HIPAA GROUP CODES FOR PAYMENT REASONS:

Group and Reason Codes are required when Medicare
is the Secondary Payer (MSP). In that case, you must bill
the Primary first to get an EOB, and then bill Medicare.
Ideally, the Primary would use these HIPAA codes on
their EOB, but they usually don't. You should call the Primary
and ask for the HIPAA Group and Reason Codes that correspond
to the codes they provided on their EOB. Then you 
can use the proper codes when you file your MSP claim.

* * * * * * * *


GROUP CODES:
-----------

CO - Contract Obligation

PR - Patient Responsibility

OA - Other Adjustments

PI - Payer Initiated Reductions.

* * * * * * * *


CLAIM ADJUSTMENT REASON CODES:  Last Update 11/5/2007 
------------------------------

1  Deductible Amount
   Start: 01/01/1995

2  Coinsurance Amount
   Start: 01/01/1995

3  Co-payment Amount
   Start: 01/01/1995

4  The procedure code is inconsistent with the modifier used or a required modifier is
   missing.
   Start: 01/01/1995

5  The procedure code/bill type is inconsistent with the place of service.
   Start: 01/01/1995

6  The procedure/revenue code is inconsistent with the patient's age.
   Start: 01/01/1995 | Last Modified: 06/30/2002

7  The procedure/revenue code is inconsistent with the patient's gender.
   Start: 01/01/1995 | Last Modified: 06/30/2002

8  The procedure code is inconsistent with the provider type/specialty (taxonomy).
   Start: 01/01/1995 | Last Modified: 06/30/2002

9  The diagnosis is inconsistent with the patient's age.
   Start: 01/01/1995

10 The diagnosis is inconsistent with the patient's gender.
   Start: 01/01/1995 | Last Modified: 02/29/2000

11 The diagnosis is inconsistent with the procedure.
   Start: 01/01/1995

12 The diagnosis is inconsistent with the provider type.
   Start: 01/01/1995

13 The date of death precedes the date of service.
   Start: 01/01/1995

14 The date of birth follows the date of service.
   Start: 01/01/1995

15 Payment adjusted because the submitted authorization number is missing, invalid,
   or does not apply to the billed services or provider. This change to be effective
   4/1/2008: The authorization number is missing, invalid, or does not apply to the
   billed services or provider.
   Start: 01/01/1995 | Last Modified: 09/30/2007


16 Claim/service lacks information which is needed for adjudication. At least one
   Remark Code must be provided (may be comprised of either the Remittance
   Advice Remark Code or NCPDP Reject Reason Code.)
   Start: 01/01/1995 | Last Modified: 06/30/2006

17 Payment adjusted because requested information was not provided or was
   insufficient/incomplete. At least one Remark Code must be provided (may be
   comprised of either the Remittance Advice Remark Code or NCPDP Reject
   Reason Code.) This change to be effective 4/1/2008: Requested information was
   not provided or was insufficient/incomplete. At least one Remark Code must be
   provided (may be comprised of either the Remittance Advice Remark Code or
   NCPDP Reject Reason Code.)
   Start: 01/01/1995 | Last Modified: 09/30/2007

18 Duplicate claim/service.
   Start: 01/01/1995

19 Claim denied because this is a work-related injury/illness and thus the liability of
   the Worker's Compensation Carrier. This change to be effective 4/1/2008: This is
   a work-related injury/illness and thus the liability of the Worker's Compensation
   Carrier.
   Start: 01/01/1995 | Last Modified: 09/30/2007

20 Claim denied because this injury/illness is covered by the liability carrier. This
   change to be effective 4/1/2008: This injury/illness is covered by the liability
   carrier.
   Start: 01/01/1995 | Last Modified: 09/30/2007


21
Claim denied because this injury/illness is the liability of the no-fault carrier. This
change to be effective 4/1/2008: This injury/illness is the liability of the no-fault
carrier.
Start: 01/01/1995 | Last Modified: 09/30/2007


22
Payment adjusted because this care may be covered by another payer per
coordination of benefits. This change to be effective 4/1/2008: This care may be
covered by another payer per coordination of benefits.
Start: 01/01/1995 | Last Modified: 09/30/2007


23
Payment adjusted due to the impact of prior payer(s) adjudication including
payments and/or adjustments. This change to be effective 4/1/2008: The impact of
prior payer(s) adjudication including payments and/or adjustments.
Start: 01/01/1995 | Last Modified: 09/30/2007


24
Payment for charges adjusted. Charges are covered under a capitation
agreement/managed care plan. This change to be effective 4/1/2008: Charges are
covered under a capitation agreement/managed care plan.
Start: 01/01/1995 | Last Modified: 09/30/2007


25
Payment denied. Your Stop loss deductible has not been met.
Start: 01/01/1995 | Stop: 04/01/2008


26
Expenses incurred prior to coverage.
Start: 01/01/1995


27
Expenses incurred after coverage terminated.
Start: 01/01/1995


28
Coverage not in effect at the time the service was provided.
Start: 01/01/1995 | Stop: 10/16/2003
Notes: Redundant to codes 26&27.


