
\n
\n\n
\n", "
File: 161.27, IEN: 4
\n", "
\nService Payment Information REF), if present.\n
\n
\n", "
\n
\n\n
\n", "
Billed Service Not Covered
\n", "
\n
\n\n
\n"], ["D14", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nClaim lacks indication that plan of treatment is on file.\n
\n
\n", "", "", ""], ["D15", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nClaim lacks indication that service was supervised or evaluated by a physician.\n
\n
\n", "", "", ""], ["D16", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nClaim lacks prior payer payment information.\n
\n
\n", "", "", ""], ["D17", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nClaim/Service has invalid non-covered days.\n
\n
\n", "", "", ""], ["D18", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nClaim/Service has missing diagnosis information.\n
\n
\n", "", "", ""], ["D19", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nClaim/Service lacks Physician/Operative or other supporting documentation\n
\n
\n", "", "", ""], ["D20", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nClaim/Service missing service/product information.\n
\n
\n", "", "", ""], ["D21", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nThis (these) diagnosis(es) is (are) missing or are invalid\n
\n
\n", "", "", ""], ["D22", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\ncorrespondence. (Note: To be used for Workers' Compensation only)\n
\n
\n", "", "", ""], ["D23", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nRemark Code that is not an ALERT.)\n
\n
\n", "", "", ""], ["50", "
\n
\n\n
\n", "
\n
\n\n
\n", "
File: 161.27, IEN: 4
\n", "
\nThese 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.\n
\n
\n", "
\n
\n\n
\n", "
Billed Service Not Covered
\n", "
\n
\n\n
\n"], ["W1", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\n2110 Service Payment information REF).\n
\n
\n", "", "", ""], ["291", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nSales Tax\n
\n
\n", "", "", ""], ["236", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nfee schedule requirements.\n
\n
\n", "
\n
\n\n
\n", "
Incorrect Claim Data
\n", "
\n
\n\n
\n"], ["293", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nLegislated/Regulatory Penalty. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.)\n
\n
\n", "", "", ""], ["238", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nClaim spans eligible and ineligible periods of coverage, this is the reduction for the ineligible period. (Use only with Group Code PR)\n
\n
\n", "", "
Billed Service Not Covered
\n", "
\n
\n\n
\n"], ["239", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nClaim spans eligible and ineligible periods of coverage. Rebill separate claims.\n
\n
\n", "", "
Billed Service Not Covered
\n", "
\n
\n\n
\n"], ["240", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nThe diagnosis is inconsistent with the patient's birth weight. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.\n
\n
\n", "
\n
\n\n
\n", "
Incorrect Claim Data
\n", "
\n
\n\n
\n"], ["297", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nLow Income Subsidy (LIS) Co-payment Amount\n
\n
\n", "", "", ""], ["242", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nServices not provided by network/primary care providers\n
\n
\n", "
\n
\n\n
\n", "
Billed Service Not Covered
\n", "
\n
\n\n
\n"], ["243", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nServices not authorized by network/primary care providers.\n
\n
\n", "
\n
\n\n
\n", "
Billed Service Not Covered
\n", "
\n
\n\n
\n"], ["3", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nCoinsurance Amount\n
\n
\n", "", "", ""], ["52", "
\n
\n\n
\n", "
\n
\n\n
\n", "
File: 161.27, IEN: 4
\n", "
\nThe referring/prescribing/rendering provider is not eligible to refer/prescribe/order/perform the service billed.\n
\n
