Claim Adjustment Reason Codes (Denials)
| 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. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. This change effective September 1, 2017: The procedure code is inconsistent with the modifier used or a required modifier is missing. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Start: 01/01/1995 | Last Modified: 03/01/2017 |
| 5 | The procedure code/bill type is inconsistent with the place of service. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. This change effective September 1, 2017: The procedure code/bill type is inconsistent with the place of service. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Start: 01/01/1995 | Last Modified: 03/01/2017 |
| 6 | The procedure/revenue code is inconsistent with the patient's age. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. This change effective September 1, 2017: The procedure/revenue code is inconsistent with the patient's age. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Start: 01/01/1995 | Last Modified: 03/01/2017 |
| 7 | The procedure/revenue code is inconsistent with the patient's gender. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. This change effective September 1, 2017: The procedure/revenue code is inconsistent with the patient's gender. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Start: 01/01/1995 | Last Modified: 03/01/2017 |
| 8 | The procedure code is inconsistent with the provider type/specialty (taxonomy). Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. This change effective September 1, 2017: The procedure code is inconsistent with the provider type/specialty (taxonomy). Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Start: 01/01/1995 | Last Modified: 03/01/2017 |
| 9 | The diagnosis is inconsistent with the patient's age. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. This change effective September 1, 2017: The diagnosis is inconsistent with the patient's age. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Start: 01/01/1995 | Last Modified: 03/01/2017 |
| 10 | The diagnosis is inconsistent with the patient's gender. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. This change effective September 1, 2017: The diagnosis is inconsistent with the patient's gender. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Start: 01/01/1995 | Last Modified: 03/01/2017 |
| 11 | The diagnosis is inconsistent with the procedure. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. This change effective September 1, 2017: The diagnosis is inconsistent with the procedure. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Start: 01/01/1995 | Last Modified: 03/01/2017 |
| 12 | The diagnosis is inconsistent with the provider type. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. This change effective September 1, 2017: The diagnosis is inconsistent with the provider type. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Start: 01/01/1995 | Last Modified: 03/01/2017 |
| 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 | 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 or has submission/billing error(s) which is needed for adjudication. Do not use this code for claims attachment(s)/other documentation. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.) Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. This change effective September 1, 2017: Claim/service lacks information or has submission/billing error(s) which is needed for adjudication. Do not use this code for claims attachment(s)/other documentation. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.) Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Start: 01/01/1995 | Last Modified: 03/01/2017 |
| 18 | Exact duplicate claim/service (Use only with Group Code OA except where state workers' compensation regulations requires CO) Start: 01/01/1995 | Last Modified: 06/02/2013 |
| 19 | 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 | This injury/illness is covered by the liability carrier. Start: 01/01/1995 | Last Modified: 09/30/2007 |
| 21 | This injury/illness is the liability of the no-fault carrier. Start: 01/01/1995 | Last Modified: 09/30/2007 |
| 22 | This care may be covered by another payer per coordination of benefits. Start: 01/01/1995 | Last Modified: 09/30/2007 |
| 23 | The impact of prior payer(s) adjudication including payments and/or adjustments. (Use only with Group Code OA) Start: 01/01/1995 | Last Modified: 09/30/2012 |
| 24 | Charges are covered under a capitation agreement/managed care plan. Start: 01/01/1995 | Last Modified: 09/30/2007 |
| 26 | Expenses incurred prior to coverage. Start: 01/01/1995 |
| 27 | Expenses incurred after coverage terminated. Start: 01/01/1995 |
| 29 | The time limit for filing has expired. Start: 01/01/1995 |
| 31 | 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 | Insured has no dependent coverage. Start: 01/01/1995 | Last Modified: 09/30/2007 |
| 34 | 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 |
| 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. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. This change effective September 1, 2017: Charges do not meet qualifications for emergent/urgent care. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Start: 01/01/1995 | Last Modified: 03/01/2017 |
| 44 | Prompt-pay discount. Start: 01/01/1995 |
| 45 | Charge exceeds fee schedule/maximum allowable or contracted/legislated fee arrangement. Note: This adjustment amount cannot equal the total service or claim charge amount; and must not duplicate provider adjustment amounts (payments and contractual reductions) that have resulted from prior payer(s) adjudication. (Use only with Group Codes PR or CO depending upon liability) This change effective September 1, 2017: Charge exceeds fee schedule/maximum allowable or contracted/legislated fee arrangement. Usage: This adjustment amount cannot equal the total service or claim charge amount; and must not duplicate provider adjustment amounts (payments and contractual reductions) that have resulted from prior payer(s) adjudication. (Use only with Group Codes PR or CO depending upon liability) Start: 01/01/1995 | Last Modified: 03/01/2017 |