29
The time limit for filing has expired.
Start: 01/01/1995


30
Payment adjusted because the patient has not met the required eligibility, spend
down, waiting, or residency requirements.
Start: 01/01/1995 | Stop: 02/01/2006


31
Claim denied as patient cannot be identified as our insured. This change to be
effective 4/1/2008: Patient cannot be identified as our insured.
Start: 01/01/1995 | Last Modified: 09/30/2007


32
Our records indicate that this dependent is not an eligible dependent as defined.
Start: 01/01/1995


33
Claim denied. Insured has no dependent coverage. This change to be effective
4/1/2008: Insured has no dependent coverage.
Start: 01/01/1995 | Last Modified: 09/30/2007


34
Claim denied. Insured has no coverage for newborns. This change to be effective
4/1/2008: Insured has no coverage for newborns.
Start: 01/01/1995 | Last Modified: 09/30/2007


35
Lifetime benefit maximum has been reached.
Start: 01/01/1995 | Last Modified: 10/31/2002


36
Balance does not exceed co-payment amount.
Start: 01/01/1995 | Stop: 10/16/2003


37
Balance does not exceed deductible.
Start: 01/01/1995 | Stop: 10/16/2003


38
Services not provided or authorized by designated (network/primary care)
providers.
Start: 01/01/1995 | Last Modified: 06/30/2003


39
Services denied at the time authorization/pre-certification was requested.
Start: 01/01/1995


40
Charges do not meet qualifications for emergent/urgent care.
Start: 01/01/1995


41
Discount agreed to in Preferred Provider contract.
Start: 01/01/1995 | Stop: 10/16/2003


42
Charges exceed our fee schedule or maximum allowable amount. (Use CARC 45)
Start: 01/01/1995 | Stop: 06/01/2007 | Last Modified: 10/31/2006


43
Gramm-Rudman reduction.
Start: 01/01/1995 | Stop: 07/01/2006


44
Prompt-pay discount.
Start: 01/01/1995


45
Charge exceeds fee schedule/maximum allowable or contracted/legislated fee
arrangement. (Use Group Codes PR or CO depending upon liability).
Start: 01/01/1995 | Last Modified: 10/31/2006


46
This (these) service(s) is (are) not covered.
Start: 01/01/1995 | Stop: 10/16/2003
Notes: Use code 96.


47
This (these) diagnosis(es) is (are) not covered, missing, or are invalid.
Start: 01/01/1995 | Stop: 02/01/2006


48
This (these) procedure(s) is (are) not covered.
Start: 01/01/1995 | Stop: 10/16/2003
Notes: Use code 96.


49
These are non-covered services because this is a routine exam or screening
procedure done in conjunction with a routine exam.
Start: 01/01/1995


50
These are non-covered services because this is not deemed a `medical necessity' by
the payer.
Start: 01/01/1995


51
These are non-covered services because this is a pre-existing condition
Start: 01/01/1995


52
The referring/prescribing/rendering provider is not eligible to
refer/prescribe/order/perform the service billed.
Start: 01/01/1995 | Stop: 02/01/2006


53
Services by an immediate relative or a member of the same household are not
covered.
Start: 01/01/1995


54
Multiple physicians/assistants are not covered in this case .
Start: 01/01/1995


55
Claim/service denied because procedure/treatment is deemed
experimental/investigational by the payer. This change to be effective 4/1/2008:
Procedure/treatment is deemed experimental/investigational by the payer.
Start: 01/01/1995 | Last Modified: 09/30/2007


56
Claim/service denied because procedure/treatment has not been deemed `proven to
be effective' by the payer. This change to be effective 4/1/2008:
Procedure/treatment has not been deemed `proven to be effective' by the payer.
Start: 01/01/1995 | Last Modified: 09/30/2007


57
Payment denied/reduced because the payer deems the information submitted does
not support this level of service, this many services, this length of service, this
dosage, or this day's supply.
Start: 01/01/1995 | Stop: 06/30/2007
Notes: Split into codes 150, 151, 152, 153 and 154.


58
Payment adjusted because treatment was deemed by the payer to have been
rendered in an inappropriate or invalid place of service. This change to be
effective 4/1/2008: Treatment was deemed by the payer to have been rendered in
an inappropriate or invalid place of service.
Start: 01/01/1995 | Last Modified: 09/30/2007


59
Charges are adjusted based on multiple or concurrent procedure rules. (For
example multiple surgery or diagnostic imaging, concurrent anesthesia.) This
change to be effective 4/1/2008: Processed based on multiple or concurrent
procedure rules. (For example multiple surgery or diagnostic imaging, concurrent
anesthesia.)
Start: 01/01/1995 | Last Modified: 09/30/2007


60
Charges for outpatient services with this proximity to inpatient services are not
covered.
Start: 01/01/1995


61
Charges adjusted as penalty for failure to obtain second surgical opinion. This
change to be effective 4/1/2008: Penalty for failure to obtain second surgical
opinion.
Start: 01/01/1995 | Last Modified: 09/30/2007


62
Payment denied/reduced for absence of, or exceeded,
pre-certification/authorization.
Start: 01/01/1995 | Stop: 04/01/2007 | Last Modified: 10/31/2006


