\nX-ray not taken within the past 12 months or near enough to the start of treatment.\n\n
\nNo separate payment for an injection administered during an office visit, and no payment for a full office visit if the patient only received an injection.\n\n
\nMissing operative note/report.\n\n
\nThis service is only covered when performed as part of a clinical trial.\n\n
\nPatient must use Workers' Compensation Set-Aside (WCSA) funds to pay for the medical service or item.\n\n
\nPatient must use Liability set-aside (LSA) funds to pay for the medical service or item.\n\n
\nPatient must use No-Fault set-aside (NFSA) funds to pay for the medical service or item.\n\n
\nA liability insurer has reported having ongoing responsibility for medical services (ORM) for this diagnosis.\n\n
\nA conditional payment is not allowed.\n\n
\nA no-fault insurer has reported having ongoing responsibility for medical services (ORM) for this diagnosis.\n\n
\nA workers' compensation insurer has reported having ongoing responsibility for medical services (ORM) for this diagnosis.\n\n
\nMissing patient medical/dental record for this service.\n\n
\nIncomplete/invalid patient medical/dental record for this service.\n\n
\nMissing pathology report.\n\n
\nIncomplete/Invalid mental health assessment.\n\n
\nServices performed at an unlicensed facility are not reimbursable.\n\n
\nRegulatory surcharges are paid directly to the state.\n\n
\nThe patient is eligible for these medical services only when unable to work or perform normal activities due to an illness or injury.\n\n
\nAdjustment without review of medical/dental record because the requested records were not received or were not received timely.\n\n
\nIncomplete/invalid Sleep Study Report.\n\n
\nMissing Sleep Study Report.\n\n
\nIncomplete/invalid Vein Study Report.\n\n
\nMissing Vein Study Report.\n\n
\nThe member's Consumer Spending Account does not contain sufficient funds to cover the member's liability for this claim/service.\n\n
\nMissing radiology report\n\n
\nThis is a site neutral payment.\n\n
\nAlert: This claim was processed based on one or more ICD-9 codes. The transition to ICD-10 is required by October 1, 2015, for health care providers, health plans, and clearinghouses. More information can be found at http://www.cms.gov/Medicare/Coding/ICD10/ProviderResources.html\n\n
\nAlert: This claim was processed based on one or more ICD-9 codes. The \ntransition to ICD-10 is required by October 1, 2015, for health care \nproviders, health plans, and clearinghouses. More information can be \nfound at http://www.cms.gov/Medicare/Coding/ICD10/ProviderResources.html\n\n
\nAdjusted because the services may be related to an employment accident.\n\n
\nAdjusted because the services may be related to an auto accident.\n\n
\nMissing Ambulance Report.\n\n
\nIncomplete/invalid Ambulance Report.\n\n
\nThis is a misdirected claim/service. Submit the claim to the payer/plan where the patient resides.\n\n
\nAdjusted because the related hospital charges have not been received.\n\n
\nMissing Blood Gas Report.\n\n
\nIncomplete/invalid Blood Gas Report.\n\n
\nAlert: This is a conditional payment made pending a decision on this \nservice by the patient's primary payer. This payment may be subject to \nrefund upon your receipt of any additional payment for this service from \nanother payer. You must contact this office immediately upon receipt of \nan additional payment for this service.\n\n
\nAdjusted because the drug is covered under a Medicare Part D plan.\n\n
\nMissing/incomplete/invalid HIPPS Treatment Authorization Code (TAC).\n\n
\nMissing/incomplete/invalid Attachment Control Number.\n\n
\nMissing/incomplete/invalid Referring Provider or Other Source Qualifier on the 1500 Claim Form.\n\n
\nMissing/incomplete/invalid ICD Indicator on the 1500 Claim Form.\n\n
\nMissing/incomplete/invalid ICD Indicator.\n\n
\nMissing/incomplete/invalid point of drop-off address.\n\n
\nAdjusted based on the Federal Indian Fees schedule (MLR).\n\n
\nAdjusted based on the prior authorization decision.\n\n
\nPayment adjusted based on the National Electrical Manufacturers Association (NEMA) Standard XR-29-2013.\n\n
\nThis facility is not authorized to receive payment for the service(s).\n\n
\nMissing/incomplete/invalid UPIN for the ordering/referring/performing provider.inactive as of 8/1/2004\n\n
\nThis provider is not authorized to receive payment for the service(s).\n\n
\nThis facility is not certified for Tomosynthesis (3-D) mammography.\n\n
\nThe demonstration code is not appropriate for this claim; resubmit \nwithout a demonstration code.\n\n
\nMissing/incomplete/invalid Hematocrit (HCT) value.\n\n
\nThis payer does not cover co-insurance assessed by a previous payer.\n\n
\nThis payer does not cover co-payment assessed by a previous payer.\n\n
\nThe Medicaid state requires provider to be enrolled in the member's \nMedicaid state program prior to any claim benefits being processed.\n\n
\nIncomplete/invalid initial evaluation report.\n\n
\nA lateral diagnosis is required.\n\n
\nThe adjustment request received from the provider has been processed. \nYour original claim has been adjusted based on the information received.\n\n
\nClaim lacks the CLIA certification number. inactive as of 8/1/2004\n\n
\nMissing/incomplete/invalid pre-operative photos or visual field results.inactive as of 2/5/2005\n\n
\nThis is the 11th rental month. We cannot pay for this until you indicate that the patient has been given the option of changing the rental to a purchase.\n\n
\nNot covered when the patient is under age 35.\n\n
\nThe patient is not liable for payment for this service as the advance notice of non-coverage you provided the patient did not comply with program requirements\n\n
\nAlert: The patient is not liable for payment of this service as the \nadvance notice of non-coverage you provided the patient did not comply \nwith program requirements.\n\n
\nSeparately billed services/tests have been bundled as they are considered components of the same procedure. Separate payment is not allowed.\n\n
\nClaim must be assigned and must be filed by the practitioner's employer.\n\n
\nThe medical necessity form must be personally signed by the attending physician\n\n
\nPayment for this service previously issued to you or another provider by another carrier/intermediary. Inactive as of1/31/2011\n\n
\nMissing/incomplete/invalid condition code.\n\n
\nMissing/incomplete/invalid occurrence code(s).\n\n
\nMissing/incomplete/invalid occurrence span code(s).\n\n
\nMissing/incomplete/invalid internal or document control number.\n\n
\nMissing/incomplete/invalid Payer Claim Control Number. Other terms exist \nfor this element including, but not limited to, Internal Control Number \n(ICN), Claim Control Number (CCN), Document Control Number (DCN).\n\n
\nPayment for services furnished to hospital inpatients (other than \nprofessional services of physicians) can only be made to the hospital. \nYou must request payment from the hospital rather than the patient for \nthis service.\n\n
\nMissing/incomplete/invalid value code(s) or amount(s\n\n
\nMonthly rental payments can continue until the earlier of the 15th month from the first rental month, or the month when the equipment is no longer needed.\n\n
\nMissing oxygen certification/re-certification.\n\n
\nMissing/incomplete/invalid revenue code(s).\n\n
\nMissing/incomplete/invalid procedure code(s).\n\n
\nMissing/incomplete/invalid "from" date(s) of service.\n\n
\nMissing/incomplete/invalid days or units of service\n\n
\nMissing/incomplete/invalid total charges.\n\n
\nWe do not pay for self-administered anti-emetic drugs that are not administered with a covered oral anti-cancer drug.\n\n
\nMissing/incomplete/invalid payer identifier.\n\n
\nMissing/incomplete/invalid provider identifier. Inactive as of 6/2/2005\n\n
\nMissing/incomplete/invalid claim information. Resubmit claim after corrections. Inactive as of 2/5/2005\n\n
\nMissing/incomplete/invalid "to" date(s) of service.\n\n
\nMissing/incomplete/invalid number of doses per vial.\n\n
\nAlert: You must furnish and service this item for any period of medical need for the remainder of the reasonable useful lifetime of the equipment.\n\n
\nMissing Certificate of Medical Necessity\n\n
\nWe cannot pay for this as the approval period for the FDA clinical trial has expired.\n\n
\nMissing/incomplete/invalid treatment authorization code.\n\n
\nMissing/incomplete/invalid other diagnosis\n\n
\nOne interpreting physician charge can be submitted per claim when a purchased diagnostic test is indicated. Please submit a separate claim for each interpreting physician\n\n
\nOur records indicate that you billed diagnostic tests subject to price \nlimitations and the procedure code submitted includes a professional \ncomponent. Only the technical component is subject to price limitations. \nPlease submit the technical and professional components of this service \nas separate line items.\n\n
\nMissing/incomplete/invalid other procedure code(s).\n\n
\nMissing/incomplete/invalid attending, ordering, rendering, supervising or referring physician identification.\n\n
\nPaid at the regular rate as you did not submit documentation to justify the modified procedure code.\n\n
\nThe patient is liable for the charges for this service as you informed the patient in writing before the service was furnished that we would not pay for it, and the patient agreed to pay.\n\n
\nAlert: The patient is liable for the charges for this service as they \nwere informed in writing before the service was furnished that we would \nnot pay for it and the patient agreed to be responsible for the charges.\n\n
\nNo rental payments after the item is purchased, or after the total of issued rental payments equals the purchase price\n\n
\nAlert: The NDC code submitted for this service was translated to a HCPCS code for processing, but please continue to submit the NDC on future claims for this item.\n\n
\nTotal payment reduced due to overlap of tests billed.\n\n
\nDid not enter full 8-digit date (MM/DD/CCYY). Inactive as of Inactive 10/16/2003\n\n
\nThe HPSA/Physician Scarcity bonus can only be paid on the professional component of this service. Rebill as separate professional and technical components\n\n
\nThis service does not qualify for a HPSA/Physician Scarcity bonus payment.\n\n
\nMultiple automated multichannel tests performed on the same day combined for payment.\n\n
\nMissing/incomplete/invalid diagnosis or condition.\n\n
\nMissing/incomplete/invalid place of service.\n\n
\nMissing/incomplete/invalid/inappropriate place of service.\n\n
\nMissing/incomplete/invalid HCPCS modifier.\n\n
\nWe do not pay for this as the patient has no legal obligation to pay for this.\n\n
\nMissing/incomplete/invalid charge.\n\n
\nYou are required to code to the highest level of specificity.\n\n
\nService is not covered when patient is under age 50.\n\n
\nService is not covered unless the patient is classified as at high risk.\n\n
\nMedical code sets used must be the codes in effect at the time of service\n\n
\nSubjected to review of physician evaluation and management services.\n\n
\nService denied because payment already made for same/similar procedure within set time frame.\n\n
\nClaim/service(s) subjected to CFO-CAP prepayment review\n\n
\nWe cannot pay for laboratory tests unless billed by the laboratory that did the work. Inactive as of 8/1/2004\n\n
\nNot covered more than once under age 40.\n\n
\nWe do not pay for more than one of these on the same day.\n\n
\nAlert: This is the tenth rental month. You must offer the patient the choice of changing the rental to a purchase agreement.\n\n
\nNot covered more than once in a 12 month period.\n\n
\nLab procedures with different CLIA certification numbers must be billed on separate claims.\n\n
\nServices subjected to review under the Home Health Medical Review Initiative. Inactive as of 08/01/2004\n\n
\nInformation supplied supports a break in therapy. A new capped rental period began with delivery of this equipment.\n\n
\nInformation supplied does not support a break in therapy. A new capped rental period will not begin.\n\n
\nServices subjected to Home Health Initiative medical review/cost report audit.\n\n
\nThe technical component of a service furnished to an inpatient may only \nbe billed by that inpatient facility. You must contact the inpatient \nfacility for technical component reimbursement. If not already billed, \nyou should bill us for the professional component only.\n\n
\nNot paid to practitioner when provided to patient in this place of service. Payment included in the reimbursement issued the facility.\n\n
\nBegin to report the Universal Product Number on claims for items of this type. We will soon begin to deny payment for items of this type if billed without the correct UPN. Inactive as of 1/31/2004\n\n
\nNot covered when performed during the same session/date as a previously processed service for the patient.\n\n
\nMissing/incomplete/invalid Universal Product Number/Serial Number.\n\n
\nAlert: If you do not agree with what we approved for these services, you \nmay appeal our decision. To make sure that we are fair to you, we require \nanother individual that did not process your initial claim to conduct the \nappeal. However, in order to be eligible for an appeal, you must write to \nus within 120 days of the date you received this notice, unless you have \na good reason for being late.\n\n
\nAlert: If you do not agree with this determination, you have the right to appeal. You must file a written request for an appeal within 180 days of the date you receive this notice.\n\n
\nIf you do not agree with the approved amounts and $100 or more is in \ndispute (less deductible and coinsurance), you may ask for a hearing \nwithin six months of the date of this notice. To meet the $100, you may \ncombine amounts on other claims that have been denied, including reopened \nappeals if you received a revised decision. You must appeal each claim on \ntime.\n\n
\nSecondary payment cannot be considered without the identity of or payment information from the primary payer. The information was either not reported or was illegible.\n\n
\nIncorrect admission date patient status or type of bill entry on claim. As of 10/16/2003\n\n