| 49 | This is a non-covered service because it is a routine/preventive exam or a diagnostic/screening procedure done in conjunction with a routine/preventive exam. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. This change effective September 1, 2017: This is a non-covered service because it is a routine/preventive exam or a diagnostic/screening procedure done in conjunction with a routine/preventive exam. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Start: 01/01/1995 | Last Modified: 03/01/2017 |
| 50 | These are non-covered services because this is not deemed a 'medical necessity' by the payer. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. This change effective September 1, 2017: These are non-covered services because this is not deemed a 'medical necessity' by the payer. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Start: 01/01/1995 | Last Modified: 03/01/2017 |
| 51 | These are non-covered services because this is a pre-existing condition. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. This change effective September 1, 2017: These are non-covered services because this is a pre-existing condition. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Start: 01/01/1995 | Last Modified: 03/01/2017 |
| 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. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. This change effective September 1, 2017: Multiple physicians/assistants are not covered in this case. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Start: 01/01/1995 | Last Modified: 03/01/2017 |
| 55 | Procedure/treatment/drug is deemed experimental/investigational by the payer. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. This change effective September 1, 2017: Procedure/treatment/drug is deemed experimental/investigational by the payer. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Start: 01/01/1995 | Last Modified: 03/01/2017 |
| 56 | Procedure/treatment has not been deemed 'proven to be effective' by the payer. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. This change effective September 1, 2017: Procedure/treatment has not been deemed 'proven to be effective' by the payer. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Start: 01/01/1995 | Last Modified: 03/01/2017 |
| 58 | Treatment was deemed by the payer to have been rendered in an inappropriate or invalid place of service. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. This change effective September 1, 2017: Treatment was deemed by the payer to have been rendered in an inappropriate or invalid place of service. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Start: 01/01/1995 | Last Modified: 03/01/2017 |
| 59 | Processed based on multiple or concurrent procedure rules. (For example multiple surgery or diagnostic imaging, concurrent anesthesia.) Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. This change effective September 1, 2017: Processed based on multiple or concurrent procedure rules. (For example multiple surgery or diagnostic imaging, concurrent anesthesia.) Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Start: 01/01/1995 | Last Modified: 03/01/2017 |
| 60 | Charges for outpatient services are not covered when performed within a period of time prior to or after inpatient services. Start: 01/01/1995 | Last Modified: 06/01/2008 |
| 61 | Adjusted for failure to obtain second surgical opinion Start: 01/01/1995 | Last Modified: 03/01/2017 Notes: The description effective date was inadvertently published as 3/1/2016 on 7/1/2016. That has been corrected to 1/1/2017. |
| 66 | Blood Deductible. Start: 01/01/1995 |
| 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 |
| 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 |
| 78 | Non-Covered days/Room charge adjustment. Start: 01/01/1995 |
| 85 | Patient Interest Adjustment (Use Only Group code PR) Start: 01/01/1995 | Last Modified: 07/09/2007 Notes: Only use when the payment of interest is the responsibility of the patient. |
| 89 | Professional fees removed from charges. Start: 01/01/1995 |
| 90 | Ingredient cost adjustment. Note: To be used for pharmaceuticals only. This change effective September 1, 2017: Ingredient cost adjustment. Usage: To be used for pharmaceuticals only. Start: 01/01/1995 | Last Modified: 03/01/2017 |
| 91 | Dispensing fee adjustment. Start: 01/01/1995 |
| 94 | Processed in Excess of charges. Start: 01/01/1995 |
| 95 | 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 NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.) Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. This change effective September 1, 2017: Non-covered charge(s). At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.) Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Start: 01/01/1995 | Last Modified: 03/01/2017 |
| 97 | The benefit for this service is included in the payment/allowance for another service/procedure that has already been adjudicated. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. This change effective September 1, 2017: The benefit for this service is included in the payment/allowance for another service/procedure that has already been adjudicated. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Start: 01/01/1995 | Last Modified: 03/01/2017 |
| 100 | Payment made to patient/insured/responsible party/employer. Start: 01/01/1995 | Last Modified: 01/27/2008 |
| 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 | The related or qualifying claim/service was not identified on this claim. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. This change effective September 1, 2017: The related or qualifying claim/service was not identified on this claim. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Start: 01/01/1995 | Last Modified: 03/01/2017 |