63
Correction to a prior claim.
Start: 01/01/1995 | Stop: 10/16/2003


64
Denial reversed per Medical Review.
Start: 01/01/1995 | Stop: 10/16/2003


65
Procedure code was incorrect. This payment reflects the correct code.
Start: 01/01/1995 | Stop: 10/16/2003


66
Blood Deductible.
Start: 01/01/1995


67
Lifetime reserve days. (Handled in QTY, QTY01=LA)
Start: 01/01/1995 | Stop: 10/16/2003


68
DRG weight. (Handled in CLP12)
Start: 01/01/1995 | Stop: 10/16/2003


69
Day outlier amount.
Start: 01/01/1995


70
Cost outlier - Adjustment to compensate for additional costs.
Start: 01/01/1995 | Last Modified: 06/30/2001


71
Primary Payer amount.
Start: 01/01/1995 | Stop: 06/30/2000
Notes: Use code 23.


72
Coinsurance day. (Handled in QTY, QTY01=CD)
Start: 01/01/1995 | Stop: 10/16/2003


73
Administrative days.
Start: 01/01/1995 | Stop: 10/16/2003


74
Indirect Medical Education Adjustment.
Start: 01/01/1995


75
Direct Medical Education Adjustment.
Start: 01/01/1995


76
Disproportionate Share Adjustment.
Start: 01/01/1995


77
Covered days. (Handled in QTY, QTY01=CA)
Start: 01/01/1995 | Stop: 10/16/2003


78
Non-Covered days/Room charge adjustment.
Start: 01/01/1995


79
Cost Report days. (Handled in MIA15)
Start: 01/01/1995 | Stop: 10/16/2003


80
Outlier days. (Handled in QTY, QTY01=OU)
Start: 01/01/1995 | Stop: 10/16/2003


81
Discharges.
Start: 01/01/1995 | Stop: 10/16/2003


82
PIP days.
Start: 01/01/1995 | Stop: 10/16/2003


83
Total visits.
Start: 01/01/1995 | Stop: 10/16/2003


84
Capital Adjustment. (Handled in MIA)
Start: 01/01/1995 | Stop: 10/16/2003


85
Patient Interest Adjustment (Use Only Group code PR)
Start: 01/01/1995 | Last Modified: 01/01/2008
Notes: Only use when the payment of interest is the responsibility of the patient.


86
Statutory Adjustment.
Start: 01/01/1995 | Stop: 10/16/2003
Notes: Duplicative of code 45.


87
Transfer amount.
Start: 01/01/1995


88
Adjustment amount represents collection against receivable created in prior
overpayment.
Start: 01/01/1995 | Stop: 06/30/2007


89
Professional fees removed from charges.
Start: 01/01/1995


90
Ingredient cost adjustment.
Start: 01/01/1995


91
Dispensing fee adjustment.
Start: 01/01/1995


92
Claim Paid in full.
Start: 01/01/1995 | Stop: 10/16/2003


93
No Claim level Adjustments.
Start: 01/01/1995 | Stop: 10/16/2003
Notes: As of 004010, CAS at the claim level is optional.


94
Processed in Excess of charges.
Start: 01/01/1995


95
Benefits adjusted. Plan procedures not followed. This change to be effective
4/1/2008: Plan procedures not followed.
Start: 01/01/1995 | Last Modified: 09/30/2007


96
Non-covered charge(s). At least one Remark Code must be provided (may be
comprised of either the Remittance Advice Remark Code or NCPDP Reject
Reason Code.)
Start: 01/01/1995 | Last Modified: 06/30/2006


97
Payment adjusted because the benefit for this service is included in the
payment/allowance for another service/procedure that has already been
adjudicated. This change to be effective 4/1/2008: The benefit for this service is
included in the payment/allowance for another service/procedure that has already
been adjudicated.
Start: 01/01/1995 | Last Modified: 09/30/2007


98
The hospital must file the Medicare claim for this inpatient non-physician service.
Start: 01/01/1995 | Stop: 10/16/2003


99
Medicare Secondary Payer Adjustment Amount.
Start: 01/01/1995 | Stop: 10/16/2003


100
Payment made to patient/insured/responsible party.
Start: 01/01/1995


101
Predetermination: anticipated payment upon completion of services or claim
adjudication.
Start: 01/01/1995 | Last Modified: 02/28/1999


102
Major Medical Adjustment.
Start: 01/01/1995


103
Provider promotional discount (e.g., Senior citizen discount).
Start: 01/01/1995 | Last Modified: 06/30/2001


104
Managed care withholding.
Start: 01/01/1995


105
Tax withholding.
Start: 01/01/1995


106
Patient payment option/election not in effect.
Start: 01/01/1995


107
Claim/service adjusted because the related or qualifying claim/service was not
identified on this claim. This change to be effective 4/1/2008: The related or
qualifying claim/service was not identified on this claim.
Start: 01/01/1995 | Last Modified: 09/30/2007


108
Payment adjusted because rent/purchase guidelines were not met. This change to
be effective 4/1/2008: Rent/purchase guidelines were not met.
Start: 01/01/1995 | Last Modified: 09/30/2007


109
Claim not covered by this payer/contractor. You must send the claim to the correct
payer/contractor.
Start: 01/01/1995


110
Billing date predates service date.
Start: 01/01/1995


111
Not covered unless the provider accepts assignment.
Start: 01/01/1995


112
Payment adjusted as not furnished directly to the patient and/or not documented.
This change to be effective 4/1/2008: Service not furnished directly to the patient
and/or not documented.
Start: 01/01/1995 | Last Modified: 09/30/2007


113
Payment denied because service/procedure was provided outside the United States
or as a result of war.
Start: 01/01/1995 | Stop: 06/30/2007 | Last Modified: 02/28/2001
Notes: Use Codes 157, 158 or 159.