\n", "", "", ""], ["300", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nPayment reduced to zero due to litigation. Additional information will be sent following the conclusion of litigation. To be used for Property & Casualty only\n
\n
\n", "", "", ""], ["301", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nProvider performance program withhold\n
\n
\n", "", "", ""], ["246", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nThis non-payable code is for required reporting only.\n
\n
\n", "
\n
\n\n
\n", "
Billed Service Not Covered
\n", "
\n
\n\n
\n"], ["303", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nDeductible for Professional service rendered in an Institutional setting and billed on an Institutional claim.\n
\n
\n", "", "", ""], ["304", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nCoinsurance for Professional service rendered in an Institutional setting and billed on an Institutional claim.\n
\n
\n", "", "", ""], ["249", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nThis claim has been identified as a readmission. (Use only with Group Code CO)\n
\n
\n", "
\n
\n\n
\n", "
Billed Service Not Covered
\n", "
\n
\n\n
\n"], ["250", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nRemittance Advice Remark Code that is not an ALERT).\n
\n
\n", "
\n
\n\n
\n", "
Incorrect Documentation
\n", "
\n
\n\n
\n"], ["251", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nor Remittance Advice Remark Code that is not an ALERT).\n
\n
\n", "
\n
\n\n
\n", "
Incorrect Documentation
\n", "
\n
\n\n
\n"], ["252", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nAn attachment/other documentation is required to adjudicate this claim/service. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT).\n
\n
\n", "
\n
\n\n
\n", "
Incorrect Documentation
\n", "
\n
\n\n
\n"], ["54", "
\n
\n\n
\n", "
\n
\n\n
\n", "
File: 161.27, IEN: 4
\n", "
\nMultiple 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.\n
\n
\n", "
\n
\n\n
\n", "
Billed Service Not Covered
\n", "
\n
\n\n
\n"], ["W2", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nPayment reduced or denied based on workers' compensation jurisdictional regulations or payment policies, use only if no other code is applicable. Note: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier 'IG') for the jurisdictional regulation. If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF). To be used for Workers' Compensation only.\n
\n
\n", "", "", ""], ["W3", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nThe Benefit for this Service is included in the payment/allowance for another service/procedure that has been performed on the same day. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. For use by Property and Casualty only.\n
\n
\n", "", "", ""], ["W4", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nWorkers' Compensation Medical Treatment Guideline Adjustment.\n
\n
\n", "", "", ""], ["Y1", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nPayment denied based on Medical Payments Coverage (MPC) or Personal Injury Protection (PIP) Benefits jurisdictional regulations or payment policies, use only if no other code is applicable. Note: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier 'IG') for the jurisdictional regulation. If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF). To be used for P&C Auto only\n
\n
\n", "", "", ""], ["Y2", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nPayment adjusted based on Medical Payments Coverage (MPC) or Personal Injury Protection (PIP) Benefits jurisdictional regulations or payment policies, use only if no other code is applicable. Note: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier 'IG') for the jurisdictional regulation. If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF). To be used for P&C Auto only\n
\n