\nMissing/incomplete/invalid beginning and/or ending date(s). As of 8/1/2004\n\n
\nAlert: The claim information has also been forwarded to Medicaid for review\n\n
\nAlert: Claim information was not forwarded because the supplemental coverage is not with a Medigap plan, or you do not participate in Medicare.\n\n
\nClaim submitted as unassigned but processed as assigned. You agreed to accept assignment for all claims.\n\n
\nClaim submitted as unassigned but processed as assigned in accordance with our current assignment/participation agreement.\n\n
\nAlert: Claim submitted as unassigned but processed as assigned in \naccordance with our current assignment/participation agreement.\n\n
\nLetter to follow containing further information.\n\n
\nLetter to follow containing further information.\n\n
\nMissing/incomplete/invalid date of current illness or symptoms\n\n
\nA Skilled Nursing Facility (SNF) is responsible for payment of outside providers who furnish these services/supplies to residents.\n\n
\nMissing/incomplete/invalid name or provider identifier for the rendering/referring/ordering/supervising provider.\n\n
\nHemophilia Add On.\n\n
\nMissing/incomplete/invalid date the patient was last seen or the provider identifier of the attending physician.\n\n
\nMissing/incomplete/invalid provider number for this place of service.\n\n
\nPIP (Periodic Interim Payment) claim.\n\n
\nPaper claim contains more than three separate data items in field 19.\n\n
\nPaper claim contains more than one data item in field 23.\n\n
\nMissing/incomplete/invalid information on whether the diagnostic test(s) were performed by an outside entity or if no purchased tests are included on the claim.\n\n
\nMissing patient medical record for this service.\n\n
\nMissing/incomplete/invalid purchase price of the test(s) and/or the performing laboratory's name and address.\n\n
\nMissing/incomplete/invalid group practice information.\n\n
\nIncomplete/invalid taxpayer identification number (TIN) submitted by you \nper the Internal Revenue Service. Your claims cannot be processed without \nyour correct TIN, and you may not bill the patient pending correction of \nyour TIN. There are no appeal rights for unprocessable claims, but you \nmay resubmit this claim after you have notified this office of your \ncorrect TIN.\n\n
\nMissing/incomplete/invalid information on where the services were furnished.\n\n
\nMissing/incomplete/invalid physical location (name and address, or PIN) where the service(s) were rendered in a Health Professional Shortage Area (HPSA).\n\n
\nDid not complete the statement 'Homebound' on the claim to validate whether laboratory services were performed at home or in an institution.\n\n
\nThis claim has been assessed a $1.00 user fee.\n\n
\nCoinsurance and/or deductible amounts apply to a claim for services or supplies furnished to a Medicare-eligible veteran through a facility of the Department of Veterans Affairs. No Medicare payment issued.\n\n
\nAlert: No Medicare payment issued for this claim for services or supplies furnished to a Medicare-eligible veteran through a facility of the Department of Veterans Affairs. Coinsurance and/or deductible are applicable.\n\n
\nProvider level adjustment for late claim filing applies to this claim.\n\n
\nYou have not established that you have the right under the law to bill for services furnished by the person(s) that furnished this (these) service(s).\n\n
\nNot paid separately when the patient is an inpatient.\n\n
\nMissing physician certified plan of care.\n\n
\nMissing/incomplete/invalid CLIA certification number.\n\n
\nMissing/incomplete/invalid x-ray date.\n\n
\nMissing/incomplete/invalid initial treatment date.\n\n
\nYour center was not selected to participate in this study, therefore, we cannot pay for these services.\n\n
\nProcessed for IME only.\n\n
\nPancreas transplant not covered unless kidney transplant performed.\n\n
\nReserved for future use.\n\n
\nMissing/incomplete/invalid FDA approval number.\n\n
\nThis provider was not certified for this procedure on this date of service.\n\n
\nAlert: You may be subject to penalties if you bill the patient for amounts not reported with the PR (patient responsibility) group code.\n\n
\nPre-/post-operative care payment is included in the allowance for the surgery/procedure.\n\n
\nYour claim contains incomplete and/or invalid information, and no appeal rights are afforded because the claim is unprocessable. Please submit a new claim with the complete/correct information.\n\n
\nPhysician already paid for services in conjunction with this demonstration claim. You must have the physician withdraw that claim and refund the payment before we can process your claim.\n\n
\nAdjustment to the pre-demonstration rate.\n\n
\nClaim overlaps inpatient stay. Rebill only those services rendered outside the inpatient stay.\n\n
\nMissing/incomplete/invalid provider number of the facility where the patient resides.\n\n
\nAlert: The patient is a member of an employer-sponsored prepaid health \nplan. Services from outside that health plan are not covered. However, as \nyou were not previously notified of this, we are paying this time. In the \nfuture, we will not pay you for non-plan services\n\n
\nAlert: Your claim has been separated to expedite handling. You will receive a separate notice for the other services reported.\n\n
\nThe patient is covered by the Black Lung Program. Send this claim to the Department of Labor, Federal Black Lung Program, P.O. Box 828, Lanham-Seabrook MD 20703.\n\n
\nAlert: The claim information is also being forwarded to the patient's supplemental insurer. Send any questions regarding supplemental benefits to them.\n\n
\nAlert: Information was not sent to the Medigap insurer due to incorrect/invalid information you submitted concerning that insurer. Please verify your information and submit your secondary claim directly to that insurer.\n\n
\nThe patient's payment was in excess of the amount owed. You must refund \nthe overpayment to the patient.\n\n
\nAlert: The patient's payment was in excess of the amount owed. You must refund the overpayment to the patient.\n\n
\nSkilled Nursing Facility (SNF) stay not covered when care is primarily related to the use of an urethral catheter for convenience or the control of incontinence.\n\n
\nSSA records indicate mismatch with name and sex.\n\n
\nPayment of less than $1.00 suppressed\n\n
\nDemand bill approved as result of medical review.\n\n
\nChristian Science Sanitarium/ Skilled Nursing Facility (SNF) bill in the same benefit period\n\n
\nA patient may not elect to change a hospice provider more than once in a benefit period\n\n
\nMissing/incomplete/invalid entitlement number or name shown on the claim.\n\n
\nAlert: Receipt of this notice by a physician or supplier who did not \naccept assignment is for information only and does not make the physician \nor supplier a party to the determination. No additional rights to appeal \nthis decision, above those rights already provided for by \nregulation/instruction, are conferred by receipt of this notice.\n\n
\nMissing/incomplete/invalid provider name, city, state, or zip code.6/2/2005\n\n
\nMissing/incomplete/invalid type of bill.\n\n
\nPayment is being issued on a conditional basis. If no-fault insurance, \nliability insurance, Workers' Compensation, Department of Veterans \nAffairs, or a group health plan for employees and dependents also covers \nthis claim, a refund may be due us. Please contact us if the patient is \ncovered by any of these sources.\n\n
\nMissing/incomplete/invalid beginning and ending dates of the period billed\n\n
\nMissing/incomplete/invalid number of covered days during the billing period\n\n
\nMissing/incomplete/invalid noncovered days during the billing period.\n\n
\nMissing/incomplete/invalid number of coinsurance days during the billing period.\n\n
\nMissing/incomplete/invalid number of lifetime reserve days.\n\n
\nMissing/incomplete/invalid patient name\n\n
\nMissing/incomplete/invalid patient's address\n\n
\nMissing/incomplete/invalid birth date6/2/2005\n\n
\nMissing/incomplete/invalid gender\n\n
\nMissing/incomplete/invalid admission date.\n\n
\nWe are the primary payer and have paid at the primary rate. You must contact the patient's other insurer to refund any excess it may have paid due to its erroneous primary payment.\n\n
\nMissing/incomplete/invalid admission type.\n\n
\nMissing/incomplete/invalid admission source.\n\n
\nMissing/incomplete/invalid patient status\n\n
\nAlert: As previously advised, a portion or all of your payment is being held in a special account.\n\n
\nThe new information was considered but additional payment will not be issued\n\n
\nAlert: The new information was considered but additional payment will not \nbe issued.\n\n
\nOur records show you have opted out of Medicare, agreeing with the patient not to bill Medicare for services/tests/supplies furnished. As result, we cannot pay this claim. The patient is responsible for payment.\n\n
\nMissing/incomplete/invalid name or address of responsible party or primary payer.\n\n
\nMissing/incomplete/invalid six-digit provider identifier for home health agency or hospice for physician(s) performing care plan oversight services.8/1/2004\n\n
\nMissing/incomplete/invalid Investigational Device Exemption number for FDA-approved clinical trial services.\n\n
\nMissing/incomplete/invalid Investigational Device Exemption number or Clinical Trial number.\n\n
\nMissing/incomplete/invalid CLIA certification number for laboratory services billed by physician office laboratory.2/5/2005\n\n
\nOur records indicate that you were previously informed of this rule.\n\n
\nAlert: Our records indicate that you were previously informed of this rule.\n\n
\nMissing/incomplete/invalid date6/2/2005\n\n
\nMissing/incomplete/invalid Competitive Bidding Demonstration Project identification\n\n
\nPhysician certification or election consent for hospice care not received timely\n\n
\nNot covered as patient received medical health care services, automatically revoking his/her election to receive religious non-medical health care services\n\n
\nOur records show you have opted out of Medicare, agreeing with the \npatient not to bill Medicare for services/tests/supplies furnished. As \nresult, we cannot pay this claim. The patient is responsible for payment, \nbut under Federal law, you cannot charge the patient more than the \nlimiting charge amount.\n\n
\nPatient submitted written request to revoke his/her election for religious non-medical health care services.\n\n
\nMissing/incomplete/invalid release of information indicator.\n\n
\nAlert: The patient overpaid you for these services. You must issue the patient a refund within 30 days for the difference between his/her payment and the total amount shown as patient responsibility on this notice.\n\n
\nMissing/incomplete/invalid patient relationship to insured\n\n
\nMissing/incomplete/invalid social security number or health insurance claim number.\n\n
\nNo appeal rights. Adjudicative decision based on law.\n\n
\nAlert: No appeal rights. Adjudicative decision based on law.\n\n
\nAlert: This is a telephone review decision.\n\n
\nMissing/incomplete/invalid principal diagnosis.\n\n
\nOur records indicate that we should be the third payer for this claim. We cannot process this claim until we have received payment information from the primary and secondary payers.\n\n
\nMissing/incomplete/invalid admitting diagnosis.\n\n
\nMissing/incomplete/invalid principal procedure code\n\n
\nCorrection to a prior claim\n\n
\nAlert: Correction to a prior claim.\n\n
\nAlert: We did not crossover this claim because the secondary insurance information on the claim was incomplete. Please supply complete information or use the PLANID of the insurer to assure correct and timely routing of the claim.\n\n
\nMissing/incomplete/invalid remarks.\n\n
\nMissing/incomplete/invalid provider representative signature.\n\n
\nMissing/incomplete/invalid provider representative signature date.\n\n
\nThis determination is the result of the appeal you filed.\n\n
\nAlert: This determination is the result of the appeal you filed.\n\n
\nAlert: The patient overpaid you for these assigned services. You must \nissue the patient a refund within 30 days for the difference between \nhis/her payment to you and the total of the amount shown as patient \nresponsibility and as paid to the patient on this notice.\n\n
\nInformational remittance associated with a Medicare demonstration. No payment issued under fee-for-service Medicare as patient has elected managed care\n\n
\nMissing/incomplete/invalid patient or authorized representative signature\n\n
\nMissing/incomplete/invalid provider identifier for home health agency or hospice when physician is performing care plan oversight services\n\n
\nAlert: The patient overpaid you. You must issue the patient a refund within 30 days for the difference between the patients payment less the total of our and other payer payments and the amount shown as patient responsibility on this notice\n\n
\nThe patient overpaid you. You must issue the patient a refund within 30 days for the difference between our allowed amount total and the amount paid by the patient.1/31/2004\n\n
\nBilled in excess of interim rate.\n\n
\nInformational notice. No payment issued for this claim with this notice. Payment issued to the hospital by its intermediary for all services for this encounter under a demonstration project\n\n
\nMissing/incomplete/invalid provider/supplier signature\n\n
\nMissing/incomplete/invalid provider/supplier billing number/identifier or billing name, address, city, state, zip code, or phone number. 06/02/2005\n\n
\nClaim processed in accordance with ambulatory surgical guidelines.\n\n
\nDid not indicate whether we are the primary or secondary payer\n\n
\nPatient identified as participating in the National Emphysema Treatment \nTrial but our records indicate that this patient is either not a \nparticipant, or has not yet been approved for this phase of the study. \nContact Johns Hopkins University, the study coordinator, to resolve if \nthere was a discrepancy.\n\n
\nOur records indicate that a primary payer exists (other than ourselves); however, you did not complete or enter accurately the insurance plan/group/program name or identification number. Enter the PlanID when effective.8/1/2004\n\n