114
Procedure/product not approved by the Food and Drug Administration.
Start: 01/01/1995


115
Payment adjusted as procedure postponed, canceled, or delayed. This change to be
effective 4/1/2008: Procedure postponed, canceled, or delayed.
Start: 01/01/1995 | Last Modified: 09/30/2007


116
Payment denied. The advance indemnification notice signed by the patient did not
comply with requirements. This change to be effective 4/1/2008: The advance
indemnification notice signed by the patient did not comply with requirements.
Start: 01/01/1995 | Last Modified: 09/30/2007


117
Payment adjusted because transportation is only covered to the closest facility that
can provide the necessary care. This change to be effective 4/1/2008:
Transportation is only covered to the closest facility that can provide the necessary
care.
Start: 01/01/1995 | Last Modified: 09/30/2007


118
Charges reduced for ESRD network support. This change to be effective 4/1/2008:
ESRD network support adjustment.
Start: 01/01/1995 | Last Modified: 09/30/2007


119
Benefit maximum for this time period or occurrence has been reached.
Start: 01/01/1995 | Last Modified: 02/29/2004


120
Patient is covered by a managed care plan.
Start: 01/01/1995 | Stop: 06/30/2007
Notes: Use code 24.


121
Indemnification adjustment. This change effective 4/1/2008: Indemnification
adjustment - compensation for outstanding member responsibility.
Start: 01/01/1995 | Last Modified: 09/30/2007


122
Psychiatric reduction.
Start: 01/01/1995


123
Payer refund due to overpayment.
Start: 01/01/1995 | Stop: 06/30/2007
Notes: Refer to implementation guide for proper handling of reversals.


124
Payer refund amount - not our patient.
Start: 01/01/1995 | Stop: 06/30/2007 | Last Modified: 06/30/1999
Notes: Refer to implementation guide for proper handling of reversals.


125
Payment adjusted due to a submission/billing error(s). At least one Remark Code
must be provided (may be comprised of either the Remittance Advice Remark
Code or NCPDP Reject Reason Code.) This change to be effective 4/1/2008:
Submission/billing error(s). At least one Remark Code must be provided (may be
comprised of either the Remittance Advice Remark Code or NCPDP Reject
Reason Code.)
Start: 01/01/1995 | Last Modified: 09/30/2007


126
Deductible -- Major Medical
Start: 02/28/1997 | Stop: 04/01/2008 | Last Modified: 09/30/2007
Notes: Use Group Code PR and code 1.


127
Coinsurance -- Major Medical
Start: 02/28/1997 | Stop: 04/01/2008 | Last Modified: 09/30/2007
Notes: Use Group Code PR and code 2.


128
Newborn's services are covered in the mother's Allowance.
Start: 02/28/1997


129
Payment denied - Prior processing information appears incorrect. This change to
be effective 4/1/2008: Prior processing information appears incorrect.
Start: 02/28/1997 | Last Modified: 09/30/2007


130
Claim submission fee.
Start: 02/28/1997 | Last Modified: 06/30/2001


131
Claim specific negotiated discount.
Start: 02/28/1997


132
Prearranged demonstration project adjustment.
Start: 02/28/1997


133
The disposition of this claim/service is pending further review.
Start: 02/28/1997 | Last Modified: 10/31/1999


134
Technical fees removed from charges.
Start: 10/31/1998


135
Claim denied. Interim bills cannot be processed. This change to be effective
4/1/2008: Interim bills cannot be processed.
Start: 10/31/1998 | Last Modified: 09/30/2007


136
Claim adjusted based on failure to follow prior payer's coverage rules. (Use Group
Code OA). This change to be effective 4/1/2008: Failure to follow prior payer's
coverage rules. (Use Group Code OA).
Start: 10/31/1998 | Last Modified: 09/30/2007


137
Payment/Reduction for Regulatory Surcharges, Assessments, Allowances or
Health Related Taxes. This change to be effective 4/1/2008: Regulatory
Surcharges, Assessments, Allowances or Health Related Taxes.
Start: 02/28/1999 | Last Modified: 09/30/2007


138
Claim/service denied. Appeal procedures not followed or time limits not met. This
change to be effective 4/1/2008: Appeal procedures not followed or time limits not
met.
Start: 06/30/1999 | Last Modified: 09/30/2007


139
Contracted funding agreement - Subscriber is employed by the provider of
services.
Start: 06/30/1999


140
Patient/Insured health identification number and name do not match.
Start: 06/30/1999


141
Claim adjustment because the claim spans eligible and ineligible periods of
coverage. This change to be effective 4/1/2008: Claim spans eligible and ineligible
periods of coverage.
Start: 06/30/1999 | Last Modified: 09/30/2007


142
Claim adjusted by the monthly Medicaid patient liability amount. This change to
be effective 4/1/2008: Monthly Medicaid patient liability amount.
Start: 06/30/2000 | Last Modified: 09/30/2007


143
Portion of payment deferred.
Start: 02/28/2001


144
Incentive adjustment, e.g. preferred product/service.
Start: 06/30/2001


145
Premium payment withholding
Start: 06/30/2002 | Stop: 04/01/2008 | Last Modified: 09/30/2007
Notes: Use Group Code CO and code 45.