\n", "", "", ""], ["Y3", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nMedical Payments Coverage (MPC) or Personal Injury Protection (PIP) Benefits jurisdictional fee schedule adjustment. Note: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Class of Contract Code Identification Segment (Loop 2100 Other Claim Related Information REF). If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF). To be used for P&C Auto only.\n
\n
\n", "", "", ""], ["316", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nSequestration - reduction in federal payment\n
\n
\n", "", "", ""], ["254", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nClaim received by the dental plan, but benefits not available under this plan. Submit these services to the patient's medical plan for further consideration.\n
\n
\n", "
\n
\n\n
\n", "
Billed Service Not Covered
\n", "
\n
\n\n
\n"], ["256", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nService not payable per managed care contract.\n
\n
\n", "
\n
\n\n
\n", "
Billed Service Not Covered
\n", "
\n
\n\n
\n"], ["319", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nlack of premium payment). (Use only with Group Code OA)\n
\n
\n", "", "", ""], ["55", "
\n
\n\n
\n", "
\n
\n\n
\n", "
File: 161.27, IEN: 4
\n", "
\n(loop 2110 Service Payment Information REF), if present.\n
\n
\n", "
\n
\n\n
\n", "
Billed Service Not Covered
\n", "
\n
\n\n
\n"], ["258", "
\n
\n\n
\n", "
\n
\n\n
\n", "
File: 161.27, IEN: 4
\n", "
\nClaim/service not covered when patient is in custody/incarcerated. Applicable federal, state or local authority may cover the claim/service.\n
\n
\n", "
\n
\n\n
\n", "
Billed Service Not Covered
\n", "
\n
\n\n
\n"], ["259", "
\n
\n\n
\n", "
\n
\n\n
\n", "
File: 161.27, IEN: 4
\n", "
\nAdditional payment for Dental/Vision service utilization.\n
\n
\n", "", "", ""], ["260", "
\n
\n\n
\n", "
\n
\n\n
\n", "
File: 161.27, IEN: 4
\n", "
\nProcessed under Medicaid ACA Enhanced Fee Schedule\n
\n
\n", "", "", ""], ["261", "
\n
\n\n
\n", "
\n
\n\n
\n", "
File: 161.27, IEN: 4
\n", "
\nThe procedure or service is inconsistent with the patient's history.\n
\n
\n", "", "
Billed Service Not Covered
\n", "
\n
\n\n
\n"], ["262", "
\n
\n\n
\n", "
\n
\n\n
\n", "
File: 161.27, IEN: 4
\n", "
\nAdjustment for delivery cost. Note: To be used for pharmaceuticals only.\n
\n
\n", "", "", ""], ["263", "
\n
\n\n
\n", "
\n
\n\n
\n", "
File: 161.27, IEN: 4
\n", "
\nAdjustment for shipping cost. Note: To be used for pharmaceuticals only.\n
\n
\n", "", "", ""], ["264", "
\n
\n\n
\n", "
\n
\n\n
\n", "
File: 161.27, IEN: 4
\n", "
\nAdjustment for postage cost. Note: To be used for pharmaceuticals only.\n
\n
\n", "", "", ""], ["327", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nAdjustment for administrative cost. Note: To be used for pharmaceuticals only.\n
\n
\n", "", "", ""], ["266", "
\n
\n\n
\n", "
\n
\n\n
\n", "
File: 161.27, IEN: 4
\n", "
\nAdjustment for compound preparation cost. Note: To be used for pharmaceuticals only.\n
\n
\n", "", "", ""], ["267", "
\n
\n\n
\n", "
\n
\n\n
\n", "
File: 161.27, IEN: 4
\n", "
\nRemittance Advice Remark Code that is not an ALERT.)\n
\n
\n", "
\n
\n\n
\n", "
Incorrect Claim Data
\n", "
\n
\n\n
\n"], ["57", "
\n
\n\n
\n", "
\n
\n\n
\n", "
File: 161.27, IEN: 4
\n", "
\nPayment 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.\n
\n
\n", "", "", ""], ["268", "
\n
\n\n
\n", "
\n
\n\n
\n", "
File: 161.27, IEN: 4
\n", "
\nThe Claim spans two calendar years. Please resubmit one claim per calendar year.\n
\n
\n", "", "
Incorrect Claim Data
\n", "
\n
\n\n
\n"], ["255", "
\n
\n\n
\n", "
\n
\n\n
\n", "
File: 161.27, IEN: 4
\n", "
\nThe disposition of the related Property & Casualty claim (injury or illness) is pending due to litigation. (Use only with Group Code OA)\n
\n
\n", "", "", ""], ["P1", "
\n
\n\n
\n", "
\n
\n\n
\n", "
File: 161.27, IEN: 4
\n", "
\nState-mandated Requirement for Property and Casualty, see Claim Payment Remarks Code for specific explanation. To be used for Property and Casualty only.\n
\n
\n", "", "", ""], ["P2", "
\n
\n\n
\n", "
\n
\n\n
\n", "
File: 161.27, IEN: 4
\n", "
