Use code 16 and remark codes if necessary. The procedure or service is inconsistent with the patient's history. External liaisons represent X12's interests to another organization as defined in a formal agreement between the two organizations. Content is added to this page regularly. Service not paid under jurisdiction allowed outpatient facility fee schedule. Claim is under investigation. 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.). Treatment was deemed by the payer to have been rendered in an inappropriate or invalid place of service. To be used for Workers' Compensation only. This Payer not liable forclaim or service/treatment. The prescribing/ordering provider is not eligible to prescribe/order the service billed. 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. Prearranged demonstration project adjustment. PR 34 Claim denied. 21 This injury/illness is the liability of the no-fault carrier. P10 Payment reduced to zero due to litigation. After this process resubmit the claims and it will be processed. Note: Inactive for 004010, since 2/99. PR 168 Payment denied as Service(s) have been considered under the patients medical plan. Adjustment for compound preparation cost. Claim did not include patients medical record for the service. 138 Appeal procedures not followed or time limits not met. Usage: To be used for pharmaceuticals only. This payment is adjusted based on the diagnosis. The disposition of the related Property & Casualty claim (injury or illness) is pending due to litigation. (Use with Group Code CO or OA). Please resubmit one claim per calendar year. The basic principles for the correct coding policy are The service represents the standard of care in accomplishing the overall procedure; This payment reflects the correct code. Secondary insurance bill or patient bill. importance of safety and hygiene tourism This change effective 1/1/2008: Patient Interest Adjustment (Use Only Group code PR). 97 The benefit for this service is included in the payment/allowance for another service/procedure that has already been adjudicated. 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. 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. 164 Attachment/other documentation referenced on the claim was not received in a timely fashion. B19 Claim/service adjusted because of the finding of a Review Organization. Claim received by the medical plan, but benefits not available under this plan. 181 Procedure code was invalid on the date of service. Discount agreed to in Preferred Provider contract. Group codes include CO (contractual obligations), OA (other adjustments) and PR (patient responsibility). I have a patient with Providence as primary and BxBs as a secondary payor and the first bxbs payment came through just fine, the patient had some copay, some deductible, and some write off. 120 Patient is covered by a managed care plan. 20 This injury/illness is covered by the liability carrier. 184 The prescribing/ordering provider is not eligible to prescribe/order the service billed. For example PR 45, We could bill patient but for CO 45, its a adjustment and we cant bill the patient. No maximum allowable defined by legislated fee arrangement. Browse and download meeting minutes by committee. Pleaseresubmit a bill with the appropriate fee schedule/fee database code(s) that best describethe service(s) provided and supporting documentation if required. (Note: To be used by Property & Casualty only). Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Procedure billed is not authorized per your Clinical Laboratory Improvement Amendment (CLIA) proficiency test. PR 204 This service/equipment/drug is not covered under the patients current benefit plan PR B1 Non-covered visits. 53 Services by an immediate relative or a member of the same household are not covered. P11 The disposition of the related Property & Casualty claim (injury or illness) is pending due to litigation. PR Patient Responsibility denial code list. Deductible for Professional service rendered in an Institutional setting and billed on an Institutional claim. (Use only with Group Code OA). Claim/service denied. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. 220 The applicable fee schedule/fee database does not contain the billed code. 194 Anesthesia performed by the operating physician, the assistant surgeon or the attending physician. Charges do not meet qualifications for emergent/urgent care. 60 Charges for outpatient services are not covered when performed within a period of time prior to or after inpatient services. The procedure/revenue code is inconsistent with the patient's gender. These are non-covered services because this is not deemed a 'medical necessity' by the payer. Claim lacks indicator that `x-ray is available for review.' 179 Patient has not met the required waiting requirements. Coverage/program guidelines were exceeded. 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). 119 Benefit maximum for this time period or occurrence has been reached.

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. To be used for Property & Casualty only. However, this amount may be billed to subsequent payer. (Use only with Group Code PR). 238 Claim spans eligible and ineligible periods of coverage, this is the reduction for the ineligible period. 46 This (these) service(s) is (are) not covered. This (these) diagnosis(es) is (are) missing or are invalid, Reimbursement was adjusted for the reasons to be provided in separate correspondence. (Use only with Group Code PR). 246 This non-payable code is for required reporting only. 249 This claim has been identified as a readmission. B21 The charges were reduced because the service/care was partially furnished by anotherphysician. The procedure/revenue code is inconsistent with the patient's age. The diagnosis is inconsistent with the procedure. B11 The claim/service has been transferred to the proper payer/processor for processing.Claim/service not covered by this payer/processor. An attachment/other documentation is required to adjudicate this claim/service. Claim has been forwarded to the patient's Behavioral Health Plan for further consideration. 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. 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. The X12 Board and the Accredited Standards Committees Steering group (Steering) collaborate to ensure the best interests of X12 are served. B22 This payment is adjusted based on the diagnosis. To be used for Workers' Compensation only. 55 Procedure/treatment is deemed experimental/investigational by the payer. Original payment decision is being maintained. The Claim spans two calendar years. The list below shows the status of change requests which are in process. Payment adjusted because the patient has not met the required eligibility, spend down, waiting, or residency requirements.