| 108 | Rent/purchase guidelines were not met. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. This change effective September 1, 2017: Rent/purchase guidelines were not met. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Start: 01/01/1995 | Last Modified: 03/01/2017 |
| 109 | Claim/service not covered by this payer/contractor. You must send the claim/service to the correct payer/contractor. Start: 01/01/1995 | Last Modified: 01/29/2012 |
| 110 | Billing date predates service date. Start: 01/01/1995 |
| 111 | Not covered unless the provider accepts assignment. Start: 01/01/1995 |
| 112 | Service not furnished directly to the patient and/or not documented. Start: 01/01/1995 | Last Modified: 09/30/2007 |
| 114 | Procedure/product not approved by the Food and Drug Administration. Start: 01/01/1995 |
| 115 | Procedure postponed, canceled, or delayed. Start: 01/01/1995 | Last Modified: 09/30/2007 |
| 116 | The advance indemnification notice signed by the patient did not comply with requirements. Start: 01/01/1995 | Last Modified: 09/30/2007 |
| 117 | Transportation is only covered to the closest facility that can provide the necessary care. Start: 01/01/1995 | Last Modified: 09/30/2007 |
| 118 | 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 |
| 121 | Indemnification adjustment - compensation for outstanding member responsibility. Start: 01/01/1995 | Last Modified: 09/30/2007 |
| 122 | Psychiatric reduction. Start: 01/01/1995 |
| 128 | Newborn's services are covered in the mother's Allowance. Start: 02/28/1997 |
| 129 | Prior processing information appears incorrect. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.) Start: 02/28/1997 | Last Modified: 01/30/2011 |
| 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 service line is pending further review. (Use only with Group Code OA). Note: Use of this code requires a reversal and correction when the service line is finalized (use only in Loop 2110 CAS segment of the 835 or Loop 2430 of the 837). This change effective September 1, 2017: The disposition of this service line is pending further review. (Use only with Group Code OA). Usage: Use of this code requires a reversal and correction when the service line is finalized (use only in Loop 2110 CAS segment of the 835 or Loop 2430 of the 837). Start: 07/01/2014 | Last Modified: 03/01/2017 |
| 134 | Technical fees removed from charges. Start: 10/31/1998 |
| 135 | Interim bills cannot be processed. Start: 10/31/1998 | Last Modified: 09/30/2007 |
| 136 | Failure to follow prior payer's coverage rules. (Use only with Group Code OA) Start: 10/31/1998 | Last Modified: 07/01/2013 |
| 137 | Regulatory Surcharges, Assessments, Allowances or Health Related Taxes. Start: 02/28/1999 | Last Modified: 09/30/2007 |
| 138 | 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 |
| 142 | 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 |
| 146 | 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 | Information from another provider was not provided or was insufficient/incomplete. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.) Start: 06/30/2002 | Last Modified: 09/20/2009 |
| 149 | Lifetime benefit maximum has been reached for this service/benefit category. Start: 10/31/2002 |
| 150 | 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/frequency of services. Start: 10/31/2002 | Last Modified: 01/27/2008 |
| 152 | Payer deems the information submitted does not support this length of service. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. This change effective September 1, 2017: Payer deems the information submitted does not support this length of service. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Start: 10/31/2002 | Last Modified: 03/01/2017 |
| 153 | Payer deems the information submitted does not support this dosage. Start: 10/31/2002 | Last Modified: 09/30/2007 |
| 154 | Payer deems the information submitted does not support this day's supply. Start: 10/31/2002 | Last Modified: 09/30/2007 |
| 155 | Patient refused the service/procedure. Start: 06/30/2003 | Last Modified: 09/30/2007 |
| 157 | Service/procedure was provided as a result of an act of war. Start: 09/30/2003 | Last Modified: 09/30/2007 |
| 158 | Service/procedure was provided outside of the United States. Start: 09/30/2003 | Last Modified: 09/30/2007 |
| 159 | Service/procedure was provided as a result of terrorism. Start: 09/30/2003 | Last Modified: 09/30/2007 |
| 160 | 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 |
| 163 | Attachment/other documentation referenced on the claim was not received. Start: 06/30/2004 | Last Modified: 06/02/2013 |
| 164 | Attachment/other documentation referenced on the claim was not received in a timely fashion. Start: 06/30/2004 | Last Modified: 06/02/2013 |
| 165 | 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. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. This change effective September 1, 2017: This (these) diagnosis(es) is (are) not covered. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Start: 06/30/2005 | Last Modified: 03/01/2017 |
| 168 | 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 | 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. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. This change effective September 1, 2017: Payment is denied when performed/billed by this type of provider. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Start: 06/30/2005 | Last Modified: 03/01/2017 |
| 171 | Payment is denied when performed/billed by this type of provider in this type of facility. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. This change effective September 1, 2017: Payment is denied when performed/billed by this type of provider in this type of facility. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Start: 06/30/2005 | Last Modified: 03/01/2017 |