\nPayment information REF). To be used for Workers' Compensation only.\n
\n
\n", "", "
Billed Service Not Covered
\n", "
\n
\n\n
\n"], ["P3", "
\n
\n\n
\n", "
\n
\n\n
\n", "
File: 161.27, IEN: 4
\n", "
\nWorkers' Compensation case settled. Patient is responsible for amount of this claim/service through WC 'Medicare set aside arrangement' or other agreement. To be used for Workers' Compensation only. (Use only with Group Code PR)\n
\n
\n", "", "
Billed Service Not Covered
\n", "
\n
\n\n
\n"], ["P4", "
\n
\n\n
\n", "
\n
\n\n
\n", "
File: 161.27, IEN: 4
\n", "
\nSegment (loop 2110 Service Payment information REF). To be used for Workers' Compensation only\n
\n
\n", "
\n
\n\n
\n", "
Billed Service Not Covered
\n", "
\n
\n\n
\n"], ["P5", "
\n
\n\n
\n", "
\n
\n\n
\n", "
File: 161.27, IEN: 4
\n", "
\nBased on payer reasonable and customary fees. No maximum allowable defined by legislated fee arrangement. To be used for Property and Casualty only.\n
\n
\n", "", "", ""], ["P6", "
\n
\n\n
\n", "
\n
\n\n
\n", "
File: 161.27, IEN: 4
\n", "
\nCasualty only.\n
\n
\n", "", "", ""], ["P7", "
\n
\n\n
\n", "
\n
\n\n
\n", "
File: 161.27, IEN: 4
\n", "
\nTo be used for Property and Casualty only.\n
\n
\n", "
\n
\n\n
\n", "
Incorrect Claim Data
\n", "
\n
\n\n
\n"], ["P8", "
\n
\n\n
\n", "
\n
\n\n
\n", "
File: 161.27, IEN: 4
\n", "
\nCasualty only.\n
\n
\n", "", "", ""], ["58", "
\n
\n\n
\n", "
\n
\n\n
\n", "
File: 161.27, IEN: 4
\n", "
\nTreatment 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.\n
\n
\n", "
\n
\n\n
\n", "
Billed Service Not Covered
\n", "
\n
\n\n
\n"], ["P9", "
\n
\n\n
\n", "
\n
\n\n
\n", "
File: 161.27, IEN: 4
\n", "
\nNo available or correlating CPT/HCPCS code to describe this service. To be used for Property and Casualty only.\n
\n
\n", "", "", ""], ["P10", "
\n
\n\n
\n", "
\n
\n\n
\n", "
File: 161.27, IEN: 4
\n", "
\nPayment reduced to zero due to litigation. Additional information will be sent following the conclusion of litigation. To be used for Property and Casualty only.\n
\n
\n", "", "", ""], ["P11", "
\n
\n\n
\n", "
\n
\n\n
\n", "
File: 161.27, IEN: 4
\n", "
\nThe disposition of the related Property & Casualty claim (injury or illness) is pending due to litigation. To be used for Property and Casualty only. (Use only with Group Code OA)\n
\n
\n", "", "", ""], ["P12", "
\n
\n\n
\n", "
\n
\n\n
\n", "
File: 161.27, IEN: 4
\n", "
\nused for Workers' Compensation only.\n
\n
\n", "", "", ""], ["P13", "
\n
\n\n
\n", "
\n
\n\n
\n", "
File: 161.27, IEN: 4
\n", "
\ncare Policy Identification Segment (loop 2110 Service Payment information REF) if the regulations apply. To be used for Workers' Compensation only.\n
\n
\n", "", "", ""], ["P14", "
\n
\n\n
\n", "
\n
\n\n
\n", "
File: 161.27, IEN: 4
\n", "
\nif present. To be used for Property and Casualty only.\n
\n
\n", "
\n
\n\n
\n", "
Benefit for Service Not Payable
\n", "
\n
\n\n
\n"], ["P15", "
\n
\n\n
\n", "
\n
\n\n
\n", "
File: 161.27, IEN: 4
\n", "
\nWorkers' Compensation Medical Treatment Guideline Adjustment. To be used for Workers' Compensation only.\n
\n
\n", "", "", ""], ["P16", "
\n
\n\n
\n", "
\n
\n\n
\n", "
File: 161.27, IEN: 4
\n", "
\nMedical provider not authorized/certified to provide treatment to injured workers in this jurisdiction. To be used for Workers' Compensation only. (Use with Group Code CO or OA)\n
\n
\n", "", "
Billed Service Not Covered
\n", "
\n
\n\n
\n"], ["P17", "
\n
\n\n
\n", "
\n
\n\n
\n", "
File: 161.27, IEN: 4
\n", "
\nReferral not authorized by attending physician per regulatory requirement. To be used for Property and Casualty only.\n
\n
\n", "", "
Billed Service Not Covered
\n", "
\n
\n\n
\n"], ["P18", "
\n
\n\n
\n", "
\n
\n\n
\n", "
File: 161.27, IEN: 4
\n", "
\nProcedure is not listed in the jurisdiction fee schedule. An allowance has been made for a comparable service. To be used for Property and Casualty only.\n
\n
\n", "", "", ""], ["59", "
\n
\n\n
\n", "
\n
\n\n
\n", "