146
Payment denied because the diagnosis was invalid for the date(s) of service
reported. This change to be effective 4/1/2008: Diagnosis was invalid for the
date(s) of service reported.
Start: 06/30/2002 | Last Modified: 09/30/2007


147
Provider contracted/negotiated rate expired or not on file.
Start: 06/30/2002


148
Claim/service rejected at this time because information from another provider was
not provided or was insufficient/incomplete. This change to be effective 4/1/2008:
Information from another provider was not provided or was
insufficient/incomplete.
Start: 06/30/2002 | Last Modified: 09/30/2007


149
Lifetime benefit maximum has been reached for this service/benefit category.
Start: 10/31/2002


150
Payment adjusted because the payer deems the information submitted does not
support this level of service. This change to be effective 4/1/2008: Payer deems
the information submitted does not support this level of service.
Start: 10/31/2002 | Last Modified: 09/30/2007


151
Payment adjusted because the payer deems the information submitted does not
support this many services. This change to be effective 4/1/2008: Payer deems the
information submitted does not support this many services.
Start: 10/31/2002 | Last Modified: 09/30/2007


152
Payment adjusted because the payer deems the information submitted does not
support this length of service. This change to be effective 4/1/2008: Payer deems
the information submitted does not support this length of service.
Start: 10/31/2002 | Last Modified: 09/30/2007


153
Payment adjusted because the payer deems the information submitted does not
support this dosage. This change to be effective 4/1/2008: Payer deems the
information submitted does not support this dosage.
Start: 10/31/2002 | Last Modified: 09/30/2007


154
Payment adjusted because the payer deems the information submitted does not
support this day's supply. This change to be effective 4/1/2008: Payer deems the
information submitted does not support this day's supply.
Start: 10/31/2002 | Last Modified: 09/30/2007


155
This claim is denied because the patient refused the service/procedure. This
change to be effective 4/1/2008: Patient refused the service/procedure.
Start: 06/30/2003 | Last Modified: 09/30/2007


156
Flexible spending account payments
Start: 09/30/2003


157
Payment denied/reduced because service/procedure was provided as a result of an
act of war. This change to be effective 4/1/2008: Service/procedure was provided
as a result of an act of war.
Start: 09/30/2003 | Last Modified: 09/30/2007


158
Payment denied/reduced because the service/procedure was provided outside of
the United States. This change to be effective 4/1/2008: Service/procedure was
provided outside of the United States.
Start: 09/30/2003 | Last Modified: 09/30/2007


159
Payment denied/reduced because the service/procedure was provided as a result of
terrorism. This change to be effective 4/1/2008: Service/procedure was provided
as a result of terrorism.
Start: 09/30/2003 | Last Modified: 09/30/2007


160
Payment denied/reduced because injury/illness was the result of an activity that is
a benefit exclusion. This change to be effective 4/1/2008: Injury/illness was the
result of an activity that is a benefit exclusion.
Start: 09/30/2003 | Last Modified: 09/30/2007


161
Provider performance bonus
Start: 02/29/2004


162
State-mandated Requirement for Property and Casualty, see Claim Payment
Remarks Code for specific explanation.
Start: 02/29/2004


163
Claim/Service adjusted because the attachment referenced on the claim was not
received. This change to be effective 4/1/2008: Attachment referenced on the
claim was not received.
Start: 06/30/2004 | Last Modified: 09/30/2007


164
Claim/Service adjusted because the attachment referenced on the claim was not
received in a timely fashion. This change to be effective 4/1/2008: Attachment
referenced on the claim was not received in a timely fashion.
Start: 06/30/2004 | Last Modified: 09/30/2007


165
Payment denied /reduced for absence of, or exceeded referral. This change to be
effective 4/1/2008: Referral absent or exceeded.
Start: 10/31/2004 | Last Modified: 09/30/2007


166
These services were submitted after this payers responsibility for processing
claims under this plan ended.
Start: 02/28/2005


167
This (these) diagnosis(es) is (are) not covered.
Start: 06/30/2005


168
Payment denied as Service(s) have been considered under the patient's medical
plan. Benefits are not available under this dental plan. This change to be effective
4/1/2008: Service(s) have been considered under the patient's medical plan.
Benefits are not available under this dental plan.
Start: 06/30/2005 | Last Modified: 09/30/2007


169
Payment adjusted because an alternate benefit has been provided. This change to
be effective 4/1/2008: Alternate benefit has been provided.
Start: 06/30/2005 | Last Modified: 09/30/2007


170
Payment is denied when performed/billed by this type of provider.
Start: 06/30/2005


171
Payment is denied when performed/billed by this type of provider in this type of
facility.
Start: 06/30/2005


172
Payment is adjusted when performed/billed by a provider of this specialty
Start: 06/30/2005


173
Payment adjusted because this service was not prescribed by a physician. This
change to be effective 4/1/2008: Service was not prescribed by a physician.
Start: 06/30/2005 | Last Modified: 09/30/2007