| 172 | Payment is adjusted when performed/billed by a provider of this specialty. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. This change effective September 1, 2017: Payment is adjusted when performed/billed by a provider of this specialty. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Start: 06/30/2005 | Last Modified: 03/01/2017 |
| 173 | Service/equipment was not prescribed by a physician. Start: 06/30/2005 | Last Modified: 07/01/2013 |
| 174 | Service was not prescribed prior to delivery. Start: 06/30/2005 | Last Modified: 09/30/2007 |
| 175 | Prescription is incomplete. Start: 06/30/2005 | Last Modified: 09/30/2007 |
| 176 | Prescription is not current. Start: 06/30/2005 | Last Modified: 09/30/2007 |
| 177 | Patient has not met the required eligibility requirements. Start: 06/30/2005 | Last Modified: 09/30/2007 |
| 178 | Patient has not met the required spend down requirements. Start: 06/30/2005 | Last Modified: 09/30/2007 |
| 179 | Patient has not met the required waiting requirements. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. This change effective September 1, 2017: Patient has not met the required waiting requirements. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Start: 06/30/2005 | Last Modified: 03/01/2017 |
| 180 | Patient has not met the required residency requirements. Start: 06/30/2005 | Last Modified: 09/30/2007 |
| 181 | Procedure code was invalid on the date of service. Start: 06/30/2005 | Last Modified: 09/30/2007 |
| 182 | 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. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. This change effective September 1, 2017: The referring provider is not eligible to refer the service billed. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Start: 06/30/2005 | Last Modified: 03/01/2017 |
| 184 | The prescribing/ordering provider is not eligible to prescribe/order the service billed. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. This change effective September 1, 2017: The prescribing/ordering provider is not eligible to prescribe/order the service billed. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Start: 06/30/2005 | Last Modified: 03/01/2017 |
| 185 | The rendering provider is not eligible to perform the service billed. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. This change effective September 1, 2017: The rendering provider is not eligible to perform the service billed. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Start: 06/30/2005 | Last Modified: 03/01/2017 |
| 186 | Level of care change adjustment. Start: 06/30/2005 | Last Modified: 09/30/2007 |
| 187 | Consumer Spending Account payments (includes but is not limited to Flexible Spending Account, Health Savings Account, Health Reimbursement Account, etc.) Start: 06/30/2005 | Last Modified: 01/25/2009 |
| 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 |
| 192 | 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. This change effective September 1, 2017: Non standard adjustment code from paper remittance. Usage: 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: 03/01/2017 |
| 193 | Original payment decision is being maintained. Upon review, it was determined that this claim was processed properly. Start: 02/28/2006 | Last Modified: 01/27/2008 |
| 194 | Anesthesia performed by the operating physician, the assistant surgeon or the attending physician. Start: 02/28/2006 | Last Modified: 09/30/2007 |
| 195 | Refund issued to an erroneous priority payer for this claim/service. Start: 02/28/2006 | Last Modified: 09/30/2007 |
| 197 | Precertification/authorization/notification absent. Start: 10/31/2006 | Last Modified: 09/30/2007 |
| 198 | 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 | Patient is responsible for amount of this claim/service through 'set aside arrangement' or other agreement. (Use only with Group Code PR) At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.) Start: 10/31/2006 | Last Modified: 09/28/2014 Notes: Not for use by Workers' Compensation payers; use code P3 instead. |
| 202 | Non-covered personal comfort or convenience services. Start: 02/28/2007 | Last Modified: 09/30/2007 |
| 203 | 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 | National Provider Identifier - missing. Start: 07/09/2007 | Last Modified: 09/30/2007 |
| 207 | National Provider identifier - Invalid format Start: 07/09/2007 | Last Modified: 06/01/2008 |
| 208 | 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 only with Group code OA) Start: 07/09/2007 | Last Modified: 07/01/2013 |
| 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 |
| 213 | Non-compliance with the physician self referral prohibition legislation or payer policy. Start: 01/27/2008 |
| 215 | Based on subrogation of a third party settlement Start: 01/27/2008 |
| 216 | Based on the findings of a review organization Start: 01/27/2008 |
| 219 | Based on extent of injury. Note: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier 'IG') for the jurisdictional regulation. If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF). This change effective September 1, 2017: Based on extent of injury. Usage: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier 'IG') for the jurisdictional regulation. If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF). Start: 01/27/2008 | Last Modified: 03/01/2017 |
| 222 | Exceeds the contracted maximum number of hours/days/units by this provider for this period. This is not patient specific. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. This change effective September 1, 2017: Exceeds the contracted maximum number of hours/days/units by this provider for this period. This is not patient specific. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Start: 06/01/2008 | Last Modified: 03/01/2017 |
| 223 | Adjustment code for mandated federal, state or local law/regulation that is not already covered by another code and is mandated before a new code can be created. Start: 06/01/2008 |
| 224 | Patient identification compromised by identity theft. Identity verification required for processing this and future claims. Start: 06/01/2008 |