File: 161.27, IEN: 4
\n", "
\nREF), if present.\n
\n
\n", "
\n
\n\n
\n", "
Billed Service Not Covered
\n", "
\n
\n\n
\n"], ["P19", "
\n
\n\n
\n", "
\n
\n\n
\n", "
File: 161.27, IEN: 4
\n", "
\nProcedure has a relative value of zero in the jurisdiction fee schedule, therefore no payment is due. To be used for Property and Casualty only.\n
\n
\n", "", "
Benefit for Service Not Payable
\n", "
\n
\n\n
\n"], ["P20", "
\n
\n\n
\n", "
\n
\n\n
\n", "
File: 161.27, IEN: 4
\n", "
\nService not paid under jurisdiction allowed outpatient facility fee schedule. To be used for Property and Casualty only.\n
\n
\n", "
\n
\n\n
\n", "
Billed Service Not Covered
\n", "
\n
\n\n
\n"], ["P21", "
\n
\n\n
\n", "
\n
\n\n
\n", "
File: 161.27, IEN: 4
\n", "
\nand the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF) if the regulations apply. To be used for Property and Casualty Auto only.\n
\n
\n", "
\n
\n\n
\n", "
Billed Service Not Covered
\n", "
\n
\n\n
\n"], ["P22", "
\n
\n\n
\n", "
\n
\n\n
\n", "
File: 161.27, IEN: 4
\n", "
\nand the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF) if the regulations apply. To be used for Property and Casualty Auto only.\n
\n
\n", "", "", ""], ["P23", "
\n
\n\n
\n", "
\n
\n\n
\n", "
File: 161.27, IEN: 4
\n", "
\ninformation REF) if the regulations apply. To be used for Property and Casualty Auto only.\n
\n
\n", "", "", ""], ["W5", "
\n
\n\n
\n", "
\n
\n\n
\n", "
File: 161.27, IEN: 4
\n", "
\nMedical provider not authorized/certified to provide treatment to injured workers in this jurisdiction. (Use with Group Code CO or OA)\n
\n
\n", "", "", ""], ["W6", "
\n
\n\n
\n", "
\n
\n\n
\n", "
File: 161.27, IEN: 4
\n", "
\nReferral not authorized by attending physician per regulatory requirement.\n
\n
\n", "", "", ""], ["W7", "
\n
\n\n
\n", "
\n
\n\n
\n", "
File: 161.27, IEN: 4
\n", "
\nProcedure is not listed in the jurisdiction fee schedule. An allowance has been made for a comparable service.\n
\n
\n", "", "", ""], ["W8", "
\n
\n\n
\n", "
\n
\n\n
\n", "
File: 161.27, IEN: 4
\n", "
\nProcedure has a relative value of zero in the jurisdiction fee schedule, therefore no payment is due.\n
\n
\n", "", "", ""], ["W9", "
\n
\n\n
\n", "
\n
\n\n
\n", "
File: 161.27, IEN: 4
\n", "
\nService not paid under jurisdiction allowed outpatient facility fee schedule.\n
\n
\n", "", "", ""], ["62", "
\n
\n\n
\n", "
\n
\n\n
\n", "
File: 161.27, IEN: 4
\n", "
\nPayment denied/reduced for absence of, or exceeded, pre-certification/authorization.\n
\n
\n", "", "", ""], ["269", "
\n
\n\n
\n", "
\n
\n\n
\n", "
File: 161.27, IEN: 4
\n", "
\nInformation REF), if present.\n
\n
\n", "
\n
\n\n
\n", "
Billed Service Not Covered
\n", "
\n
\n\n
\n"], ["270", "
\n
\n\n
\n", "
\n
\n\n
\n", "
File: 161.27, IEN: 4
\n", "
\nconsideration.\n
\n
\n", "
\n
\n\n
\n", "
Billed Service Not Covered
\n", "
\n
\n\n
\n"], ["362", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\npreviously reported. (Use only with group code OA)\n
\n
\n", "", "", ""], ["272", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nCoverage/program guidelines were not met.\n
\n
\n", "
\n
\n\n
\n", "
Billed Service Not Covered
\n", "
\n
\n\n
\n"], ["273", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nCoverage/program guidelines were exceeded.\n
\n
\n", "
\n
\n\n
\n", "
Billed Service Not Covered
\n", "
\n
\n\n
\n"], ["274", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nFee/Service not payable per patient Care Coordination arrangement.\n
\n
\n", "", "
Billed Service Not Covered
\n", "
\n
\n\n
\n"], ["366", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\ncoinsurance, co-payment) not covered. (Use only with Group Code PR)\n
\n
\n", "", "", ""], ["276", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nServices denied by the prior payer(s) are not covered by this payer.\n
\n
\n", "
\n
\n\n
\n", "
Billed Service Not Covered
\n", "
\n
\n\n
\n"], ["368", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nGroup Code OA)\n