\nMissing/incomplete/invalid group or policy number of the insured for the primary coverage.8/1/2004\n\n
\nMissing/incomplete/invalid insured's name for the primary payer.8/1/2004\n\n
\nMissing/incomplete/invalid insured's address and/or telephone number for the primary payer\n\n
\nMissing/incomplete/invalid patient's relationship to the insured for the primary payer.\n\n
\nMissing/incomplete/invalid employment status code for the primary insured.\n\n
\nMissing plan information for other insurance.\n\n
\nNon-PIP (Periodic Interim Payment) claim.\n\n
\nYou may appeal this decision in writing within the required time \nlimits following receipt of this notice by following the instructions \nincluded in your contract or plan benefit documents.\n\n
\nAlert: You may appeal this decision in writing within the required time limits following receipt of this notice by following the instructions included in your contract or plan benefit documents.\n\n
\nDid not enter the statement "Attending physician not hospice employee" on \nthe claim form to certify that the rendering physician is not an employee \nof the hospice.\n\n
\nA not otherwise classified or unlisted procedure code(s) was billed but a narrative description of the procedure was not entered on the claim. Refer to item 19 on the HCFA-1500.\n\n
\nClaim rejected. Coded as a Medicare Managed Care Demonstration but patient is not enrolled in a Medicare managed care plan.\n\n
\nMissing/incomplete/invalid Medicare Managed Care Demonstration contract number or clinical trial registry number.\n\n
\nClaim Rejected. Does not contain the correct Medicare Managed Care Demonstration contract number for this beneficiary.\n\n
\nMissing/incomplete/invalid Medigap information.\n\n
\nPayment based on the findings of a review organization/professional consult/manual adjudication/medical or dental advisor.\n\n
\nPayment based on the findings of a review organization/professional consult/manual adjudication/medical advisor/dental advisor/peer review.\n\n
\nAdjustment based on the findings of a review organization/professional \nconsult/manual adjudication/medical advisor/dental advisor/peer review.\n\n
\nPPS (Prospect Payment System) code corrected during adjudication.\n\n
\nAdditional information is needed in order to process this claim. Please \nresubmit the claim with the identification number of the provider where \nthis service took place. The Medicare number of the site of service \nprovider should be preceded with the letters 'HSP' and entered into item \n#32 on the claim form. You may bill only one site of service provider \nnumber per claim.\n\n
\nSocial Security records indicate that this patient was a prisoner when the service was rendered. This payer does not cover items and services furnished to an individual while they are in State or local custody under a penal authority, unless under State or local law, the individual is personally liable for the cost of his or her health care while incarcerated and the State or local government pursues such debt in the same way and with the same vigor as any other debt.\n\n
\nRecords indicate this patient was a prisoner or in custody of a Federal, State, or local authority when the service was rendered. This payer does not cover items and services furnished to an individual while he or she is in custody under a penal\nstatute or rule, unless under State or local law, the individual is personally liable for the cost of his or her health care while in custody and the State or local government pursues the collection of such debt in the same way and with the same\nvigor as the collection of its other debts. The provider can collect from the Federal/State/ Local Authority as appropriate.\n\n
\nEquipment is the same or similar to equipment already being used.\n\n
\nDenial reversed because of medical review.\n\n
\nThis claim/service is not payable under our claims jurisdiction area. You can identify the correct Medicare contractor to process this claim/service through the CMS website at www.cms.gov.\n\n
\nThis is a misdirected claim/service for an RRB beneficiary. Submit paper claims to the RRB carrier: Palmetto GBA, P.O. Box 10066, Augusta, GA 30999. Call 866-749-4301 for RRB EDI information for electronic claims processing.\n\n
\nPayment for services furnished to Skilled Nursing Facility (SNF) inpatients (except for excluded services) can only be made to the SNF. You must request payment from the SNF rather than the patient for this service.\n\n
\nServices furnished to Skilled Nursing Facility (SNF) inpatients must be billed on the inpatient claim. They cannot be billed separately as outpatient services.\n\n
\nMissing/incomplete/invalid upgrade information.\n\n
\nThis claim/service was chosen for complex review and was denied after reviewing the medical records.\n\n
\nAlert: This claim/service was chosen for complex review.\n\n
\nThis facility is not certified for film mammography.\n\n
\nNo appeal right except duplicate claim/service issue. This service was included in a claim that has been previously billed and adjudicated.\n\n
\nThis claim is excluded from your electronic remittance advice.\n\n
\nOnly one initial visit is covered per physician, group practice or provider.\n\n
\nPayment based on a contractual amount or agreement, fee schedule, or maximum allowable amount. Stopped as of 10/01/2007\n\n
\nDuring the transition to the Ambulance Fee Schedule, payment is based on \nthe lesser of a blended amount calculated using a percentage of the \nreasonable charge/cost and fee schedule amounts, or the submitted charge \nfor the service. You will be notified yearly what the percentages for the \nblended payment calculation will be.\n\n
\nThis decision was based on a Local Coverage Determination (LCD). An LCD \nprovides a guide to assist in determining whether a particular item or \nservice is covered. A copy of this policy is available at \nwww.cms.gov/mcd, or if you do not have web access, you may contact the \ncontractor to request a copy of the LCD.\n\n
\nThis payment is being made conditionally because the service was provided \nin the home, and it is possible that the patient is under a home health \nepisode of care. When a patient is treated under a home health episode of \ncare, consolidated billing requires that certain therapy services and \nsupplies, such as this, be included in the home health agency's (HHA's) \npayment. This payment will need to be recouped from you if we establish \nthat the patient is concurrently receiving treatment under an HHA episode\nof care. \n\n
\nThis service is paid only once in a patient's lifetime.\n\n
\nThis service is not paid if billed more than once every 28 days.\n\n
\nThis service is not paid if billed once every 28 days, and the patient has spent 5 or more consecutive days in any inpatient or Skilled /nursing Facility (SNF) within those 28 days.\n\n
\nPolicy provides coverage supplemental to Medicare. As the member does not appear to be enrolled in the applicable part of Medicare, the member is responsible for payment of the portion of the charge that would have been covered by Medicare.\n\n
\nPayment is subject to home health prospective payment system partial episode payment adjustment. Patient was transferred/discharged/readmitted during payment episode.\n\n
\nMedicare Part B does not pay for items or services provided by this type of practitioner for beneficiaries in a Medicare Part A covered Skilled Nursing Facility (SNF) stay.\n\n
\nAdd-on code cannot be billed by itself.\n\n
\nPayment based on the Medicare allowed amount.1/31/2004\n\n
\nThis is a split service and represents a portion of the units from the originally submitted service.\n\n
\nAlert: This is a split service and represents a portion of the units from \nthe originally submitted service.\n\n
\nPayment has been denied for the/made only for a less extensive \nservice/item because the information furnished does not substantiate the \nneed for the (more extensive) service/item. The patient is liable for the \ncharges for this service/item as you informed the patient in writing \nbefore the service/item was furnished that we would not pay for it, and \nthe patient agreed to pay.\n\n
\nPayment has been (denied for the/made only for a less extensive) \nexclusion from the Medicare program. If you have any questions about this \nnotice, please contact this office.\nservice/item because the information furnished does not substantiate the \nneed for the (more extensive) service/item. If you have collected any \namount from the patient, you must refund that amount to the patient \nwithin 30 days of receiving this notice. The requirements for a refund \nare in 1834(a)(18) of the Social Security Act (and in 1834(j)(4) and \n1879(h) by cross-reference to 1834(a)(18)). Section 1834(a)(18)(B) \nspecifies that suppliers which knowingly and willfully fail to make \nappropriate refunds may be subject to civil money penalties and/or \n\n
\nSocial Security Records indicate that this individual has been deported. This payer does not cover items and services furnished to individuals who have been deported.\n\n
\nThis is a misdirected claim/service for a United Mine Workers of America (UMWA) beneficiary. Please submit claims to them.\n\n
\nThis amount represents the prior to coverage portion of the allowance.\n\n
\nNot eligible due to the patient's age.\n\n
\nPayment based on professional/technical component modifier(s).\n\n
\nConsult plan benefit documents/guidelines for information about restrictions for this service.\n\n
\nTotal payments under multiple contracts cannot exceed the allowance for this service.\n\n
\nProcedure code incidental to primary procedure.\n\n
\nAlert: Payments will cease for services rendered by this US Government debarred or excluded provider after the 30 day grace period as previously notified.\n\n
\nAlert: Services for predetermination and services requesting payment are being processed separately.\n\n
\nAlert: This represents your scheduled payment for this service. If treatment has been discontinued, please contact Customer Service.\n\n
\nRecord fees are the patient's responsibility and limited to the specified co-payment.\n\n
\nAlert: To obtain information on the process to file an appeal in Arizona, call the Department's Consumer Assistance Office at (602) 912-8444 or (800) 325-2548.\n\n
\nAlert: The provider acting on the Member's behalf, may file an appeal \nwith the Payer. The provider, acting on the Member's behalf, may file a \ncomplaint with the State Insurance Regulatory Authority without first \nfiling an appeal, if the coverage decision involves an urgent condition \nfor which care has not been rendered. The address may be obtained from \nthe State Insurance Regulatory Authority.\n\n
\nAlert: In the event you disagree with the Dental Advisor's opinion and \nhave additional information relative to the case, you may submit \nradiographs to the Dental Advisor Unit at the subscriber's dental \ninsurance carrier for a second Independent Dental Advisor Review.\n\n
\nAlert: Under the Code of Federal Regulations, Chapter 32, Section 199.13 \na non-participating provider is not an appropriate appealing party. \nTherefore, if you disagree with the Dental Advisor's opinion, you may \nappeal the determination if appointed in writing, by the beneficiary, to \nact as his/her representative. Should you be appointed as a \nrepresentative, submit a copy of this letter, a signed statement \nexplaining the matter in which you disagree, and any radiographs and \nrelevant information to the subscriber's Dental insurance carrier within \n90 days from the date of this letter.\n\n
\nAlert: You have not been designated as an authorized OCONUS provider \ntherefore are not considered an appropriate appealing party. If the \nbeneficiary has appointed you, in writing, to act as his/her \nrepresentative and you disagree with the Dental Advisor's opinion, you \nmay appeal by submitting a copy of this letter, a signed statement \nexplaining the matter in which you disagree, and any relevant information \nto the subscriber's Dental insurance carrier within 90 days from the date \nof this letter.\n\n
\nThe patient was not residing in a long-term care facility during all or part of the service dates billed.\n\n
\nMissing/incomplete/invalid documentation/orders/notes/summary/report/\ninvoice.\n\n
\nMissing/incomplete/invalid documentation/orders/notes/summary/report/invoice.\n\n
\nMissing documentation/orders/notes/summary/report/chart.\n\n
\nThe original claim was denied. Resubmit a new claim, not a replacement claim.\n\n
\nThe patient was not in a hospice program during all or part of the service dates billed.\n\n
\nThe rate changed during the dates of service billed.\n\n
\nMissing/incomplete/invalid provider identifier for this place of service.\n\n
\nMissing screening document.\n\n
\nLong term care case mix or per diem rate cannot be determined because the patient ID number is missing, incomplete, or invalid on the assignment request.\n\n
\nMissing/incomplete/invalid date of last menstrual period.\n\n
\nRebill all applicable services on a single claim.\n\n
\nServices for a newborn must be billed separately\n\n
\nMissing/incomplete/invalid model number.\n\n
\nRecipient ineligible for this service.\n\n
\nPatient ineligible for this service.\n\n
\nTelephone contact services will not be paid until the face-to-face contact requirement has been met.\n\n
\nMissing/incomplete/invalid replacement claim information.\n\n
\nMissing/incomplete/invalid room and board rate.\n\n
\nAlert: This payment was delayed for correction of provider's mailing address.\n\n
\nAlert: Our records do not indicate that other insurance is on file. Please submit other insurance information for our records.\n\n
\nAlert: The patient is responsible for the difference between the approved treatment and the elective treatment.\n\n
\nTransportation in a vehicle other than an ambulance is not covered.\n\n
\nPayment denied/reduced because mileage is not covered when the patient is not in the ambulance.\n\n
\nFamily/member Out-of-Pocket maximum has been met. Payment based on a higher percentage.\n\n