| 225 | Penalty or Interest Payment by Payer (Only used for plan to plan encounter reporting within the 837) Start: 06/01/2008 |
| 226 | Information requested from the Billing/Rendering Provider was not provided or not provided timely or was insufficient/incomplete. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.) Start: 09/21/2008 | Last Modified: 07/01/2013 |
| 227 | Information requested from the patient/insured/responsible party was not provided or was insufficient/incomplete. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.) Start: 09/21/2008 | Last Modified: 09/20/2009 |
| 228 | Denied for failure of this provider, another provider or the subscriber to supply requested information to a previous payer for their adjudication Start: 09/21/2008 |
| 229 | Partial charge amount not considered by Medicare due to the initial claim Type of Bill being 12X. Note: This code can only be used in the 837 transaction to convey Coordination of Benefits information when the secondary payer's cost avoidance policy allows providers to bypass claim submission to a prior payer. (Use only with Group Code PR) This change effective September 1, 2017: Partial charge amount not considered by Medicare due to the initial claim Type of Bill being 12X. Usage: This code can only be used in the 837 transaction to convey Coordination of Benefits information when the secondary payer's cost avoidance policy allows providers to bypass claim submission to a prior payer. (Use only with Group Code PR) Start: 01/25/2009 | Last Modified: 03/01/2017 |
| 231 | Mutually exclusive procedures cannot be done in the same day/setting. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. This change effective September 1, 2017: Mutually exclusive procedures cannot be done in the same day/setting. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Start: 07/01/2009 | Last Modified: 03/01/2017 |
| 232 | Institutional Transfer Amount. Note - Applies to institutional claims only and explains the DRG amount difference when the patient care crosses multiple institutions. This change effective September 1, 2017: Institutional Transfer Amount. Usage - Applies to institutional claims only and explains the DRG amount difference when the patient care crosses multiple institutions. Start: 11/01/2009 | Last Modified: 03/01/2017 |
| 233 | Services/charges related to the treatment of a hospital-acquired condition or preventable medical error. Start: 01/24/2010 |
| 234 | This procedure is not paid separately. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.) Start: 01/24/2010 |
| 235 | Sales Tax Start: 06/06/2010 |
| 236 | This procedure or procedure/modifier combination is not compatible with another procedure or procedure/modifier combination provided on the same day according to the National Correct Coding Initiative or workers compensation state regulations/ fee schedule requirements. Start: 01/30/2011 | Last Modified: 07/01/2013 |
| 237 | Legislated/Regulatory Penalty. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.) Start: 06/05/2011 |
| 238 | Claim spans eligible and ineligible periods of coverage, this is the reduction for the ineligible period. (Use only with Group Code PR) Start: 03/01/2012 | Last Modified: 07/01/2013 |
| 239 | Claim spans eligible and ineligible periods of coverage. Rebill separate claims. Start: 03/01/2012 | Last Modified: 01/29/2012 |
| 240 | The diagnosis is inconsistent with the patient's birth weight. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. This change effective September 1, 2017: The diagnosis is inconsistent with the patient's birth weight. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Start: 06/03/2012 | Last Modified: 03/01/2017 |
| 241 | Low Income Subsidy (LIS) Co-payment Amount Start: 06/03/2012 |
| 242 | Services not provided by network/primary care providers. Start: 06/03/2012 | Last Modified: 06/02/2013 Notes: This code replaces deactivated code 38 |
| 243 | Services not authorized by network/primary care providers. Start: 06/03/2012 | Last Modified: 06/02/2013 Notes: This code replaces deactivated code 38 |
| 245 | Provider performance program withhold. Start: 09/30/2012 |
| 246 | This non-payable code is for required reporting only. Start: 09/30/2012 |
| 247 | Deductible for Professional service rendered in an Institutional setting and billed on an Institutional claim. Start: 09/30/2012 Notes: For Medicare Bundled Payment use only, under the Patient Protection and Affordable Care Act (PPACA). |
| 248 | Coinsurance for Professional service rendered in an Institutional setting and billed on an Institutional claim. Start: 09/30/2012 Notes: For Medicare Bundled Payment use only, under the Patient Protection and Affordable Care Act (PPACA). |
| 249 | This claim has been identified as a readmission. (Use only with Group Code CO) Start: 09/30/2012 |
| 250 | The attachment/other documentation that was received was the incorrect attachment/document. The expected attachment/document is still missing. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT). Start: 09/30/2012 | Last Modified: 06/01/2014 |
| 251 | The attachment/other documentation that was received was incomplete or deficient. The necessary information is still needed to process the claim. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT). Start: 09/30/2012 | Last Modified: 06/01/2014 |
| 252 | An attachment/other documentation is required to adjudicate this claim/service. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT). Start: 09/30/2012 | Last Modified: 06/02/2013 |
| 253 | Sequestration - reduction in federal payment Start: 06/02/2013 | Last Modified: 11/01/2013 |
| 254 | Claim received by the dental plan, but benefits not available under this plan. Submit these services to the patient's medical plan for further consideration. Start: 06/02/2013 |
| 256 | Service not payable per managed care contract. Start: 06/02/2013 |