\n
\n", "", "", ""], ["66", "
\n
\n\n
\n", "
\n
\n\n
\n", "
File: 161.27, IEN: 4
\n", "
\nBlood Deductible.\n
\n
\n", "", "", ""], ["85", "
\n
\n\n
\n", "
\n
\n\n
\n", "
File: 161.27, IEN: 4
\n", "
\nPatient Interest Adjustment (Use Only Group code PR).\n
\n
\n", "", "", ""], ["88", "
\n
\n\n
\n", "
\n
\n\n
\n", "
File: 161.27, IEN: 4
\n", "
\nAdjustment amount represents collection against receivable created in prior overpayment.\n
\n
\n", "", "", ""], ["4", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nCo-payment Amount\n
\n
\n", "", "", ""], ["89", "
\n
\n\n
\n", "
\n
\n\n
\n", "
File: 161.27, IEN: 4
\n", "
\nProfessional fees removed from charges.\n
\n
\n", "
\n
\n\n
\n", "
Billed Service Not Covered
\n", "
\n
\n\n
\n"], ["94", "
\n
\n\n
\n", "
\n
\n\n
\n", "
File: 161.27, IEN: 4
\n", "
\nProcessed in Excess of charges.\n
\n
\n", "", "", ""], ["96", "
\n
\n\n
\n", "
\n
\n\n
\n", "
File: 161.27, IEN: 4
\n", "
\nNon-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.\n
\n
\n", "
\n
\n\n
\n", "
Billed Service Not Covered
\n", "
\n
\n\n
\n"], ["97", "
\n
\n\n
\n", "
\n
\n\n
\n", "
File: 161.27, IEN: 4
\n", "
\nThe 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.\n
\n
\n", "
\n
\n\n
\n", "
Benefit for Service Not Payable
\n", "
\n
\n\n
\n"], ["100", "
\n
\n\n
\n", "
\n
\n\n
\n", "
File: 161.27, IEN: 4
\n", "
\nPayment made to patient/insured/responsible party/employer.\n
\n
\n", "", "", ""], ["109", "
\n
\n\n
\n", "
\n
\n\n
\n", "
File: 161.27, IEN: 4
\n", "
\nClaim/service not covered by this payer/contractor. You must send the claim/service to the correct payer/contractor.\n
\n
\n", "
\n
\n\n
\n", "
Billed Service Not Covered
\n", "
\n
\n\n
\n"], ["114", "
\n
\n\n
\n", "
\n
\n\n
\n", "
File: 161.27, IEN: 4
\n", "
\nProcedure/product not approved by the Food and Drug Administration.\n
\n
\n", "
\n
\n\n
\n", "
Billed Service Not Covered
\n", "
\n
\n\n
\n"], ["119", "
\n
\n\n
\n", "
\n
\n\n
\n", "
File: 161.27, IEN: 4
\n", "
\nBenefit maximum for this time period or occurrence has been reached.\n
\n
\n", "
\n
\n\n
\n", "
Billed Service Not Covered
\n", "
\n
\n\n
\n"], ["122", "
\n
\n\n
\n", "
\n
\n\n
\n", "
File: 161.27, IEN: 4
\n", "
\nPsychiatric reduction.\n
\n
\n", "", "", ""], ["131", "
\n
\n\n
\n", "
\n
\n\n
\n", "
File: 161.27, IEN: 4
\n", "
\nClaim specific negotiated discount.\n
\n
\n", "", "", ""], ["5", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nThe 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.\n
\n
\n", "
\n
\n\n
\n", "
Billed Service Not Covered
\n", "
\n
\n\n
\n"], ["132", "
\n
\n\n
\n", "
\n
\n\n
\n", "
File: 161.27, IEN: 4
\n", "
\nPrearranged demonstration project adjustment.\n
\n
\n", "", "", ""], ["135", "
\n
\n\n
\n", "
\n
\n\n
\n", "
File: 161.27, IEN: 4
\n", "
\nInterim bills cannot be processed.\n
\n
\n", "", "", ""], ["138", "
\n
\n\n
\n", "
\n
\n\n
\n", "
File: 161.27, IEN: 4
\n", "
\nAppeal procedures not followed or time limits not met.\n
\n
\n", "
\n
\n\n
\n", "
Billed Service Not Covered
\n", "
\n
\n\n
\n"], ["140", "
\n
\n\n
\n", "
\n
\n\n
\n", "
File: 161.27, IEN: 4
\n", "
\nPatient/Insured health identification number and name do not match.\n
\n
\n", "
\n
\n\n
\n", "
Incorrect Claim Data
\n", "
\n
\n\n
\n"], ["141", "
\n
\n\n
\n", "
\n
\n\n
\n", "
File: 161.27, IEN: 4
\n", "
\nClaim spans eligible and ineligible periods of coverage.\n
\n
\n", "", "", ""], ["142", "
\n
\n\n
\n", "
\n
\n\n
\n", "
File: 161.27, IEN: 4
\n", "
\nMonthly Medicaid patient liability amount.\n
\n
\n", "", "", ""], ["143", "
\n
\n\n
\n", "
\n
\n\n
\n", "
File: 161.27, IEN: 4
\n", "
\nPortion of payment deferred.\n
\n
\n", "", "", ""], ["146", "
\n
\n\n
\n", "
\n
\n\n
\n", "
File: 161.27, IEN: 4
\n", "
\nDiagnosis was invalid for the date(s) of service reported.\n
\n
\n", "
\n
\n\n
\n", "
Incorrect Claim Data
\n", "
\n
\n\n
\n"], ["147", "
\n
\n\n
\n", "
\n
\n\n
\n", "
File: 161.27, IEN: 4
\n", "