\nThe patient must choose an option before a payment can be made for this procedure/ equipment/ supply/ service.\n\n
\nBed hold or leave days exceeded.\n\n
\nThis drug/service/supply is covered only when the associated service is covered.\n\n
\nAlert: Although your claim was paid, you have billed for a test/specialty not included in your Laboratory Certification. Your failure to correct the laboratory certification information will result in a denial of payment in the near future.\n\n
\nMedical record does not support code billed per the code definition.\n\n
\nTransportation to/from this destination is not covered.\n\n
\nTransportation in a vehicle other than an ambulance is not covered.\n\n
\nPayment denied/reduced because mileage is not covered when the patient is not in the ambulance.\n\n
\nCharges exceed the post-transplant coverage limit.\n\n
\nThe patient must choose an option before a payment can be made for this procedure/equipment/supply/ service.\n\n
\nThis drug/service/supply is covered only when the associated service is covered\n\n
\nPer admission deductible.8/1/2004\n\n
\nClaim information is inconsistent with pre-certified/authorized services.\n\n
\nA new/revised/renewed certificate of medical necessity is needed.\n\n
\nPayment for repair or replacement is not covered or has exceeded the purchase price.\n\n
\nThe patient is not liable for the denied/adjusted charge(s) for receiving any updated service/item.\n\n
\nNo qualifying hospital stay dates were provided for this episode of care.\n\n
\nThis is not a covered service/procedure/ equipment/bed, however patient liability is limited to amounts shown in the adjustments under group 'PR'.\n\n
\nMissing review organization approval.\n\n
\nServices provided aboard a ship are covered only when the ship is of United States registry and is in United States waters. In addition, a doctor licensed to practice in the United States must provide the service.\n\n
\nAlert: We did not send this claim to patient's other insurer. They have indicated no additional payment can be made.\n\n
\nMissing pre-operative photos or visual field results.\n\n
\nMissing pre-operative images/visual field results.\n\n
\nAdditional information has been requested from the member. The charges will be reconsidered upon receipt of that information.\n\n
\nThis claim has been denied without reviewing the medical record because the requested records were not received or were not received timely\n\n
\nThis claim has been denied without reviewing the medical/dental record because the requested records were not received or were not received timely.\n\n
\nThis item or service does not meet the criteria for the category under which it was billed.\n\n
\nAdditional information is required from another provider involved in this service.\n\n
\nThis claim/service must be billed according to the schedule for this plan.\n\n
\nAlert: This is a predetermination advisory message, when this service is submitted for payment additional documentation as specified in plan documents will be required to process benefits.\n\n
\nAlert: Do not resubmit this claim/service.\n\n
\nNon-Availability Statement (NAS) required for this service. Contact the nearest Military Treatment Facility (MTF) for assistance.\n\n
\nAlert: You may request a review in writing within the required time limits following receipt of this notice by following the instructions included in your contract or plan benefit documents.\n\n
\nAlert: This service has been paid as a one-time exception to the plan's benefit restrictions.\n\n
\nMissing contract indicator.\n\n
\nThe provider must update insurance information directly with payer.\n\n
\nThis payment replaces an earlier payment for this claim that was either lost, damaged, or returned.\n\n
\nAlert: This payment replaces an earlier payment for this claim that was \neither lost, damaged or returned.\n\n
\nPatient is a Medicaid/Qualified Medicare Beneficiary.\n\n
\nSpecific federal/state/local program may cover this service through another payer.\n\n
\nAlert: Specific federal/state/local program may cover this service \nthrough another payer.\n\n
\nTechnical component not paid if provider does not own the equipment used.\n\n
\nAlert: Patient eligible to apply for other coverage which may be primary.\n\n
\nThe subscriber must update insurance information directly with payer.\n\n
\nRendering provider must be affiliated with the pay-to provider.\n\n
\nAdditional payment/recoupment approved based on payer-initiated review/audit.\n\n
\nThis allowance has been made in accordance with the most appropriate course of treatment provision of the plan.\n\n
\nService not payable with other service rendered on the same date.\n\n
\nA mental health facility is responsible for payment of outside providers who furnish these services/supplies to residents.\n\n
\nThis is the last monthly installment payment for this durable medical \nequipment.\n\n
\nAlert: This is the last monthly installment payment for this durable medical equipment.\n\n
\nAdditional information/explanation will be sent separately\n\n
\nAlert: Additional information/explanation will be sent separately.\n\n
\nMissing/incomplete/invalid anesthesia time/units\n\n
\nServices under review for possible pre-existing condition. Send medical records for prior 12 months\n\n
\nInformation provided was illegible\n\n
\nThe supporting documentation does not match the information sent on the claim.\n\n
\nMissing/incomplete/invalid weight.\n\n
\nMissing/incomplete/invalid DRG code\n\n
\nMissing/incomplete/invalid taxpayer identification number (TIN).\n\n
\nAlert: Your line item has been separated into multiple lines to expedite handling.\n\n
\nAlert: You may appeal this decision\n\n
\nTransportation to and from this destination is not covered.\n\n
\nTransportation to/from this destination is not covered.\n\n
\nAlert: You may not appeal this decision\n\n
\nCharges processed under a Point of Service benefit\n\n
\nMissing/incomplete/invalid facility/discrete unit DRG/DRG exempt status information\n\n
\nMissing/incomplete/invalid history of the related initial surgical procedure(s)\n\n
\nAlert: A payer providing supplemental or secondary coverage shall not require a claims determination for this service from a primary payer as a condition of making its own claims determination.\n\n
\nWe do not offer coverage for this type of service or the patient is not enrolled in this portion of our benefit package\n\n
\nWe pay only one site of service per provider per claim\n\n
\nYou must furnish and service this item for as long as the patient continues to need it. We can pay for maintenance and/or servicing for the time period specified in the contract or coverage manual.\n\n
\nPayment based on previous payer's allowed amount.\n\n
\nThis procedure code was added/changed because it more accurately describes the services rendered.\n\n
\nAlert: This procedure code was added/changed because it more accurately \ndescribes the services rendered.\n\n
\nRebill technical and professional components separately.\n\n
\nAlert: See the payer's web site or contact the payer's Customer Service department to obtain forms and instructions for filing a provider dispute.\n\n
\nMissing Admitting History and Physical report.\n\n
\nIncomplete/invalid Admitting History and Physical report.\n\n
\nMissing documentation of benefit to the patient during initial treatment period.\n\n
\nIncomplete/invalid documentation of benefit to the patient during initial treatment period.\n\n
\nIncomplete/invalid documentation/orders/notes/summary/report/chart.\n\n
\nIncomplete/invalid American Diabetes Association Certificate of Recognition.\n\n
\nIncomplete/invalid Certificate of Medical Necessity.\n\n
\nIncomplete/invalid consent form.\n\n
\nIncomplete/invalid contract indicator.\n\n
\nThe approved level of care does not match the procedure code submitted.\n\n
\nAlert: Patient liability may be affected due to coordination of benefits with other carriers and/or maximum benefit provisions.\n\n
\nIncomplete/invalid indication of whether the patient owns the equipment that requires the part or supply.\n\n
\nIncomplete/invalid invoice or statement certifying the actual cost of the lens, less discounts, and/or the type of intraocular lens used.\n\n
\nIncomplete/invalid itemized bill/statement.\n\n
\nIncomplete/invalid operative note/report.\n\n
\nIncomplete/invalid oxygen certification/re-certification.\n\n
\nIncomplete/invalid pacemaker registration form.\n\n
\nIncomplete/invalid pathology report.\n\n
\nIncomplete/invalid patient medical record for this service.\n\n
\nIncomplete/invalid physician certified plan of care\n\n
\nThe technical component must be billed separately.\n\n
\nIncomplete/invalid physician financial relationship form.\n\n
\nMissing/incomplete/invalid Electronic Funds Transfer (EFT) banking information.\n\n
\nIncomplete/invalid radiology report.\n\n
\nIncomplete/invalid review organization approval.\n\n
\nIncomplete/invalid radiology film(s)/image(s).\n\n
\nIncomplete/invalid/not approved screening document.\n\n
\nIncomplete/invalid pre-operative photos/visual field results.\n\n
\nIncomplete/Invalid pre-operative images/visual field results.\n\n
\nIncomplete/invalid plan information for other insurance\n\n
\nState regulated patient payment limitations apply to this service.\n\n
\nMissing/incomplete/invalid assistant surgeon taxonomy.\n\n
\nThe professional component must be billed separately.\n\n
\nMissing/incomplete/invalid assistant surgeon name.\n\n
\nMissing/incomplete/invalid assistant surgeon primary identifier.\n\n
\nThis company has been contracted by your benefit plan to provide administrative claims payment services only. This company does not assume financial risk or obligation with respect to claims processed on behalf of your benefit plan.\n\n
\nMissing/incomplete/invalid assistant surgeon secondary identifier.\n\n
\nMissing/incomplete/invalid attending provider taxonomy.\n\n
\nMissing/incomplete/invalid attending provider name.\n\n
\nMissing/incomplete/invalid attending provider primary identifier.\n\n
\nMissing/incomplete/invalid attending provider secondary identifier.\n\n
\nMissing/incomplete/invalid billing provider taxonomy.\n\n
\nMissing/incomplete/invalid billing provider/supplier name.\n\n
\nEquipment purchases are limited to the first or the tenth month of medical necessity.\n\n
\nMissing/incomplete/invalid billing provider/supplier primary identifier.\n\n
\nMissing/incomplete/invalid billing provider/supplier address.\n\n
\nMissing/incomplete/invalid billing provider/supplier secondary identifier.\n\n
\nMissing itemized bill/statement.\n\n
\nMissing/incomplete/invalid billing provider/supplier contact information.\n\n
\nMissing/incomplete/invalid operating provider name.\n\n
\nMissing/incomplete/invalid operating provider primary identifier.\n\n
\nMissing/incomplete/invalid operating provider secondary identifier.\n\n
\nMissing/incomplete/invalid ordering provider name.\n\n
\nMissing/incomplete/invalid ordering provider primary identifier.\n\n
\nWe do not pay for an oral anti-emetic drug that is not administered for use immediately before, at, or within 48 hours of administration of a covered chemotherapy drug.\n\n
\nMissing/incomplete/invalid ordering provider address.\n\n
\nMissing/incomplete/invalid ordering provider secondary identifier.\n\n
\nMissing/incomplete/invalid ordering provider contact information.\n\n
\nMissing/incomplete/invalid other provider name.\n\n
\nMissing/incomplete/invalid treatment number.\n\n
\nMissing/incomplete/invalid other provider primary identifier.\n\n
\nMissing/incomplete/invalid other provider secondary identifier.\n\n
\nMissing/incomplete/invalid other payer attending provider identifier.\n\n
\nMissing/incomplete/invalid other payer operating provider identifier.\n\n
\nMissing/incomplete/invalid other payer other provider identifier.\n\n
\nBegin to report a G1-G5 modifier with this HCPCS. We will soon begin to deny payment for this service if billed without a G1-G5 modifier. Inactive as of 1/31/2001\n\n
\nMissing/incomplete/invalid other payer purchased service provider identifier.\n\n
\nMissing/incomplete/invalid other payer referring provider identifier.\n\n
\nMissing/incomplete/invalid other payer rendering provider identifier.\n\n
\nMissing/incomplete/invalid other payer service facility provider identifier.\n\n
\nMissing/incomplete/invalid pay-to provider name.\n\n
\nConsent form requirements not fulfilled.\n\n
\nMissing/incomplete/invalid pay-to provider primary identifier.\n\n
\nMissing/incomplete/invalid pay-to provider address.\n\n
\nMissing/incomplete/invalid pay-to provider secondary identifier.\n\n
\nMissing/incomplete/invalid purchased service provider identifier.\n\n
\nService not performed on equipment approved by the FDA for this purpose\n\n
\nMissing/incomplete/invalid referring provider taxonomy.\n\n
\nMissing/incomplete/invalid referring provider name.\n\n
\nMissing/incomplete/invalid referring provider primary identifier.\n\n
\nMissing/incomplete/invalid referring provider secondary identifier.\n\n
\nMissing/incomplete/invalid rendering provider taxonomy.\n\n
\nMissing/incomplete/invalid rendering provider name.\n\n
\nMissing/incomplete/invalid rendering provider primary identifier.\n\n
\nMissing/incomplete/invalid rendering provider secondary identifier.\n\n
\nMissing/incomplete/invalid service facility name.\n\n
\nMissing/incomplete/invalid service facility primary identifier.\n\n
\nPer legislation governing this program, payment constitutes payment in full.\n\n
\nInformation supplied supports a break in therapy. However, the medical \ninformation we have for this patient does not support the need for this \nitem as billed. We have approved payment for this item at a reduced \nlevel, and a new capped rental period will begin with the delivery of \nthis equipment.\n\n
\nMissing/incomplete/invalid service facility primary address.\n\n
\nMissing/incomplete/invalid service facility secondary identifier.\n\n
\nMissing/incomplete/invalid supervising provider name.\n\n
\nMissing/incomplete/invalid supervising provider primary identifier.\n\n
\nMissing/incomplete/invalid supervising provider secondary identifier.\n\n
\nMissing/incomplete/invalid occurrence date(s).\n\n
\nMissing consent form.\n\n