| 257 | The disposition of the claim/service is undetermined during the premium payment grace period, per Health Insurance Exchange requirements. This claim/service will be reversed and corrected when the grace period ends (due to premium payment or lack of premium payment). (Use only with Group Code OA) Start: 11/01/2013 | Last Modified: 06/01/2014 Notes: To be used after the first month of the grace period. |
| 258 | Claim/service not covered when patient is in custody/incarcerated. Applicable federal, state or local authority may cover the claim/service. Start: 11/01/2013 |
| 259 | Additional payment for Dental/Vision service utilization. Start: 01/26/2014 |
| 260 | Processed under Medicaid ACA Enhanced Fee Schedule Start: 01/26/2014 |
| 261 | The procedure or service is inconsistent with the patient's history. Start: 06/01/2014 |
| 262 | Adjustment for delivery cost. Note: To be used for pharmaceuticals only. This change effective September 1, 2017: Adjustment for delivery cost. Usage: To be used for pharmaceuticals only. Start: 11/01/2014 | Last Modified: 03/01/2017 |
| 263 | Adjustment for shipping cost. Note: To be used for pharmaceuticals only. This change effective September 1, 2017: Adjustment for shipping cost. Usage: To be used for pharmaceuticals only. Start: 11/01/2014 | Last Modified: 03/01/2017 |
| 264 | Adjustment for postage cost. Note: To be used for pharmaceuticals only. This change effective September 1, 2017: Adjustment for postage cost. Usage: To be used for pharmaceuticals only. Start: 11/01/2014 | Last Modified: 03/01/2017 |
| 265 | Adjustment for administrative cost. Note: To be used for pharmaceuticals only. This change effective September 1, 2017: Adjustment for administrative cost. Usage: To be used for pharmaceuticals only. Start: 11/01/2014 | Last Modified: 03/01/2017 |
| 266 | Adjustment for compound preparation cost. Note: To be used for pharmaceuticals only. This change effective September 1, 2017: Adjustment for compound preparation cost. Usage: To be used for pharmaceuticals only. Start: 11/01/2014 | Last Modified: 03/01/2017 |
| 267 | Claim/service spans multiple months. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.) Start: 11/01/2014 | Last Modified: 04/01/2015 |
| 268 | The Claim spans two calendar years. Please resubmit one claim per calendar year. Start: 11/01/2014 |
| 269 | Anesthesia not covered for this service/procedure. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. This change effective September 1, 2017: Anesthesia not covered for this service/procedure. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Start: 03/01/2015 | Last Modified: 03/01/2017 |
| 270 | Claim received by the medical plan, but benefits not available under this plan. Submit these services to the patient’s dental plan for further consideration. Start: 07/01/2015 |
| 271 | Prior contractual reductions related to a current periodic payment as part of a contractual payment schedule when deferred amounts have been previously reported. (Use only with group code OA) Start: 11/01/2015 |
| 272 | Coverage/program guidelines were not met. Start: 11/01/2015 |
| 273 | Coverage/program guidelines were exceeded. Start: 11/01/2015 |
| 274 | Fee/Service not payable per patient Care Coordination arrangement. Start: 11/01/2015 |
| 275 | Prior payer's (or payers') patient responsibility (deductible, coinsurance, co-payment) not covered. (Use only with Group Code PR) Start: 11/01/2015 |
| 276 | Services denied by the prior payer(s) are not covered by this payer. Start: 11/01/2015 |
| 277 | The disposition of the claim/service is undetermined during the premium payment grace period, per Health Insurance SHOP Exchange requirements. This claim/service will be reversed and corrected when the grace period ends (due to premium payment or lack of premium payment). (Use only with Group Code OA) Start: 11/01/2015 Notes: To be used during 31 day SHOP grace period. |
| 278 | Performance program proficiency requirements not met. (Use only with Group Codes CO or PI) Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. This change effective September 1, 2017: Performance program proficiency requirements not met. (Use only with Group Codes CO or PI) Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Start: 07/01/2016 | Last Modified: 03/01/2017 |
| 279 | Services not provided by Preferred network providers. Start: 11/01/2016 |
| 280 | Claim received by the medical plan, but benefits not available under this plan. Submit these services to the patient's Pharmacy plan for further consideration. Start: 03/01/2017 |
| 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 NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.) Start: 01/01/1995 | Last Modified: 09/20/2009 |
| 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 |
| A8 | Ungroupable DRG. Start: 01/01/1995 | Last Modified: 09/30/2007 |
| B1 | Non-covered visits. Start: 01/01/1995 |
| B4 | Late filing penalty. Start: 01/01/1995 |
| B7 | This provider was not certified/eligible to be paid for this procedure/service on this date of service. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. This change effective September 1, 2017: This provider was not certified/eligible to be paid for this procedure/service on this date of service. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Start: 01/01/1995 | Last Modified: 03/01/2017 |
| B8 | Alternative services were available, and should have been utilized. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. This change effective September 1, 2017: Alternative services were available, and should have been utilized. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Start: 01/01/1995 | Last Modified: 03/01/2017 |
| B9 | 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 | Only one visit or consultation per physician per day is covered. Start: 01/01/1995 | Last Modified: 09/30/2007 |