\nProvider contracted/negotiated rate expired or not on file.\n
\n
\n", "", "", ""], ["A1", "
\n
\n\n
\n", "
\n
\n\n
\n", "
File: 161.27, IEN: 4
\n", "
\nClaim/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.)\n
\n
\n", "", "", ""], ["6", "
\n
\n\n
\n", "
\n
\n\n
\n", "
File: 161.27, IEN: 4
\n", "
\nThe 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.\n
\n
\n", "
\n
\n\n
\n", "
Billed Service Not Covered
\n", "
\n
\n\n
\n"], ["A2", "
\n
\n\n
\n", "
\n
\n\n
\n", "
File: 161.27, IEN: 4
\n", "
\nContractual adjustment.\n
\n
\n", "", "", ""], ["B12", "
\n
\n\n
\n", "
\n
\n\n
\n", "
File: 161.27, IEN: 4
\n", "
\nServices not documented in patients' medical records.\n
\n
\n", "
\n
\n\n
\n", "
Billed Service Not Covered
\n", "
\n
\n\n
\n"], ["B7", "
\n
\n\n
\n", "
\n
\n\n
\n", "
File: 161.27, IEN: 4
\n", "
\nThis 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\n
\n
\n", "
\n
\n\n
\n", "
Billed Service Not Covered
\n", "
\n
\n\n
\n"], ["B8", "
\n
\n\n
\n", "
\n
\n\n
\n", "
File: 161.27, IEN: 4
\n", "
\nAlternative 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.\n
\n
\n", "", "
Billed Service Not Covered
\n", "
\n
\n\n
\n"], ["B1", "
\n
\n\n
\n", "
\n
\n\n
\n", "
File: 161.27, IEN: 4
\n", "
\nNon-covered visits.\n
\n
\n", "
\n
\n\n
\n", "
Billed Service Not Covered
\n", "
\n
\n\n
\n"], ["9", "
\n
\n\n
\n", "
\n
\n\n
\n", "
File: 161.27, IEN: 4
\n", "
\nThe 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.\n
\n
\n", "
\n
\n\n
\n", "
Billed Service Not Covered
\n", "
\n
\n\n
\n"], ["10", "
\n
\n\n
\n", "
\n
\n\n
\n", "
File: 161.27, IEN: 4
\n", "
\nThe 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.\n
\n
\n", "
\n
\n\n
\n", "
Billed Service Not Covered
\n", "
\n
\n\n
\n"], ["11", "
\n
\n\n
\n", "
\n
\n\n
\n", "
File: 161.27, IEN: 4
\n", "
\nThe diagnosis is inconsistent with the procedure. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.\n
\n
\n", "
\n
\n\n
\n", "
Billed Service Not Covered
\n", "
\n
\n\n
\n"], ["12", "
\n
\n\n
\n", "
\n
\n\n
\n", "
File: 161.27, IEN: 4
\n", "
\nThe diagnosis is inconsistent with the provider type. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.\n
\n
\n", "
\n
\n\n
\n", "
Billed Service Not Covered
\n", "
\n
\n\n
\n"], ["14", "
\n
\n\n
\n", "
\n
\n\n
\n", "
File: 161.27, IEN: 4
\n", "
\nThe date of birth follows the date of service.\n
\n
\n", "", "
Incorrect Claim Data
\n", "
\n
\n\n
\n"], ["7", "
\n
\n\n
\n", "
\n
\n\n
\n", "
File: 161.27, IEN: 4
\n", "
\nThe 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.\n
\n
\n", "
\n
\n\n
\n", "
Billed Service Not Covered
\n", "
\n
\n\n
\n"], ["15", "
\n
\n\n
\n", "
\n
\n\n
\n", "
File: 161.27, IEN: 4
\n", "
\nThe authorization number is missing, invalid, or does not apply to the billed services or provider.\n
\n
\n", "
\n
\n\n
\n", "
Incorrect Claim Data
\n", "
\n
\n\n
\n"], ["71", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nRemittance Advice Remark Code or NCPDP Reject Reason Code.)\n
\n
\n", "", "", ""], ["21", "
\n
\n\n
\n", "
\n
\n\n
\n", "
File: 161.27, IEN: 4
\n", "
\nThis injury/illness is the liability of the no-fault carrier.\n
\n
\n", "
\n
\n\n
\n", "
Billed Service Not Covered
\n", "
\n
\n\n
\n"], ["22", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nThis care may be covered by another payer per coordination of benefits.\n
\n
\n", "
\n
\n\n
\n", "
Billed Service Not Covered
\n", "
\n
\n\n
\n"], ["23", "
\n
\n\n
\n", "
\n
\n\n
\n", "
File: 161.27, IEN: 4
\n", "
\nThe impact of prior payer(s) adjudication including payments and/or adjustments. (Use only with Group Code OA)\n
\n
\n", "", "", ""], ["24", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nCharges are covered under a capitation agreement/managed care plan.\n
\n
\n", "
\n
\n\n
\n", "
Benefit for Service Not Payable
\n", "
\n
\n\n
\n"], ["76", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nPayment denied. Your Stop loss deductible has not been met.\n
\n