\nMissing/incomplete/invalid occurrence span date(s).\n\n
\nMissing/incomplete/invalid procedure date(s).\n\n
\nMissing/incomplete/invalid other procedure date(s).\n\n
\nInformation supplied supports a break in therapy. A new capped rental period will begin with delivery of the equipment. This is the maximum approved under the fee schedule for this item or service.\n\n
\nMissing/incomplete/invalid principal procedure date.\n\n
\nMissing/incomplete/invalid dispensed date.\n\n
\nMissing/incomplete/invalid accident date.\n\n
\nMissing/incomplete/invalid acute manifestation date.\n\n
\nMissing/incomplete/invalid adjudication or payment date.\n\n
\nMissing/incomplete/invalid appliance placement date.\n\n
\nMissing/incomplete/invalid assessment date.\n\n
\nMissing/incomplete/invalid prescribing provider identifier.\n\n
\nMissing/incomplete/invalid assumed or relinquished care date.\n\n
\nMissing/incomplete/invalid authorized to return to work date.\n\n
\nInformation supplied does not support a break in therapy. The medical \ninformation we have for this patient does not support the need for this \nitem as billed. We have approved payment for this item at a reduced \nlevel, and a new capped rental period will not begin.\n\n
\nMissing/incomplete/invalid begin therapy date.\n\n
\nMissing/incomplete/invalid certification revision date.\n\n
\nMissing/incomplete/invalid diagnosis date.\n\n
\nMissing/incomplete/invalid disability from date.\n\n
\nMissing/incomplete/invalid disability to date.\n\n
\nMissing/incomplete/invalid discharge hour.\n\n
\nMissing/incomplete/invalid discharge or end of care date.\n\n
\nMissing/incomplete/invalid hearing or vision prescription date.\n\n
\nClaim must be submitted by the provider who rendered the service.\n\n
\nMissing/incomplete/invalid Home Health Certification Period.\n\n
\nInformation supplied does not support a break in therapy. A new capped rental period will not begin. This is the maximum approved under the fee schedule for this item or service. Inactive as of 1/31/2004\n\n
\nMissing/incomplete/invalid last admission period.\n\n
\nMissing/incomplete/invalid last certification date.\n\n
\nMissing/incomplete/invalid last contact date.\n\n
\nMissing/incomplete/invalid last seen/visit date.\n\n
\nMissing/incomplete/invalid last worked date.\n\n
\nMissing/incomplete/invalid last x-ray date.\n\n
\nMissing/incomplete/invalid other insured birth date.\n\n
\nMissing/incomplete/invalid Oxygen Saturation Test date.\n\n
\nMissing/incomplete/invalid patient birth date.\n\n
\nNo record of health check prior to initiation of treatment.\n\n
\nPayment reduced as 90-day rolling average hematocrit for ESRD patient exceeded 36.5%.\n\n
\nMissing/incomplete/invalid patient death date.\n\n
\nMissing/incomplete/invalid physician order date.\n\n
\nMissing/incomplete/invalid prior hospital discharge date.\n\n
\nMissing/incomplete/invalid prior placement date.\n\n
\nMissing/incomplete/invalid re-evaluation date\n\n
\nMissing/incomplete/invalid referral date.\n\n
\nMissing/incomplete/invalid replacement date.\n\n
\nMissing/incomplete/invalid secondary diagnosis date.\n\n
\nMissing/incomplete/invalid shipped date.\n\n
\nMissing/incomplete/invalid similar illness or symptom date.\n\n
\nMissing/incomplete/invalid provider identifier for the provider who interpreted the diagnostic test.inactive as of 6/2/2005\n\n
\nIncorrect claim form/format for this service.\n\n
\nMissing/incomplete/invalid subscriber birth date.\n\n
\nMissing/incomplete/invalid surgery date.\n\n
\nMissing/incomplete/invalid test performed date.\n\n
\nMissing/incomplete/invalid Transcutaneous Electrical Nerve Stimulator (TENS) trial start date.\n\n
\nMissing/incomplete/invalid Transcutaneous Electrical Nerve Stimulator (TENS) trial end date.\n\n
\nDate range not valid with units submitted.\n\n
\nMissing/incomplete/invalid oral cavity designation code.\n\n
\nYour claim for a referred or purchased service cannot be paid because payment has already been made for this same service to another provider by a payment contractor representing the payer.\n\n
\nYou chose that this service/supply/drug would be rendered/supplied and billed by a different practitioner/supplier.\n\n
\nWe have provided you with a bundled payment for a teleconsultation. You must send 25 percent of the teleconsultation payment to the referring practitioner.\n\n
\nThe administration method and drug must be reported to adjudicate this service.\n\n
\nProgram integrity/utilization review decision.\n\n
\nMissing/incomplete/invalid description of service for a Not Otherwise Classified (NOC) code or for an Unlisted/By Report procedure.\n\n
\nService date outside of the approved treatment plan service dates.\n\n
\nAlert: There are no scheduled payments for this service. Submit a claim for each patient visit.\n\n
\nAlert: Benefits have been estimated, when the actual services have been rendered, additional payment will be considered based on the submitted claim.\n\n
\nIncomplete/invalid invoice\n\n
\nAlert: The law permits exceptions to the refund requirement in two cases: \nthis notice. Your request for review should include any additional \ninformation necessary to support your position. If you request an appeal \nwithin 30 days of receiving this notice, you may delay refunding the \namount to the patient until you receive the results of the review. If the \nreview decision is favorable to you, you do not need to make any refund. \nIf, however, the review is unfavorable, the law specifies that you must \nmake the refund within 15 days of receiving the unfavorable review \ndecision. The law also permits you to request an appeal at any time \nwithin 120 days of the date you receive this notice. However, an appeal \nrequest that is received more than 30 days after the date of this notice, \n- If you did not know, and could not have reasonably been expected to \ndoes not permit you to delay making the refund. Regardless of when a \nreview is requested, the patient will be notified that you have requested \none, and will receive a copy of the determination. The patient has \nreceived a separate notice of this denial decision. The notice advises \nthat he/she may be entitled to a refund of any amounts paid, if you \nshould have known that we would not pay and did not tell him/her. It also \ninstructs the patient to contact our office if he/she does not hear \nanything about a refund within 30 days\nknow, that we would not pay for this service; or - If you notified the \npatient in writing before providing the service that you believed that we \nwere likely to deny the ser\nvice, and the patient signed a statement agreeing to pay for the service. \nIf you come within either exception, or if you believe the carrier was \nwrong in its determination that we do not pay for this service, you \nshould request appeal of this determination within 30 days of the date of \n\n
\nNot covered when performed with, or subsequent to, a non-covered service.\n\n
\nTime frame requirements between this service/procedure/supply and a related service/procedure/supply have not been met.\n\n
\nDME, orthotics and prosthetics must be billed to the DME carrier who services the patient's zip code\n\n
\nAlert: This decision may be reviewed if additional documentation as described in the contract or plan benefit documents is submitted.\n\n
\nMissing/incomplete/invalid height.\n\n
\nClaim must meet primary payer's processing requirements before we can consider payment.\n\n
\nAlert: Coordination of benefits has not been calculated when estimating benefits for this pre-determination. Submit payment information from the primary payer with the secondary claim.\n\n
\nPayment adjusted based on multiple diagnostic imaging procedure rules\n\n
\nThe number of Days or Units of Service exceeds our acceptable maximum.\n\n
\nAlert: in the near future we are implementing new policies/procedures that would affect this determination.\n\n
\nAlert: According to our agreement, you must waive the deductible and/or coinsurance amounts.\n\n
\nThis procedure code is not payable. It is for reporting/information purposes only.\n\n
\nRequested information not provided. The claim will be reopened if the information previously requested is submitted within one year after the date of this denial notice.\n\n
\nMissing/incomplete/invalid provider identifier for the provider from whom you purchased interpretation services. Inactive as of 6/2/2005\n\n
\nAlert: The claim information has been forwarded to a Consumer Spending Account processor for review; for example, flexible spending account or health savings account.\n\n
\nYou must appeal the determination of the previously adjudicated claim.\n\n
\nAlert: Although this claim has been processed, it is deficient according to state legislation/regulation.\n\n
\nMissing/incomplete/invalid tooth number/letter.\n\n
\nBilling exceeds the rental months covered/approved by the payer.\n\n
\nAlert: title of this equipment must be transferred to the patient.\n\n
\nOnly reasonable and necessary maintenance/service charges are covered.\n\n
\nIt has been determined that another payer paid the services as primary when they were not the primary payer. Therefore, we are refunding to the payer that paid as primary on your behalf.\n\n
\nPrimary Medicare Part A insurance has been exhausted and a Part B Remittance Advice is required.\n\n
\nMissing/incomplete/invalid questionnaire/information required to determine dependent eligibility.\n\n
\nWe do not pay for chiropractic manipulative treatment when the patient refuses to have an x-ray taken.\n\n
\nSubscriber/patient is assigned to active military duty, therefore primary coverage may be TRICARE.\n\n
\nPayment based on a processed replacement claim.\n\n
\nMissing/incomplete/invalid prescription quantity.\n\n
\nClaim level information does not match line level information.\n\n
\nMissing/incomplete/invalid place of service. 2/5/2005\n\n
\nThe original claim has been processed, submit a corrected claim.\n\n
\nConsult our contractual agreement for restrictions/billing/payment information related to these charges.\n\n
\nAlert: Consult our contractual agreement for restrictions/billing/payment \ninformation related to these charges.\n\n
\nMissing/incomplete/invalid patient identifier.\n\n
\nNot covered when deemed cosmetic.\n\n
\nRecords indicate that the referenced body part/tooth has been removed in a previous procedure.\n\n
\nPayment based on authorized amount.\n\n
\nReimbursement for this item is based on the single payment amount required under the DMEPOS Competitive Bidding Program for the area where the patient resides.\n\n
\nNotification of admission was not timely according to published plan procedures.\n\n
\nThis decision was based on a National Coverage Determination (NCD). An \nNCD provides a coverage determination as to whether a particular item or \nservice is covered. A copy of this policy is available at \nwww.cms.gov/mcd/search.asp. If you do not have web access, you may \ncontact the contractor to request a copy of the NCD.\n\n
\nAlert: Submit this claim to the patient's other insurer for potential payment of supplemental benefits. We did not forward the claim information.\n\n
\nMissing/incomplete/invalid prescription number\n\n
\nDuplicate prescription number submitted.\n\n
\nProcedure code is not compatible with tooth number/letter.\n\n
\nThis service/report cannot be billed separately.\n\n
\nMissing emergency department records.\n\n
\nIncomplete/invalid emergency department records.\n\n
\nMissing progress notes/report.\n\n
\nOur records indicate that this patient began using this item/service prior to the current contract period for the DMEPOS Competitive Bidding Program.\n\n
\nIncomplete/invalid progress notes/report.\n\n
\nMissing laboratory report.\n\n
\nIncomplete/invalid laboratory report.\n\n
\nBenefits are not available for incomplete service(s)/undelivered item(s).\n\n
\nMissing elective consent form.\n\n
\nIncomplete/invalid elective consent form.\n\n
\nMissing/Incomplete/Invalid prior Insurance Carrier(s) EOB.\n\n
\nMissing radiology film(s)/image(s).\n\n
\nAlert: Electronically enabled providers should submit claims electronically.\n\n
\nMissing periodontal charting.\n\n
\nThis service was processed in accordance with rules and guidelines under the DMEPOS Competitive Bidding Program or a Demonstration Project. For more information regarding these projects, contact your local contractor.\n\n
\nIncomplete/invalid periodontal charting.\n\n
\nMissing facility certification.\n\n
\nIncomplete/invalid facility certification.\n\n
\nThis service is only covered when the donor's insurer(s) do not provide coverage for the service.\n\n
\nThis service is only covered when the recipient's insurer(s) do not provide coverage for the service.\n\n
\nYou are not an approved submitter for this transmission format.\n\n
\nThis payer does not cover deductibles assessed by a previous payer.\n\n
\nThis service is related to an accidental injury and is not covered unless provided within a specific time frame from the date of the accident.\n\n
\nAuthorization request denied.\n\n
\nNot covered unless the prescription changes.\n\n
\nThis item is denied when provided to this patient by a non-contract or non-demonstration supplier.\n\n
\nThis service is allowed one time in a 6-month period. (This temporary code will be deactivated on 2/1/09. Must be used with Reason Code 119.)\n\n
\nThis service is allowed 2 times in a 12-month period. (This temporary code will be deactivated on 2/1/09. Must be used with Reason Code 119.)\n\n
\nThis service is allowed 2 times in a benefit year. (This temporary code will be deactivated on 2/1/09. Must be used with Reason Code 119.)\n\n
\nThis service is allowed 4 times in a 12-month period. (This temporary code will be deactivated on 2/1/09. Must be used with Reason Code 119.)\n\n
\nThis service is allowed 1 time in an 18-month period. (This temporary code will be deactivated on 2/1/09. Must be used with Reason Code 119.)\n\n
\nThis service is allowed 1 time in a 3-year period. (This temporary code will be deactivated on 2/1/09. Must be used with Reason Code 119.)\n\n
\nThis service is allowed 1 time in a 5-year period. (This temporary code will be deactivated on 2/1/09. Must be used with Reason Code 119.)\n\n