| B15 | This service/procedure requires that a qualifying service/procedure be received and covered. The qualifying other service/procedure has not been received/adjudicated. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. This change effective September 1, 2017: This service/procedure requires that a qualifying service/procedure be received and covered. The qualifying other service/procedure has not been received/adjudicated. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Start: 01/01/1995 | Last Modified: 03/01/2017 |
| B16 | 'New Patient' qualifications were not met. Start: 01/01/1995 | Last Modified: 09/30/2007 |
| B20 | Procedure/service was partially or fully furnished by another provider. Start: 01/01/1995 | Last Modified: 09/30/2007 |
| B22 | This payment is adjusted based on the diagnosis. Start: 01/01/1995 | Last Modified: 02/28/2001 |
| B23 | Procedure billed is not authorized per your Clinical Laboratory Improvement Amendment (CLIA) proficiency test. Start: 01/01/1995 | Last Modified: 09/30/2007 |
| P1 | State-mandated Requirement for Property and Casualty, see Claim Payment Remarks Code for specific explanation. To be used for Property and Casualty only. Start: 11/01/2013 Notes: This code replaces deactivated code 162 |
| P2 | Not a work related injury/illness and thus not the liability of the workers' compensation carrier Note: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier 'IG') for the jurisdictional regulation. If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF). To be used for Workers' Compensation only. This change effective September 1, 2017: Not a work related injury/illness and thus not the liability of the workers' compensation carrier Usage: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier 'IG') for the jurisdictional regulation. If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF). To be used for Workers' Compensation only. Start: 11/01/2013 | Last Modified: 03/01/2017 Notes: This code replaces deactivated code 191 |
| P3 | Workers' Compensation case settled. Patient is responsible for amount of this claim/service through WC 'Medicare set aside arrangement' or other agreement. To be used for Workers' Compensation only. (Use only with Group Code PR) Start: 11/01/2013 Notes: This code replaces deactivated code 201 |
| P4 | Workers' Compensation claim adjudicated as non-compensable. This Payer not liable for claim or service/treatment. Note: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier 'IG') for the jurisdictional regulation. If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF). To be used for Workers' Compensation only This change effective September 1, 2017: Workers' Compensation claim adjudicated as non-compensable. This Payer not liable for claim or service/treatment. Usage: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier 'IG') for the jurisdictional regulation. If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF). To be used for Workers' Compensation only Start: 11/01/2013 | Last Modified: 03/01/2017 Notes: This code replaces deactivated code 214 |
| P5 | Based on payer reasonable and customary fees. No maximum allowable defined by legislated fee arrangement. To be used for Property and Casualty only. Start: 11/01/2013 Notes: This code replaces deactivated code 217 |
| P6 | Based on entitlement to benefits. Note: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier 'IG') for the jurisdictional regulation. If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF). To be used for Property and Casualty only. This change effective September 1, 2017: Based on entitlement to benefits. Usage: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier 'IG') for the jurisdictional regulation. If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF). To be used for Property and Casualty only. Start: 11/01/2013 | Last Modified: 03/01/2017 Notes: This code replaces deactivated code 218 |
| P7 | The applicable fee schedule/fee database does not contain the billed code. Please resubmit a bill with the appropriate fee schedule/fee database code(s) that best describe the service(s) provided and supporting documentation if required. To be used for Property and Casualty only. Start: 11/01/2013 Notes: This code replaces deactivated code 220 |
| P8 | Claim is under investigation. Note: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier 'IG') for the jurisdictional regulation. If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF). To be used for Property and Casualty only. This change effective September 1, 2017: Claim is under investigation. Usage: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier 'IG') for the jurisdictional regulation. If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF). To be used for Property and Casualty only. Start: 11/01/2013 | Last Modified: 03/01/2017 Notes: This code replaces deactivated code 221 |
| P9 | No available or correlating CPT/HCPCS code to describe this service. To be used for Property and Casualty only. Start: 11/01/2013 Notes: This code replaces deactivated code 230 |
| P10 | Payment reduced to zero due to litigation. Additional information will be sent following the conclusion of litigation. To be used for Property and Casualty only. Start: 11/01/2013 Notes: This code replaces deactivated code 244 |
| P11 | The disposition of the related Property & Casualty claim (injury or illness) is pending due to litigation. To be used for Property and Casualty only. (Use only with Group Code OA) Start: 11/01/2013 Notes: This code replaces deactivated code 255 |
| P12 | Workers' compensation jurisdictional fee schedule adjustment. Note: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Class of Contract Code Identification Segment (Loop 2100 Other Claim Related Information REF). If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF) if the regulations apply. To be used for Workers' Compensation only. This change effective September 1, 2017: Workers' compensation jurisdictional fee schedule adjustment. Usage: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Class of Contract Code Identification Segment (Loop 2100 Other Claim Related Information REF). If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF) if the regulations apply. To be used for Workers' Compensation only. Start: 11/01/2013 | Last Modified: 03/01/2017 Notes: This code replaces deactivated code W1 |