\n", "", "", ""], ["27", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nExpenses incurred after coverage terminated.\n
\n
\n", "
\n
\n\n
\n", "
Billed Service Not Covered
\n", "
\n
\n\n
\n"], ["32", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nOur records indicate that this dependent is not an eligible dependent as defined.\n
\n
\n", "
\n
\n\n
\n", "
Billed Service Not Covered
\n", "
\n
\n\n
\n"], ["33", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nInsured has no dependent coverage.\n
\n
\n", "
\n
\n\n
\n", "
Billed Service Not Covered
\n", "
\n
\n\n
\n"], ["8", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nCoverage not in effect at the time the service was provided.\n
\n
\n", "", "", ""], ["80", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nBalance does not exceed co-payment amount.\n
\n
\n", "", "", ""], ["81", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nBalance does not exceed deductible.\n
\n
\n", "", "", ""], ["38", "
\n
\n\n
\n", "
\n
\n\n
\n", "
File: 161.27, IEN: 4
\n", "
\nServices not provided or authorized by designated (network/primary care) providers.\n
\n
\n", "", "", ""], ["39", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nServices denied at the time authorization/pre-certification was requested.\n
\n
\n", "", "
Billed Service Not Covered
\n", "
\n
\n\n
\n"], ["84", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nDiscount agreed to in Preferred Provider contract.\n
\n
\n", "", "", ""], ["85", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nGramm-Rudman reduction.\n
\n
\n", "", "", ""], ["86", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nPrompt-pay discount.\n
\n
\n", "", "", ""], ["87", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nThis (these) service(s) is (are) not covered.\n
\n
\n", "", "", ""], ["88", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nThis (these) procedure(s) is (are) not covered.\n
\n
\n", "", "", ""], ["51", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nThese 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\n
\n
\n", "
\n
\n\n
\n", "
Billed Service Not Covered
\n", "
\n
\n\n
\n"], ["29", "
\n
\n\n
\n", "
\n
\n\n
\n", "
File: 161.27, IEN: 4
\n", "
\nThe time limit for filing has expired.\n
\n
\n", "", "
Billed Service Not Covered
\n", "
\n
\n\n
\n"], ["53", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nServices by an immediate relative or a member of the same household are not covered.\n
\n
\n", "", "
Billed Service Not Covered
\n", "
\n
\n\n
\n"], ["56", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nProcedure/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.\n
\n
\n", "
\n
\n\n
\n", "
Billed Service Not Covered
\n", "
\n
\n\n
\n"], ["60", "
\n
\n\n
\n", "
\n
\n\n
\n", "
File: 161.27, IEN: 4
\n", "
\nCharges for outpatient services are not covered when performed within a period of time prior to or after inpatient services.\n
\n
\n", "
\n
\n\n
\n", "
Billed Service Not Covered
\n", "
\n
\n\n
\n"], ["61", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nPenalty for failure to obtain second surgical opinion. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.\n
\n
\n", "", "
Billed Service Not Covered
\n", "
\n
\n\n
\n"], ["94", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nCorrection to a prior claim.\n
\n
\n", "", "", ""], ["95", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nDenial reversed per Medical Review.\n
\n
\n", "", "", ""], ["96", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nProcedure code was incorrect. This payment reflects the correct code.\n
\n
\n", "", "", ""], ["97", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nLifetime reserve days.\n
\n
\n", "", "", ""], ["98", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nDRG weight.\n
\n
\n", "", "", ""], ["69", "
\n
\n\n
\n", "
\n
\n\n
\n", "", "
\nDay outlier amount.\n
\n
\n", "", "
Incorrect Claim Data
\n", "
\n
\n\n
\n"]]}