174
Payment denied because this service was not prescribed prior to delivery. This
change to be effective 4/1/2008: Service was not prescribed prior to delivery.
Start: 06/30/2005 | Last Modified: 09/30/2007


175
Payment denied because the prescription is incomplete. This change to be
effective 4/1/2008: Prescription is incomplete.
Start: 06/30/2005 | Last Modified: 09/30/2007


176
Payment denied because the prescription is not current. This change to be effective
4/1/2008: Prescription is not current.
Start: 06/30/2005 | Last Modified: 09/30/2007


177
Payment denied because the patient has not met the required eligibility
requirements. This change to be effective 4/1/2008: Patient has not met the
required eligibility requirements.
Start: 06/30/2005 | Last Modified: 09/30/2007


178
Payment adjusted because the patient has not met the required spend down
requirements. This change to be effective 4/1/2008: Patient has not met the
required spend down requirements.
Start: 06/30/2005 | Last Modified: 09/30/2007


179
Payment adjusted because the patient has not met the required waiting
requirements. This change to be effective 4/1/2008: Patient has not met the
required waiting requirements.
Start: 06/30/2005 | Last Modified: 09/30/2007


180
Payment adjusted because the patient has not met the required residency
requirements. This change to be effective 4/1/2008: Patient has not met the
required residency requirements.
Start: 06/30/2005 | Last Modified: 09/30/2007


181
Payment adjusted because this procedure code was invalid on the date of service.
This change to be effective 4/1/2008: Procedure code was invalid on the date of
service.
Start: 06/30/2005 | Last Modified: 09/30/2007


182
Payment adjusted because the procedure modifier was invalid on the date of
service. This change to be effective 4/1/2008: Procedure modifier was invalid on
the date of service.
Start: 06/30/2005 | Last Modified: 09/30/2007


183
The referring provider is not eligible to refer the service billed.
Start: 06/30/2005


184
The prescribing/ordering provider is not eligible to prescribe/order the service
billed.
Start: 06/30/2005


185
The rendering provider is not eligible to perform the service billed.
Start: 06/30/2005


186
Payment adjusted since the level of care changed. This change to be effective
4/1/2008: Level of care change adjustment.
Start: 06/30/2005 | Last Modified: 09/30/2007


187
Health Savings account payments
Start: 06/30/2005


188
This product/procedure is only covered when used according to FDA
recommendations.
Start: 06/30/2005


189
"Not otherwise classified" or "unlisted" procedure code (CPT/HCPCS) was billed
when there is a specific procedure code for this procedure/service
Start: 06/30/2005


190
Payment is included in the allowance for a Skilled Nursing Facility (SNF)
qualified stay.
Start: 10/31/2005


191
Claim denied because this is not a work related injury/illness and thus not the
liability of the workers' compensation carrier. This change to be effective
4/1/2008: Not a work related injury/illness and thus not the liability of the
workers' compensation carrier.
Start: 10/31/2005 | Last Modified: 09/30/2007


192
Non standard adjustment code from paper remittance advice. This change to be
effective 4/1/2008: Non standard adjustment code from paper remittance. Note:
This code is to be used by providers/payers providing Coordination of Benefits
information to another payer in the 837 transaction only. This code is only used
when the non-standard code cannot be reasonably mapped to an existing Claims
Adjustment Reason Code, specifically Deductible, Coinsurance and Co-payment.
Start: 10/31/2005 | Last Modified: 09/30/2007


193
Original payment decision is being maintained. This claim was processed properly
the first time.
Start: 02/28/2006


194
Payment adjusted when anesthesia is performed by the operating physician, the
assistant surgeon or the attending physician. This change to be effective 4/1/2008:
Anesthesia performed by the operating physician, the assistant surgeon or the
attending physician.
Start: 02/28/2006 | Last Modified: 09/30/2007


195
Payment denied/reduced due to a refund issued to an erroneous priority payer for
this claim/service. This change to be effective 4/1/2008: Refund issued to an
erroneous priority payer for this claim/service.
Start: 02/28/2006 | Last Modified: 09/30/2007


196
Claim/service denied based on prior payer's coverage determination.
Start: 06/30/2006 | Stop: 02/01/2007
Notes: Use code 136.


197
Payment adjusted for absence of precertification/authorization/notification. This
change effective 4/1/2008: Precertification/authorization/notification absent.
Start: 10/31/2006 | Last Modified: 09/30/2007


198
Payment Adjusted for exceeding precertification/ authorization. This change to be
effective 4/1/2008: Precertification/authorization exceeded.
Start: 10/31/2006 | Last Modified: 09/30/2007


199
Revenue code and Procedure code do not match.
Start: 10/31/2006


200
Expenses incurred during lapse in coverage
Start: 10/31/2006


201
Workers Compensation case settled. Patient is responsible for amount of this
claim/service through WC "Medicare set aside arrangement" or other agreement.
(Use group code PR).
Start: 10/31/2006


202
Payment adjusted due to non-covered personal comfort or convenience services.
This change to be effective 4/1/2008: Non-covered personal comfort or
convenience services.
Start: 02/28/2007 | Last Modified: 09/30/2007