| P13 | Payment reduced or denied based on workers' compensation jurisdictional regulations or payment policies, use only if no other code is applicable. Note: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier 'IG') if the jurisdictional regulation applies. If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF) if the regulations apply. To be used for Workers' Compensation only. This change effective September 1, 2017: Payment reduced or denied based on workers' compensation jurisdictional regulations or payment policies, use only if no other code is applicable. Usage: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier 'IG') if the jurisdictional regulation applies. If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF) if the regulations apply. To be used for Workers' Compensation only. Start: 11/01/2013 | Last Modified: 03/01/2017 Notes: This code replaces deactivated code W2 |
| P14 | The Benefit for this Service is included in the payment/allowance for another service/procedure that has been performed on the same day. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. To be used for Property and Casualty only. This change effective September 1, 2017: The Benefit for this Service is included in the payment/allowance for another service/procedure that has been performed on the same day. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. To be used for Property and Casualty only. Start: 11/01/2013 | Last Modified: 03/01/2017 Notes: This code replaces deactivated code W3 |
| P15 | Workers' Compensation Medical Treatment Guideline Adjustment. To be used for Workers' Compensation only. Start: 11/01/2013 Notes: This code replaces deactivated code W4 |
| P16 | Medical provider not authorized/certified to provide treatment to injured workers in this jurisdiction. To be used for Workers' Compensation only. (Use with Group Code CO or OA) Start: 11/01/2013 Notes: This code replaces deactivated code W5 |
| P17 | Referral not authorized by attending physician per regulatory requirement. To be used for Property and Casualty only. Start: 11/01/2013 Notes: This code replaces deactivated code W6 |
| P18 | Procedure is not listed in the jurisdiction fee schedule. An allowance has been made for a comparable service. To be used for Property and Casualty only. Start: 11/01/2013 Notes: This code replaces deactivated code W7 |
| P19 | Procedure has a relative value of zero in the jurisdiction fee schedule, therefore no payment is due. To be used for Property and Casualty only. Start: 11/01/2013 Notes: This code replaces deactivated code W8 |
| P20 | Service not paid under jurisdiction allowed outpatient facility fee schedule. To be used for Property and Casualty only. Start: 11/01/2013 Notes: This code replaces deactivated code W9 |
| P21 | Payment denied based on Medical Payments Coverage (MPC) or Personal Injury Protection (PIP) Benefits jurisdictional regulations or payment policies, use only if no other code is applicable. Note: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier 'IG') if the jurisdictional regulation applies. If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF) if the regulations apply. To be used for Property and Casualty Auto only. This change effective September 1, 2017: Payment denied based on Medical Payments Coverage (MPC) or Personal Injury Protection (PIP) Benefits jurisdictional regulations or payment policies, use only if no other code is applicable. Usage: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier 'IG') if the jurisdictional regulation applies. If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF) if the regulations apply. To be used for Property and Casualty Auto only. Start: 11/01/2013 | Last Modified: 03/01/2017 Notes: This code replaces deactivated code Y1 |
| P22 | Payment adjusted based on Medical Payments Coverage (MPC) or Personal Injury Protection (PIP) Benefits jurisdictional regulations or payment policies, use only if no other code is applicable. Note: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier 'IG') if the jurisdictional regulation applies. If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF) if the regulations apply. To be used for Property and Casualty Auto only. This change effective September 1, 2017: Payment adjusted based on Medical Payments Coverage (MPC) or Personal Injury Protection (PIP) Benefits jurisdictional regulations or payment policies, use only if no other code is applicable. Usage: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier 'IG') if the jurisdictional regulation applies. If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF) if the regulations apply. To be used for Property and Casualty Auto only. Start: 11/01/2013 | Last Modified: 03/01/2017 Notes: This code replaces deactivated code Y2 |
| P23 | Medical Payments Coverage (MPC) or Personal Injury Protection (PIP) Benefits jurisdictional fee schedule adjustment. Note: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Class of Contract Code Identification Segment (Loop 2100 Other Claim Related Information REF). If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF) if the regulations apply. To be used for Property and Casualty Auto only. This change effective September 1, 2017: Medical Payments Coverage (MPC) or Personal Injury Protection (PIP) Benefits jurisdictional fee schedule adjustment. Usage: If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835 Class of Contract Code Identification Segment (Loop 2100 Other Claim Related Information REF). If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF) if the regulations apply. To be used for Property and Casualty Auto only. Start: 11/01/2013 | Last Modified: 03/01/2017 Notes: This code replaces deactivated code Y3 |