If adjustment is at the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment information REF) if the regulations apply. This service/equipment/drug is not covered under the patient's current benefit plan, National Provider identifier - Invalid format. This service/procedure requires that a qualifying service/procedure be received and covered. Claim adjustment reason codes (CARCs) communicate an adjustment, meaning that they must communicate why a claim or service line was paid differently than it was billed.If there is W7 Procedure is not listed in the jurisdiction fee schedule. Coverage/program guidelines were not met.

Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. The CO16 denial code alerts you that there is information that is missing in order for Medicare to process the claim. WebANSI Reason & Remark Codes The Washington Publishing Company maintains a standard code set used industry wide to provide information regarding claim processing.. Benefits are not available under this dental plan, PR 177 Payment denied because the patient has not met the required eligibility requirements, PR 200 Expenses incurred during lapse in coverage. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Once your claim has been rejected and it bears the CO 4 Denial code, there are two options that you are left with: Check if the modifier is in the consistent mode. (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.). 204: Denial Code - Lifetime reserve days. PI (Payer Initiated Reductions) is used by payers when it is believed the adjustment is not the responsibility of the patient. 148 Information from another provider was not provided or was insufficient/incomplete. X12 appoints various types of liaisons, including external and internal liaisons. 197 Precertification/authorization/notification absent. Alternative services were available, and should have been utilized. P12 Workers compensation jurisdictional fee schedule adjustment. Reason Code 2: The procedure code/bill type is inconsistent with the place of service. P2 Not a work related injury/illness and thus not the liability of the workers compensation carrier. We have already discussed with great detail that the denial code stands as a piece of The authorization number is missing, invalid, or does not apply to the billed services or provider. What is PR 1 medical billing?

PR 201 Workers Compensation case settled. Procedure/treatment has not been deemed 'proven to be effective' by the payer. PR 140 Patient/Insured health identification number and name do not match.PR 149 Lifetime benefit maximum has been reached for this service/benefit category. P5 Based on payer reasonable and customary fees. P4 Workers Compensation claim adjudicated as non-compensable.

192 Non standard adjustment code from paper remittance. Claim/Service has invalid non-covered days. W6 Referral not authorized by attending physician per regulatory requirement. Low Income Subsidy (LIS) Co-payment Amount. 256 Service not payable per managed care contract. Based on industry feedback, X12 is using a phased approach for the recommendations rather than presenting the entire catalog of adopted and mandated transactions at once. Precertification/authorization/notification/pre-treatment absent. 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.) Claims should be filed to the correct payer the beneficiary resides in at the time of claim submission. The date of birth follows the date of service. Insured has no dependent coverage. 173 Service/equipment was not prescribed by a physician. Payment adjusted based on Voluntary Provider network (VPN). (Use only with Group Code CO). The rendering provider is not eligible to perform the service billed.

Predetermination: anticipated payment upon completion of services or claim adjudication. To be used for Workers' Compensation only. 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). All of our contact information is here. Claim received by the medical plan, but benefits not available under this plan. Non-covered charge(s). Usage: To be used for pharmaceuticals only. Identify the correct Medicare contractor to process the claim.Verify the beneficiary through insurance websites. 129 Prior processing information appears incorrect. (Use only with Group code OA), Payment adjusted because pre-certification/authorization not received in a timely fashion. D20 Claim/Service missing service/product information. 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. Ingredient cost adjustment. 208 National Provider Identifier Not matched. 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). Medical provider not authorized/certified to provide treatment to injured workers in this jurisdiction. 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. These services were submitted after this payers responsibility for processing claims under this plan ended. 9 The diagnosis is inconsistent with the patients age. 149 Lifetime benefit maximum has been reached for this service/benefit category. Claim/Service lacks Physician/Operative or other supporting documentation. Service not paid under jurisdiction allowed outpatient facility fee schedule. D5 Claim/service denied. 150 Payer deems the information submitted does not support this level of service. Payment adjusted based on the Medical Payments Coverage (MPC) and/or Personal Injury Protection (PIP) Benefits jurisdictional regulations, or payment policies. Each recommendation will cover a set of logically grouped transactions and will include supporting information that will assist reviewers as they look at the functionality enhancements and other revisions.

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