203
Payment adjusted for discontinued or reduced service. This change to be effective
4/1/2008: Discontinued or reduced service.
Start: 02/28/2007 | Last Modified: 09/30/2007


204
This service/equipment/drug is not covered under the patient's current benefit plan
Start: 02/28/2007


205
Pharmacy discount card processing fee
Start: 07/09/2007


206
NPI denial - Missing. This change to be effective 4/1/2008: National Provider
Identifier - missing.
Start: 07/09/2007 | Last Modified: 09/30/2007


207
NPI denial - Invalid format. This change effective 4/1/2008: National Provider
identifier - Invalid format
Start: 07/09/2007 | Stop: 05/23/2008 | Last Modified: 09/30/2007


208
NPI denial - not matched. This change to be effective 4/1/2008: National Provider
Identifier - Not matched.
Start: 07/09/2007 | Last Modified: 09/30/2007


209
Per regulatory or other agreement. The provider cannot collect this amount from
the patient. However, this amount may be billed to subsequent payer. Refund to
patient if collected. (Use Group code OA)
Start: 07/09/2007


210
Payment adjusted because pre-certification/authorization not received in a timely
fashion
Start: 07/09/2007


211
National Drug Codes (NDC) not eligible for rebate, are not covered.
Start: 07/09/2007


212
Administrative surcharges are not covered
Start: 11/05/2007


A0
Patient refund amount.
Start: 01/01/1995


A1
Claim/Service denied. At least one Remark Code must be provided (may be
comprised of either the Remittance Advice Remark Code or NCPDP Reject
Reason Code.)
Start: 01/01/1995 | Last Modified: 10/31/2006


A2
Contractual adjustment.
Start: 01/01/1995 | Stop: 01/01/2008 | Last Modified: 01/01/2008
Notes: Use Code 45 with Group Code 'CO' or use another appropriate specific
adjustment code.


A3
Medicare Secondary Payer liability met.
Start: 01/01/1995 | Stop: 10/16/2003


A4
Medicare Claim PPS Capital Day Outlier Amount.
Start: 01/01/1995 | Stop: 04/01/2008 | Last Modified: 09/30/2007


A5
Medicare Claim PPS Capital Cost Outlier Amount.
Start: 01/01/1995


A6
Prior hospitalization or 30 day transfer requirement not met.
Start: 01/01/1995


A7
Presumptive Payment Adjustment
Start: 01/01/1995


A8
Claim denied; ungroupable DRG. This change to be effective 4/1/2008:
Ungroupable DRG.
Start: 01/01/1995 | Last Modified: 09/30/2007


B1
Non-covered visits.
Start: 01/01/1995


B2
Covered visits.
Start: 01/01/1995 | Stop: 10/16/2003


B3
Covered charges.
Start: 01/01/1995 | Stop: 10/16/2003


B4
Late filing penalty.
Start: 01/01/1995


B5
Payment adjusted because coverage/program guidelines were not met or were
exceeded. This change to be effective 4/1/2008: Coverage/program guidelines
were not met or were exceeded.
Start: 01/01/1995 | Last Modified: 09/30/2007


B6
This payment is adjusted when performed/billed by this type of provider, by this
type of provider in this type of facility, or by a provider of this specialty.
Start: 01/01/1995 | Stop: 02/01/2006


B7
This provider was not certified/eligible to be paid for this procedure/service on
this date of service.
Start: 01/01/1995 | Last Modified: 10/31/1998


B8
Claim/service not covered/reduced because alternative services were available,
and should have been utilized. This change to be effective 4/1/2008: Alternative
services were available, and should have been utilized.
Start: 01/01/1995 | Last Modified: 09/30/2007


B9
Services not covered because the patient is enrolled in a Hospice. This change to
be effective 4/1/2008: Patient is enrolled in a Hospice.
Start: 01/01/1995 | Last Modified: 09/30/2007


B10
Allowed amount has been reduced because a component of the basic
procedure/test was paid. The beneficiary is not liable for more than the charge
limit for the basic procedure/test.
Start: 01/01/1995


B11
The claim/service has been transferred to the proper payer/processor for
processing. Claim/service not covered by this payer/processor.
Start: 01/01/1995


B12
Services not documented in patients' medical records.
Start: 01/01/1995


B13
Previously paid. Payment for this claim/service may have been provided in a
previous payment.
Start: 01/01/1995


B14
Payment denied because only one visit or consultation per physician per day is
covered. This change to be effective 4/1/2008: Only one visit or consultation per
physician per day is covered.
Start: 01/01/1995 | Last Modified: 09/30/2007


B15
Payment adjusted because this service/procedure requires that a qualifying
service/procedure be received and covered. The qualifying other service/procedure
has not been received/adjudicated. This change to be effective 4/1/2008: This
service/procedure requires that a qualifying service/procedure be received and
covered. The qualifying other service/procedure has not been
received/adjudicated.
Start: 01/01/1995 | Last Modified: 09/30/2007


B16
Payment adjusted because `New Patient' qualifications were not met. This change
to be effective 4/1/2008: `New Patient' qualifications were not met.
Start: 01/01/1995 | Last Modified: 09/30/2007