\nMisrouted claim. See the payer's claim submission instructions.\n\n
\nClaim payment was the result of a payer's retroactive adjustment due to a retroactive rate change.\n\n
\nNo record of mental health assessment.\n\n
\nMissing mental health assessment.\n\n
\nProcessed under a demonstration project or program. Project or program is ending and additional services may not be paid under this project or program.\n\n
\nClaim payment was the result of a payer's retroactive adjustment due to a Coordination of Benefits or Third Party Liability Recovery.\n\n
\nClaim payment was the result of a payer's retroactive adjustment due to a review organization decision.\n\n
\nClaim payment was the result of a payer's retroactive adjustment due to a payer's contract incentive program.\n\n
\nClaim payment was the result of a payer's retroactive adjustment due to a non standard program.\n\n
\nPatient does not reside in the geographic area required for this type of payment.\n\n
\nStatutorily excluded service(s).\n\n
\nNo coverage when self-administered.\n\n
\nPayment for eyeglasses or contact lenses can be made only after cataract surgery.\n\n
\nNot covered when performed in this place of service.\n\n
\nNot covered when considered routine.\n\n
\nNot covered unless submitted via electronic claim.\n\n
\nProcedure code is inconsistent with the units billed.\n\n
\nNot covered with this procedure.\n\n
\nAdjustment based on a Recovery Audit.\n\n
\nAlert: Adjustment based on a Recovery Audit.\n\n
\nResubmit this claim using only your National Provider Identifier (NPI)\n\n
\nResubmit this claim using only your National Provider Identifier (NPI).\n\n
\nMissing/Incomplete/Invalid Present on Admission indicator.\n\n
\nExceeds number/frequency approved /allowed within time period without support documentation.\n\n
\nThe injury claim has not been accepted and a mandatory medical reimbursement has been made.\n\n
\nAlert: If the injury claim is accepted, these charges will be reconsidered.\n\n
\nThis jurisdiction only accepts paper claims\n\n
\nThis jurisdiction only accepts paper claims.\n\n
\nMissing anesthesia physical status report/indicators.\n\n
\nMissing/incomplete/invalid/ deactivated/withdrawn National Drug Code (NDC).\n\n
\nPayer's share of regulatory surcharges, assessments, allowances or health care-related taxes paid directly to the regulatory authority.\n\n
\nIncomplete/invalid anesthesia physical status report/indicators.\n\n
\nThis missed appointment is not covered.\n\n
\nThis missed/cancelled appointment is not covered.\n\n
\nPayment based on an alternate fee schedule.\n\n
\nMissing/incomplete/invalid total time or begin/end time\n\n
\nAlert: This facility has not filed the Election for High Cost Outlier form with the Division of Workers' Compensation.\n\n
\nMissing document for actual cost or paid amount.\n\n
\nIncomplete/invalid document for actual cost or paid amount.\n\n
\nPayment is based on a generic equivalent as required documentation was not provided.\n\n
\nThis drug/service/supply is not included in the fee schedule or contracted/legislated fee arrangement\n\n
\nDiagnostic tests performed by a physician must indicate whether purchased services are included on the claim.\n\n
\nPayment based on a comparable drug/service/supply.\n\n
\nCovered only when performed by the primary treating physician or the designee.\n\n
\nMissing Admission Summary Report.\n\n
\nIncomplete/invalid Admission Summary Report.\n\n
\nMissing Consultation Report.\n\n
\nIncomplete/invalid Consultation Report.\n\n
\nMissing Physician Order.\n\n
\nIncomplete/invalid Physician Order.\n\n
\nMissing Diagnostic Report.\n\n
\nIncomplete/invalid Diagnostic Report.\n\n
\nMissing/incomplete/invalid provider identifier for the substituting physician who furnished the service(s) under a reciprocal billing or locum tenens arrangement. AS OF 6/2/2005\n\n
\nMissing Discharge Summary.\n\n
\nMissing/incomplete/invalid admission hour.\n\n
\nIncomplete/invalid Discharge Summary.\n\n
\nMissing Nursing Notes.\n\n
\nIncomplete/invalid Nursing Notes.\n\n
\nMissing support data for claim.\n\n
\nIncomplete/invalid support data for claim.\n\n
\nMissing Physical Therapy Notes/Report.\n\n
\nIncomplete/invalid Physical Therapy Notes/Report.\n\n
\nMissing Report of Tests and Analysis Report.\n\n
\nMissing Tests and Analysis Report.\n\n
\nWe pay for this service only when performed with a covered cryosurgical ablation.\n\n
\nIncomplete/invalid Report of Tests and Analysis Report.\n\n
\nAlert: Claim/Service(s) subject to appeal process, see section 935 of Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA).\n\n
\nClaim conflicts with another inpatient stay.\n\n
\nThis payment will complete the mandatory medical reimbursement limit.\n\n
\nMissing/incomplete/invalid HIPPS Rate Code.\n\n
\nPayment for this service has been issued to another provider.\n\n
\nMissing certification.\n\n
\nIncomplete/invalid certification\n\n
\nIncomplete/invalid certification.\n\n
\nMissing completed referral form.\n\n
\nIncomplete/invalid completed referral form\n\n
\nIncomplete/invalid completed referral form.\n\n
\nPayment approved as you did not know, and could not reasonably have been \nexpected to know, that this would not normally have been covered for this \npatient. In the future, you will be liable for charges for the same \nservice(s) under the same or similar conditions.\n\n
\nAlert: Payment approved as you did not know, and could not reasonably \nhave been expected to know, that this would not normally have been \ncovered for this patient. In the future, you will be liable for charges \nfor the same service(s) under the same or similar conditions.\n\n
\nMissing/incomplete/invalid level of subluxation.\n\n
\nMissing Dental Models.\n\n
\nIncomplete/invalid Dental Models\n\n
\nIncomplete/invalid Dental Models.\n\n
\nMissing Explanation of Benefits (Coordination of Benefits or Medicare Secondary Payer).\n\n
\nClaim information does not agree with information received from other insurance carrier.\n\n
\nIncomplete/invalid Explanation of Benefits (Coordination of Benefits or Medicare Secondary Payer).\n\n
\nMissing Models.\n\n
\nIncomplete/invalid Models\n\n
\nIncomplete/invalid Models.\n\n
\nMissing Periodontal Charts.\n\n
\nMissing Periodontal Charts.\n\n
\nIncomplete/invalid Periodontal Charts\n\n
\nIncomplete/invalid Periodontal Charts.\n\n
\nMissing Physical Therapy Certification.\n\n
\nMissing/incomplete/invalid name, strength, or dosage of the drug furnished.\n\n
\nIncomplete/invalid Physical Therapy Certification.\n\n
\nMissing Prosthetics or Orthotics Certification.\n\n
\nIncomplete/invalid Prosthetics or Orthotics Certification\n\n
\nIncomplete/invalid Prosthetics or Orthotics Certification.\n\n
\nMissing referral form.\n\n
\nCourt ordered coverage information needs validation.\n\n
\nIncomplete/invalid referral form\n\n
\nIncomplete/invalid referral form.\n\n
\nMissing/Incomplete/Invalid Exclusionary Rider Condition.\n\n
\nAlert: A network provider may bill the member for this service if the member requested the service and agreed in writing, prior to receiving the service, to be financially responsible for the billed charge.\n\n
\nMissing Doctor First Report of Injury.\n\n
\nIncomplete/invalid Doctor First Report of Injury.\n\n
\nMissing indication of whether the patient owns the equipment that requires the part or supply.\n\n
\nMissing Supplemental Medical Report.\n\n
\nIncomplete/invalid Supplemental Medical Report.\n\n
\nMissing Medical Permanent Impairment or Disability Report.\n\n
\nIncomplete/invalid Medical Permanent Impairment or Disability Report.\n\n
\nMissing Medical Legal Report.\n\n
\nEOB received from previous payer. Claim not on file.\n\n
\nMissing/incomplete/invalid discharge information.\n\n
\nIncomplete/invalid Medical Legal Report.\n\n
\nMissing Vocational Report.\n\n
\nIncomplete/invalid Vocational Report.\n\n
\nMissing/incomplete/invalid information on the period of time for which the service/supply/equipment will be needed.\n\n
\nMissing Work Status Report.\n\n
\nIncomplete/invalid Work Status Report.\n\n
\nAlert: This response includes only services that could be estimated in real time. No estimate will be provided for the services that could not be estimated in real time.\n\n
\nAlert: This is an estimate of the member's liability based on the \ninformation available at the time the estimate was processed. Actual \ncoverage and member liability amounts will be determined when the claim \nis processed. This is not a pre-authorization or a guarantee of payment.\n\n
\nPlan distance requirements have not been met.\n\n
\nAlert: This real time claim adjudication response represents the member \nresponsibility to the provider for services reported. The member will \nreceive an Explanation of Benefits electronically or in the mail. Contact \nthe insurer if there are any questions.\n\n
\nAlert: A current inquiry shows the member's Consumer Spending Account \ncontains sufficient funds to cover the member liability for this \nclaim/service. Actual payment from the Consumer Spending Account will \ndepend on the availability of funds and determination of eligible \nservices at the time of payment processing.\n\n
\nElectronic interchange agreement not on file for provider/submitter\n\n
\nAlert: A current inquiry shows the member's Consumer Spending Account \ndoes not contain sufficient funds to cover the member's liability for \nthis claim/service. Actual payment from the Consumer Spending Account \nwill depend on the availability of funds and determination of eligible \nservices at the time of payment processing.\n\n
\nAlert: Information on the availability of Consumer Spending Account funds to cover the member liability on this claim/service is not available at this time.\n\n
\nMissing/incomplete/invalid individual lab codes included in the test.\n\n
\nAlert: This is the initial remit of a non-NCPDP claim originally submitted real-time without change to the adjudication.\n\n
\nAlert: This is the initial remit of a non-NCPDP claim originally submitted real-time with a change to the adjudication.\n\n
\nConsult plan benefit documents/guidelines for information about restrictions for this service.\n\n
\nAlert: Submit this claim to the patient's other insurer for potential payment of supplemental benefits. We did not forward the claim information. (use N387 instead)\n\n
\nRecords indicate a mismatch between the submitted NPI and EIN.\n\n
\nResubmit a new claim with the requested information.\n\n
\nNo separate payment for accessories when furnished for use with oxygen equipment.\n\n
\nInvalid combination of HCPCS modifiers.\n\n
\nPatient not enrolled in the billing provider's managed care plan on the date of service.\n\n
\nAlert: Payment made from a Consumer Spending Account.\n\n
\nMissing/incomplete/invalid date of the patient's last physician visit. STOPPED AS OF 6/2/2005\n\n
\nMismatch between the submitted provider information and the provider information stored in our system.\n\n
\nDuplicate of a claim processed, or to be processed, as a crossover claim.\n\n
\nThe limitation on outlier payments defined by this payer for this service period has been met. The outlier payment otherwise applicable to this claim has not been paid.\n\n
\nBased on policy this payment constitutes payment in full.\n\n
\nThese services are not covered when performed within the global period of another service.\n\n
\nNot qualified for recovery based on employer size.\n\n
\nWe processed this claim as the primary payer prior to receiving the recovery demand.\n\n
\nPatient is entitled to benefits for Institutional Services only.\n\n
\nPatient is entitled to benefits for Professional Services only.\n\n
\nMissing/incomplete/invalid point of pick-up address.\n\n
\nMissing/incomplete/invalid indicator of x-ray availability for review.\n\n
\nNot Qualified for Recovery based on enrollment information.\n\n
\nNot qualified for recovery based on direct payment of premium.\n\n
\nNot qualified for recovery based on disability and working status.\n\n
\nServices performed in an Indian Health Services facility under a self-insured tribal Group Health Plan.\n\n
\nThis is an individual policy, the employer does not participate in plan sponsorship.\n\n
\nPayment is adjusted when procedure is performed in this place of service based on the submitted procedure code and place of service.\n\n
\nWe are not changing the prior payer's determination of patient responsibility, which you may collect, as this service is not covered by us.\n\n
\nWe have examined claims history and no records of the services have been found.\n\n
\nA facility is responsible for payment to outside providers who furnish these services/supplies/drugs to its patients/residents.\n\n
\nAlert: We processed appeals/waiver requests on your behalf and that request has been denied.\n\n
\nMissing invoice or statement certifying the actual cost of the lens, less discounts, and/or the type of intraocular lens used.\n\n
\nPayment adjusted based on the interrupted stay policy.\n\n
\nMismatch between the submitted insurance type code and the information stored in our system.\n\n
\nMissing income verification.\n\n
\nIncomplete/invalid income verification\n\n
\nIncomplete/invalid income verification.\n\n
\nAlert: Although this was paid, you have billed with a referring/ordering provider that does not match our system record. Unless, corrected, this will not be paid in the future.\n\n
\nAlert: Although this was paid, you have billed with a referring/ordering provider that does not match our system record. Unless corrected this will not be paid in the future.\n\n
\nPayment reduced based on status as an unsuccessful eprescriber per the Electronic Prescribing (eRx) Incentive Program.\n\n
\nPayment represents a previous reduction based on the Electronic Prescribing (eRx) Incentive Program.\n\n
\nA refund request (Frequency Type Code 8) was processed previously.\n\n
\nAlert: Patient's calendar year deductible has been met.\n\n
\nAlert: Patient's calendar year out-of-pocket maximum has been met.\n\n
\nMissing physician financial relationship form.\n\n
\nProcedures for billing with group/referring/performing providers were not followed.\n\n
\nAlert: You have not responded to requests to revalidate your provider/supplier enrollment information. Your failure to revalidate your enrollment information will result in a payment hold in the near future.\n\n
\nPayment adjusted based on the Ambulatory Surgical Center (ASC) Quality Reporting Program.\n\n
\nPayment adjusted to reverse a previous withhold/bonus amount.\n\n
\nPayment adjusted based on a Low Income Subsidy (LIS) retroactive coverage or status change.\n\n
\nMissing/Incomplete/Invalid Family Planning Indicator\n\n
\nMissing/Incomplete/Invalid Family Planning Indicator.\n\n
\nMissing medication list.\n\n
\nIncomplete/invalid medication list.\n\n
\nThis claim/service is not payable under our service area. The claim must be filed to the Payer/Plan in whose service area the specimen was collected.\n\n
\nThis claim/service is not payable under our service area. The claim must be filed to the Payer/Plan in whose service area the equipment was received.\n\n
\nMissing pacemaker registration form\n\n
\nThis claim/service is not payable under our service area. The claim must be filed to the Payer/Plan in whose service area the Ordering Physician is located.\n\n
\nProcedure code billed is not correct/valid for the services billed or the date of service billed.\n\n
\nThe pilot program requires an interim or final claim within 60 days of the Notice of Admission. A claim was not received.\n\n
\nThe bundled claim originally submitted for this episode of care includes related readmissions. You may resubmit the original claim to receive a corrected payment based on this readmission\n\n
\nThe provider number of your incoming claim does not match the provider number on the processed Notice of Admission (NOA) for this bundled payment.\n\n
\nMissing required provider/supplier issuance of advance patient notice of non-coverage. The patient is not liable for payment for this service.\n\n
\nAlert: Missing required provider/supplier issuance of advance patient \nnotice of non-coverage. The patient is not liable for payment for this \nservice.\n\n
\nPatient did not meet the inclusion criteria for the demonstration project or pilot program.\n\n
\nAlert: This non-payable reporting code requires a modifier. Future claims containing this non-payable reporting code must include an appropriate modifier for the claim to be processed\n\n
\nAlert: This procedure code requires functional reporting. Future claims containing this procedure code must include an applicable non-payable code and appropriate modifiers for the claim to be processed.\n\n
\nNot covered when considered preventative.\n\n
\nWe do not accept blood gas tests results when the test was conducted by a medical supplier or taken while the patient is on oxygen.\n\n
\nClaim did not identify who performed the purchased diagnostic test or the amount you were charged for the test.\n\n
\nAlert: Initial payment based on the Notice of Admission (NOA) under the Bundled Payment Model IV initiative\n\n
\nNot covered when performed for the reported diagnosis\n\n
\nMissing/incomplete/invalid prescribing date.\n\n
\nMissing/incomplete/invalid credentialing data\n\n
\nMissing/incomplete/invalid credentialing data.\n\n
\nAlert: Payment will be issued quarterly by another payer/contractor.\n\n
\nThis procedure is not payable unless non-payable reporting codes and appropriate modifiers are submitted.\n\n
\nThis procedure is not payable unless appropriate non-payable reporting codes and associated modifiers are submitted.\n\n
\nAlert: You have been overpaid and must refund the overpayment. The refund will be requested separately by another payer/contractor.\n\n
\nMissing/incomplete/invalid patient liability amount.\n\n
\nPlease refer to your provider manual for additional program and provider information.\n\n
\nAlert: Please refer to your provider manual for additional program and \nprovider information.\n\n
\nUnder FEHB law (U.S.C. 8904(b)), we cannot pay more for covered care than the amount Medicare would have allowed if the patient were enrolled in Medicare Part A and/or Medicare Part B.\n\n
\nPerformed by a facility/supplier in which the provider has a financial interest\n\n
\nA valid NDC is required for payment of drug claims effective October 02. 02/05/2005\n\n
\nRebill services on separate claims.\n\n
\nDates of service span multiple rate periods. Resubmit separate claims.\n\n
\nRebill services on separate claim lines.\n\n
\nThe "from" and "to" dates must be different.\n\n
\nProcedure code or procedure rate count cannot be determined, or was not on file, for the date of service/provider.\n\n
\nMissing/incomplete/invalid documentation. 02/05/2005\n\n
\nProfessional provider services not paid separately. Included in facility \nclaim.\npayment under a demonstration project. Apply to that facility for \npayment, or resubmit your claim if: the facility notifies you the patient \nwas excluded from this demonstration; or if you furnished these services \nin another location on the date of the patient's admission or discharge \nfrom a demonstration hospital. If services were furnished in a facility \nnot involved in the demonstration on the same date the patient was \ndischarged from or admitted to a demonstration facility, you must report \nthe provider ID number for the non-demonstration facility on the new \n\n
\nPrior payment being cancelled as we were subsequently notified this \npatient was covered by a demonstration project in this site of service. \nProfessional services were included in the payment made to the facility. \nYou must contact the facility for your payment. Prior payment made to you \nby the patient or another insurer for this claim must be refunded to the \npayer within 30 days.\n\n
\nPPS (Prospective Payment System) code changed by claims processing system. \n\n
\nAlert: PPS (Prospective Payment System) code changed by claims processing \nsystem.\n\n
\nMissing/incomplete/invalid plan of treatment.\n\n
\nProcessing of this claim/service has included consideration under Major Medical provisions.\n\n
\nConsolidated billing and payment applies.\n\n
\nYour unassigned claim for a drug or biological, clinical diagnostic laboratory services or ambulance service was processed as an assigned claim. You are required by law to accept assignment for these types of claims.\n\n
\nPPS (Prospective Payment System) code changed by medical reviewers. Not supported by clinical records.\n\n
\nA Skilled Nursing Facility is responsible for payment of outside providers who furnish these services/supplies under arrangement to its residents.\n\n
\nResubmit with multiple claims, each claim covering services provided in only one calendar month.\n\n
\nMissing/incomplete/invalid tooth surface information.\n\n
\nMissing/incomplete/invalid number of riders.\n\n
\nMissing/incomplete/invalid designated provider number.\n\n
\nThe necessary components of the child and teen checkup (EPSDT) were not completed.\n\n
\nMissing/incomplete/invalid indication that the service was supervised or evaluated by a physician.\n\n
\nService billed is not compatible with patient location information.\n\n
\nCrossover claim denied by previous payer and complete claim data not forwarded. Resubmit this claim to this payer to provide adequate data for adjudication.\n\n
\nMissing/incomplete/invalid prenatal screening information.\n\n
\nProcedure billed is not compatible with tooth surface code.\n\n
\nProvider must accept insurance payment as payment in full when a third party payer contract specifies full reimbursement.\n\n
\nNo appeal rights. Adjudicative decision based on the provisions of a demonstration project.\n\n
\nAlert: Further installment payments are forthcoming.\n\n
\nAlert: This is the final installment payment.\n\n
\nA failed trial of pelvic muscle exercise training is required in order for biofeedback training for the treatment of urinary incontinence to be covered.\n\n
\nHome use of biofeedback therapy is not covered.\n\n
\nPart B coinsurance under a demonstration project or pilot program.\n\n
\nAlert: This payment is being made conditionally. An HHA episode of care \nnotice has been filed for this patient. When a patient is treated under a \nHHA episode of care, consolidated billing requires that certain therapy \nservices and supplies, such as this, be included in the HHA's payment. \nThis payment will need to be recouped from you if we establish that the \npatient is concurrently receiving treatment under a HHA episode of care.\n\n
\nAlert: Payment information for this claim has been forwarded to more than one other payer, but format limitations permit only one of the secondary payers to be identified in this remittance advice.\n\n
\nAdjustment represents the estimated amount a previous payer may pay.\n\n
\nCovered only when performed by the attending physician.\n\n
\nServices not included in the appeal review.\n\n
\nThis facility is not certified for digital mammography.\n\n
\nA separate claim must be submitted for each place of service. Services furnished at multiple sites may not be billed in the same claim.\n\n
\nClaim/Service denied because a more specific taxonomy code is required for adjudication.\n\n
\nThis provider type/provider specialty may not bill this service.\n\n
\nPatient must be refractory to conventional therapy (documented behavioral, pharmacologic and/or surgical corrective therapy) and be an appropriate surgical candidate such that implantation with anesthesia can occur.\n\n
\nPatient identified as a demonstration participant but the patient was not enrolled in the demonstration at the time services were rendered. Coverage is limited to demonstration participants.\n\n
\nPatients with stress incontinence, urinary obstruction, and specific neurologic diseases (e.g., diabetes with peripheral nerve involvement) which are associated with secondary manifestations of the above three indications are excluded.\n\n
\nPatient must have had a successful test stimulation in order to support \nsubsequent implantation. Before a patient is eligible for permanent \nimplantation, he/she must demonstrate a 50 percent or greater improvement \nthrough test stimulation. Improvement is measured through voiding diaries.\n\n
\nPatient must be able to demonstrate adequate ability to record voiding diary data such that clinical results of the implant procedure can be properly evaluated.\n\n
\nOur records indicate the ordering/referring provider is of a type/specialty that cannot order or refer. Please verify that the claim ordering/referring provider information is accurate or contact the ordering/referring provider.\n\n
\nMismatch between the submitted ordering/referring provider name and the ordering/referring provider name stored in our records.\n\n
\nServices not related to the specific incident/claim/accident/loss being reported.\n\n
\nPersonal Injury Protection (PIP) Coverage.\n\n
\nCoverages do not apply to this loss.\n\n
\nMedical Payments Coverage (MPC).\n\n
\nDetermination based on the provisions of the insurance policy.\n\n
\nDenied services exceed the coverage limit for the demonstration.\n\n
\nInvestigation of coverage eligibility is pending.\n\n
\nBenefits suspended pending the patient's cooperation.\n\n
\nPatient was not an occupant of our insured vehicle and therefore, is not an eligible injured person.\n\n
\nNot covered based on the insured's noncompliance with policy or statutory conditions.\n\n
\nBenefits are no longer available based on a final injury settlement.\n\n
\nThe injured party does not qualify for benefits.\n\n
\nPolicy benefits have been exhausted.\n\n
\nThe patient has instructed that medical claims/bills are not to be paid.\n\n
\nCoverage is excluded to any person injured as a result of operating a motor vehicle while in an intoxicated condition or while the ability to operate such a vehicle is impaired by the use of a drug.\n\n
\nMissing independent medical exam detailing the cause of injuries sustained and medical necessity of services rendered.\n\n
\nService not covered until after the patient's 50th birthday, i.e., no coverage prior to the day after the 50th birthday. STOPPED AS OF 1/30/2004\n\n
\nPayment based on an Independent Medical Examination (IME) or Utilization Review (UR).\n\n
\nAdjusted because this is not the initial prescription or exceeds the amount allowed for the initial prescription.\n\n
\nNot covered based on failure to attend a scheduled Independent Medical Exam (IME).\n\n
\nRecords reflect the injured party did not complete an Application for Benefits for this loss.\n\n
\nRecords reflect the injured party did not complete an Assignment of Benefits for this loss.\n\n
\nRecords reflect the injured party did not complete a Medical Authorization for this loss.\n\n
\nAdjusted based on a medical/dental provider's apportionment of care between related injuries and other unrelated medical/dental conditions/injuries.\n\n
\nAdjusted based on a medical/dental provider's apportionment of care between related injuries and other unrelated medical/dental conditions/injuries.\n\n
\nHealth care policy coverage is primary.\n\n
\nOur payment for this service is based upon a reasonable amount pursuant \n200% of the Participating Level of Medicare Part B fee schedule for the \nlocale in which the services were rendered.\nto both the terms and conditions of the policy of insurance under which \nthe subject claim is being made as well as the Florida No-Fault Statute, \nwhich permits, when determining a reasonable charge for a service, an \ninsurer to consider usual and customary charges and payments accepted by \nthe provider, reimbursement levels in the community and various federal \nand state fee schedules applicable to automobile and other insurance \ncoverages, and other information relevant to the reasonableness of the \nreimbursement for the service. The payment for this service is based upon \n\n
\nAdjusted based on the applicable fee schedule for the region in which the service was rendered.\n\n
\nMissing American Diabetes Association Certificate of Recognition\n\n
\nIn accordance with Hawaii Administrative Rules, Title 16, Chapter 23 Motor Vehicle Insurance Law payment is recommended based on Medicare Resource Based Relative Value Scale System applicable to Hawaii.\n\n
\nAdjusted based on the Redbook maximum allowance.\n\n
\nThis fee is calculated according to the New Jersey medical fee schedules for Automobile Personal Injury Protection and Motor Bus Medical Expense Insurance Coverage.\n\n