B17
Payment adjusted because this service was not prescribed by a physician, not
prescribed prior to delivery, the prescription is incomplete, or the prescription is
not current.
Start: 01/01/1995 | Stop: 02/01/2006


B18
Payment adjusted because this procedure code and modifier were invalid on the
date of service. This change to be effective 4/1/2008: This procedure code and
modifier were invalid on the date of service.
Start: 01/01/1995 | Last Modified: 09/30/2007


B19
Claim/service adjusted because of the finding of a Review Organization.
Start: 01/01/1995 | Stop: 10/16/2003


B20
Payment adjusted because procedure/service was partially or fully furnished by
another provider. This change to be effective 4/1/2008: Procedure/service was
partially or fully furnished by another provider.
Start: 01/01/1995 | Last Modified: 09/30/2007


B21
The charges were reduced because the service/care was partially furnished by
another physician.
Start: 01/01/1995 | Stop: 10/16/2003


B22
This payment is adjusted based on the diagnosis.
Start: 01/01/1995 | Last Modified: 02/28/2001


B23
Payment denied because this provider has failed an aspect of a proficiency testing
program. This change effective 4/1/2008: Procedure billed is not authorized per
your Clinical Laboratory Improvement Amendment (CLIA) proficiency test.
Start: 01/01/1995 | Last Modified: 09/30/2007


D1
Claim/service denied. Level of subluxation is missing or inadequate.
Start: 01/01/1995 | Stop: 10/16/2003
Notes: Use code 16 and remark codes if necessary.


D2
Claim lacks the name, strength, or dosage of the drug furnished.
Start: 01/01/1995 | Stop: 10/16/2003
Notes: Use code 16 and remark codes if necessary.


D3
Claim/service denied because information to indicate if the patient owns the
equipment that requires the part or supply was missing.
Start: 01/01/1995 | Stop: 10/16/2003
Notes: Use code 16 and remark codes if necessary.


D4
Claim/service does not indicate the period of time for which this will be needed.
Start: 01/01/1995 | Stop: 10/16/2003
Notes: Use code 16 and remark codes if necessary.


D5
Claim/service denied. Claim lacks individual lab codes included in the test.
Start: 01/01/1995 | Stop: 10/16/2003
Notes: Use code 16 and remark codes if necessary.


D6
Claim/service denied. Claim did not include patient's medical record for the
service.
Start: 01/01/1995 | Stop: 10/16/2003
Notes: Use code 16 and remark codes if necessary.


D7
Claim/service denied. Claim lacks date of patient's most recent physician visit.
Start: 01/01/1995 | Stop: 10/16/2003
Notes: Use code 16 and remark codes if necessary.


D8
Claim/service denied. Claim lacks indicator that `x-ray is available for review.'
Start: 01/01/1995 | Stop: 10/16/2003
Notes: Use code 16 and remark codes if necessary.


D9
Claim/service denied. Claim lacks invoice or statement certifying the actual cost
of the lens, less discounts or the type of intraocular lens used.
Start: 01/01/1995 | Stop: 10/16/2003
Notes: Use code 16 and remark codes if necessary.


D10
Claim/service denied. Completed physician financial relationship form not on file.
Start: 01/01/1995 | Stop: 10/16/2003
Notes: Use code 17.


D11
Claim lacks completed pacemaker registration form.
Start: 01/01/1995 | Stop: 10/16/2003
Notes: Use code 17.


D12
Claim/service denied. Claim does not identify who performed the purchased
diagnostic test or the amount you were charged for the test.
Start: 01/01/1995 | Stop: 10/16/2003
Notes: Use code 17.


D13
Claim/service denied. Performed by a facility/supplier in which the
ordering/referring physician has a financial interest.
Start: 01/01/1995 | Stop: 10/16/2003
Notes: Use code 17.


D14
Claim lacks indication that plan of treatment is on file.
Start: 01/01/1995 | Stop: 10/16/2003
Notes: Use code 17.


D15
Claim lacks indication that service was supervised or evaluated by a physician.
Start: 01/01/1995 | Stop: 10/16/2003
Notes: Use code 17.


D16
Claim lacks prior payer payment information.
Start: 01/01/1995 | Stop: 06/30/2007
Notes: Use code 16 with appropriate claim payment remark code [N4].


D17
Claim/Service has invalid non-covered days.
Start: 01/01/1995 | Stop: 06/30/2007
Notes: Use code 16 with appropriate claim payment remark code.


D18
Claim/Service has missing diagnosis information.
Start: 01/01/1995 | Stop: 06/30/2007
Notes: Use code 16 with appropriate claim payment remark code.


D19
Claim/Service lacks Physician/Operative or other supporting documentation
Start: 01/01/1995 | Stop: 06/30/2007
Notes: Use code 16 with appropriate claim payment remark code.


D20
Claim/Service missing service/product information.
Start: 01/01/1995 | Stop: 06/30/2007
Notes: Use code 16 with appropriate claim payment remark code.


D21
This (these) diagnosis(es) is (are) missing or are invalid
Start: 01/01/1995 | Stop: 06/30/2007


W1
Workers Compensation State Fee Schedule Adjustment
Start: 02/29/2000

 
* * * * * * * *