\nIn accordance with New York No-Fault Law, Regulation 68, this base fee was calculated according to the New York Workers' Compensation Board Schedule of Medical Fees, pursuant to Regulation 83 and / or Appendix 17-C of 11 NYCRR.\n\n
\nThis fee was calculated based upon New York All Patients Refined Diagnosis Related Groups (APR-DRG), pursuant to Regulation 68.\n\n
\nThe Oregon allowed amount for this procedure is based upon the Workers Compensation Fee Schedule (OAR 436-009). The allowed amount has been calculated in accordance with Section 4 of ORS 742.524.\n\n
\nService provided for non-compensable condition(s).\n\n
\nThe fee schedule amount allowed is calculated at 110% of the Medicare Fee Schedule for this region, specialty and type of service. This fee is calculated in compliance with Act 6.\n\n
\n80% of the provider's billed amount is being recommended for payment according to Act 6.\n\n
\n80% of the provider's billed amount is being recommended for payment according to Act 6.\n\n
\nAlert: Payment based on an appropriate level of care.\n\n
\nThe provider must update license information with the payer\n\n
\nClaim in litigation. Contact insurer for more information.\n\n
\nMedical provider not authorized/certified to provide treatment to injured workers in this jurisdiction.\n\n
\nAlert: Although this was paid, you have billed with an ordering provider \nthat needs to update their enrollment record. Please verify that the \nordering provider information you submitted on the claim is accurate and \nif it is, contact the ordering provider instructing them to update their \nenrollment record. Unless corrected, a claim with this ordering provider \nwill not be paid in the future.\n\n
\nAlert: Additional information is included in the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information).\n\n
\nAlert: This enrollee receiving advance payments of the premium tax credit is in the grace period of three consecutive months for non-payment of premium. Under the Code of Federal Regulations, Title 45, Part 156.270, a Qualified Health Plan \nissuer must pay all appropriate claims for services rendered to the enrollee during the first month of the grace period and may pend claims for services rendered to the enrollee in the second and third months of the grace period.\n\n
\nAlert: This enrollee is in the first month of the advance premium tax credit grace period.\n\n
\nThis enrollee is in the second or third month of the advance premium tax credit grace period.\n\n
\nAlert: This claim will automatically be reprocessed if the enrollee pays their premiums.\n\n
\nCoverage terminated for non-payment of premium.\n\n
\nAlert: This procedure code is for quality reporting/informational purposes only.\n\n
\nNo more than one initial visit may be covered per specialty per medical \ngroup. Visit may be rebilled with an established visit code.\n\n
\nOnly one initial visit is covered per specialty per medical group.\n\n
\nAlert: Please see our web site, mailings, or bulletins for more details concerning this policy/procedure/decision.\n\n
\nCharges for Jurisdiction required forms, reports, or chart notes are not payable.\n\n
\nNot covered based on the date of injury/accident.\n\n
\nNot covered when deemed unscientific/unproven/outmoded/experimental/excessive/inappropriate.\n\n
\nThe associated Workers' Compensation claim has been withdrawn.\n\n
\nMissing/Incomplete/Invalid Workers' Compensation Claim Number.\n\n
\nNew or established patient E/M codes are not payable with chiropractic care codes.\n\n
\nService not payable per managed care contract.\n\n
\nOut-patient follow up visits on the same date of service as a scheduled test or treatment is disallowed.\n\n
\nReviews/documentation/notes/summaries/reports/charts not requested.\n\n
\nReferral not authorized by attending physician.\n\n
\nCertain services may be approved for home use. Neither a hospital nor a Skilled Nursing Facility (SNF) is considered to be a patient's home\n\n
\nMedical Fee Schedule does not list this code. An allowance was made for a comparable service.\n\n
\nAccording to the Official Medical Fee Schedule this service has a relative value of zero and therefore no payment is due.\n\n
\nAdditional anesthesia time units are not allowed.\n\n
\nThe allowance is calculated based on anesthesia time units.\n\n
\nThe Allowance is calculated based on the anesthesia base units plus time.\n\n
\nAdjusted because this is reimbursable only once per injury.\n\n
\nConsultations are not allowed once treatment has been rendered by the same provider.\n\n
\nReimbursement has been made according to the home health fee schedule.\n\n
\nReimbursement has been made according to the inpatient rehabilitation facilities fee schedule.\n\n
\nExceeds number/frequency approved/allowed within time period.\n\n
\nMissing/incomplete/invalid HCPCS.\n\n
\nReimbursement has been based on the number of body areas rated.\n\n
\nAdjusted when billed as individual tests instead of as a panel.\n\n
\nThe services billed are considered Not Covered or Non-Covered (NC) in the applicable state fee schedule.\n\n
\nReimbursement has been made according to the bilateral procedure rule.\n\n
\nMark-up allowance.\n\n
\nMark-up allowance.\n\n
\nReimbursement has been adjusted based on the guidelines for an assistant.\n\n
\nAdjusted based on diagnosis-related group (DRG).\n\n
\nAdjusted based on Stop Loss.\n\n
\nPayment based on invoice.\n\n
\nThis policy was not in effect for this date of loss. No coverage is available.\n\n
\nMissing/incomplete/invalid place of residence for this service/item provided in a home\n\n
\nNo Personal Injury Protection/Medical Payments Coverage on the policy at the time of the loss.\n\n
\nThe date of service is before the date of loss.\n\n
\nThe date of injury does not match the reported date of loss.\n\n
\nAdjusted based on achievement of maximum medical improvement (MMI).\n\n
\nPayment based on provider's geographic region.\n\n
\nAn interest payment is being made because benefits are being paid outside the statutory requirement.\n\n
\nThis should be billed with the appropriate code for these services.\n\n
\nThe billed service(s) are not considered medical expenses.\n\n
\nThis item is exempt from sales tax.\n\n
\nSales tax has been included in the reimbursement.\n\n
\nMissing/incomplete/invalid number of miles traveled\n\n
\nDocumentation does not support that the services rendered were medically necessary.\n\n
\nAlert: Consideration of payment will be made upon receipt of a final bill.\n\n
\nAdjusted based on an agreed amount.\n\n
\nAdjusted based on a legal settlement.\n\n
\nServices by an unlicensed provider are not reimbursable.\n\n
\nOnly one evaluation and management code at this service level is covered during the course of care.\n\n
\nMissing prescription.\n\n
\nMissing prescription.\n\n
\nIncomplete/invalid prescription.\n\n
\nIncomplete/invalid prescription.\n\n
\nAdjusted based on the Medicare fee schedule.\n\n
\nThis service code has been identified as the primary procedure code subject to the Medicare Multiple Procedure Payment Reduction (MPPR) rule.\n\n
\nMissing invoice.\n\n
\nPayment based on a jurisdiction cost-charge ratio.\n\n
\nAlert: Amount applied to Health Insurance Offset.\n\n
\nReimbursement has been calculated based on an outpatient per diem or an outpatient factor and/or fee schedule amount.\n\n
\nNot covered unless a pre-requisite procedure/service has been provided.\n\n
\nAdditional information is required from the injured party.\n\n
\nService does not qualify for payment under the Outpatient Facility Fee Schedule.\n\n
\nAlert: Films/Images will not be returned.\n\n
\nMissing post-operative images/visual field results.\n\n
\nIncomplete/Invalid post-operative images/visual field results.\n\n
\nMissing/Incomplete/Invalid date of previous dental extractions.\n\n
\nThe information furnished does not substantiate the need for this level \nexcess of any deductible and coinsurance amounts. We will recover the \nreimbursement from you as an overpayment\nof service. If you believe the service should have been fully covered as \nbilled, or if you did not know and could not reasonably have been \nexpected to know that we would not pay for this level of service, or if \nyou notified the patient in writing in advance that we would not pay for \nthis level of service and he/she agreed in writing to pay, ask us to \nreview your claim within 120 days of the date of this notice. If you do \nnot request an appeal, we will, upon application from the patient, \nreimburse him/her for the amount you have collected from him/her in \n\n
\nMissing/Incomplete/Invalid full arch series.\n\n
\nMissing/Incomplete/Invalid history of prior periodontal therapy/maintenance.\n\n
\nMissing/Incomplete/Invalid prior treatment documentation.\n\n
\nPayment denied as this is a specialty claim submitted as a general claim.\n\n
\nMissing/Incomplete/Invalid Prosthesis, Crown or Inlay Code.\n\n
\nMissing/incomplete/Invalid questionnaire needed to complete payment determination.\n\n
\nAlert: This reversal is due to a retroactive disenrollment.\n\n
\nAlert: This reversal is due to a retroactive disenrollment.\n\n
\nAlert: This reversal is due to a medical or utilization review decision.\n\n
\nAlert: This reversal is due to a medical or utilization review decision.\n\n
\nAlert: This reversal is due to a retroactive rate change.\n\n
\nAlert: This reversal is due to a retroactive rate change.\n\n
\nAlert: This reversal is due to a provider submitted appeal.\n\n
\nAlert: This reversal is due to a provider submitted appeal.\n\n
\nThe information furnished does not substantiate the need for this level of service. If you have collected any amount from the patient for this level of service /any amount that exceeds the limiting charge for the less extensive service, the law\nrequires you to refund that amount to the patient within 30 days of receiving this notice.\n \nThe requirements for refund are in 1824(I) of the Social Security Act and 42CFR411.408. The section specifies that physicians who knowingly and willfully\nfail to make appropriate refunds may be subject to civil monetary penalties and/or exclusion from the program. If you have any questions about this notice, please contact this office.\n\n
\nAlert: This reversal is due to a patient submitted appeal.\n\n
\nAlert: This reversal is due to a patient submitted appeal.\n\n
\nAlert: This reversal is due to an incorrect rate on the initial adjudication.\n\n
\nAlert: This reversal is due to an incorrect rate on the initial adjudication.\n\n
\nAlert: This reversal is due to a cancellation of the claim by the provider.\n\n
\nAlert: This reversal is due to a cancellation of the claim by the provider.\n\n
\nAlert: This reversal is due to a resubmission/change to the claim by the provider.\n\n
\nAlert: This reversal is due to incorrect patient financial responsibility information on the initial adjudication.\n\n
\nAlert: This reversal is due to a Coordination of Benefits or Third Party Liability Recovery retroactive adjustment.\n\n
\nAlert: This reversal is due to a Coordination of Benefits or Third Party Liability Recovery retroactive adjustment.\n\n
\nAlert: This reversal is due to a payer's retroactive contract incentive program adjustment.\n\n
\nAlert: This reversal is due to a payer's retroactive contract incentive program adjustment.\n\n
\nAlert: This reversal is due to non-payment of the Health Insurance Exchange premiums by the end of the premium payment grace period, resulting in loss of coverage.\n\n
\nAlert: This reversal is due to non-payment of the Health Insurance Exchange premiums by the end of the premium payment grace period, resulting in loss of coverage.\n\n
\nAlert: This reversal is due to non-payment of the health insurance \npremiums (Health Insurance Exchange or other) by the end of the premium \npayment grace period, resulting in loss of coverage.\n\n
\nPayment adjusted based on the Physician Quality Reporting System (PQRS) Incentive Program.\n\n
\nPayment adjusted based on the Electronic Health Records (EHR) Incentive Program.\n\n
\nAlert: The patient has been relieved of liability of payment of these \nthe date you receive this notice. You must make the request through this \noffice.\nitems and services under the limitation of liability provision of the \nlaw. The provider is ultimately liable for the patient's waived charges, \nincluding any charges for coinsurance, since the items or services were \nnot reasonable and necessary or constituted custodial care, and you knew \nor could reasonably have been expected to know, that they were not \ncovered. You may appeal this determination. You may ask for an appeal \nregarding both the coverage determination and the issue of whether you \nexercised due care. The appeal request must be filed within 120 days of \n\n
\nPayment adjusted based on the Value-based Payment Modifier.\n\n
\nDecision based on review of previously adjudicated claims or for claims in process for the same/similar type of services.\n\n
\nThis service is incompatible with previously adjudicated claims or claims in process.\n\n
\nAlert: You may not appeal this decision but can resubmit this claim/service with corrected information if warranted.\n\n
\nAlert: You may not appeal this decision but can resubmit this claim/service with corrected information if warranted.\n\n
\nIncomplete/invalid documentation.\n\n
\nMissing documentation.\n\n
\nIncomplete/invalid orders.\n\n
\nMissing orders.\n\n
\nIncomplete/invalid notes.\n\n
\nMissing notes.\n\n
\nThis does not qualify for payment under Part B when Part A coverage is exhausted or not otherwise available.\n\n
\nIncomplete/invalid summary.\n\n
\nMissing summary.\n\n
\nIncomplete/invalid report.\n\n
\nMissing report.\n\n
\nIncomplete/invalid chart.\n\n
\nMissing chart.\n\n
\nIncomplete/Invalid documentation of face-to-face examination.\n\n
\nMissing documentation of face-to-face examination.\n\n
\nPenalty applied based on plan requirements not being met.\n\n
\nAlert: The patient overpaid you. You may need to issue the patient a refund for the difference between the patient's payment and the amount shown as patient responsibility on this notice.\n\n