Anesthesia performed by the operating physician, the assistant surgeon or the attending physician. 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. Payment is included in the allowance for a Skilled Nursing Facility (SNF) qualified stay. 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. Reason Code Description 1 Deductible Amount 2 Coinsurance Amount 3 Co-payment Amount 4 The procedure code is inconsistent with the modifier used or a required Service was not prescribed prior to delivery. 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). Claim/service denied. Injury/illness was the result of an activity that is a benefit exclusion. At least one Remark Code must be provided (may be comprised of either the Remittance Advice Remark Code or NCPDP Reject Reason Code. The list below shows the status of change requests which are in process. 0. 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. If any error on the claim that caused it to deny can be corrected, the corrected claim can be resubmitted to MassHealth. Payment adjusted because the patient has not met the required eligibility, spend down, waiting, or residency requirements. 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. Reason Code 111: Procedure/product not approved by the Food and Drug Administration. Refund to patient if collected. (Use only with Group Code PR), Workers' Compensation claim adjudicated as non-compensable. (Use only with Group Code OA). B10 and click the NEXT button in the Search Box to locate the Adjustment Reason code you are inquiring on. Lifetime benefit maximum has been reached. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. This reason code list will help you to identify the actual reason of adjustment or reduced payment. Patient has not met the required spend down requirements. 5 The procedure code/bill type is inconsistent with the place of service. Note: To be used for pharmaceuticals only. 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. Additional information will be sent following the conclusion of litigation. To be used for Property and Casualty Auto only. Non-covered personal comfort or convenience services. 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. To be used for P&C Auto only. Upon review, it was determined that this claim was processed properly. This non-payable code is for required reporting only. Reason Code 238: Low Income Subsidy (LIS) Co-payment Amount. 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.) Claim/service denied based on prior payer's coverage determination. The disposition of the claim/service is undetermined during the premium payment grace period, per Health Insurance Exchange requirements. Balance does not exceed co-payment amount. 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. Use only with Group Code CO. Payment adjusted based on Medical Provider Network (MPN). Claim spans eligible and ineligible periods of coverage. Did you receive a code from a health plan, such as: PR32 or CO286? 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). Reason Code 264: Claim/service spans multiple months. To be used for Property and Casualty only. Submit these services to the patient's dental plan for further consideration. WebCode Description 01 Deductible amount. Anesthesia performed by the operating physician, the assistant surgeon or the attending physician. Refund issued to an erroneous priority payer for this claim/service. Reason Code 59: Payment denied/reduced for absence of, or exceeded, pre-certification/authorization. Reason Code 166: Alternate benefit has been provided. Based on payer reasonable and customary fees. Just hold control key and press F. Incentive adjustment, e.g. Payment reduced to zero due to litigation. Reason Code 195: Precertification/authorization exceeded. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. 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. An allowance has been made for a comparable service. Reason Code 205: National Provider Identifier - Not matched. Reason Code 126: Prior processing information appears incorrect. Charges exceed our fee schedule or maximum allowable amount. Reason Code 186: 'Not otherwise classified' or 'unlisted' procedure code (CPT/HCPCS) was billed when there is a specific procedure code for this procedure/service. Coinsurance day. The procedure/revenue code is inconsistent with the patient's gender. 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. Reason Code 158: Provider performance bonus. Patient has not met the required residency requirements. This is not patient specific. Reason Code 29: Our records indicate that this dependent is not an eligible dependent as defined. 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. Payment adjusted based on Voluntary Provider network (VPN). ), Claim spans eligible and ineligible periods of coverage, this is the reduction for the ineligible period (use 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.). Reason Code 120: Payer refund due to overpayment. Claim has been forwarded to the patient's medical plan for further consideration. Your Stop loss deductible has not been met. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Reason Code 165: Service(s) have been considered under the patient's medical plan. Coverage/program guidelines were not met or were exceeded. Contact Our Denial Management Experts Now. Submission/billing error(s). WebRefer Senate Bill 21-256, as amended, to the Committee of the Whole. Administrative surcharges are not covered. Lifetime benefit maximum has been reached. Prior processing information appears incorrect. To renewan X12 membership, complete and submit an application form which will be reviewed and verified, then you will be notified of the next steps. The benefit for this service is included in the payment/allowance for another service/procedure that has already been adjudicated. Patient payment option/election not in effect. Reason Code: 204. The diagnosis is inconsistent with the patient's gender. Indemnification adjustment - compensation for outstanding member responsibility. Search box will appear then put your adjustment reason code in search box e.g. Claim/service not covered by this payer/contractor. Reason Code 129: Prearranged demonstration project adjustment. Claim lacks indication that service was supervised or evaluated by a physician. ), Reason Code 123: Deductible -- Major Medical, Reason Code 124: Coinsurance -- Major Medical. Applicable federal, state or local authority may cover the claim/service. To be used for Workers' Compensation only. Reason Code 201: This service/equipment/drug is not covered under the patients current benefit plan, Reason Code 202: Pharmacy discount card processing fee. The "PR" is a Claim Adjustment Group Code and the description for "32" is below. Identity verification required for processing this and future claims. Reimbursement vs Contract rate updates. Reason Code 191: Anesthesia performed by the operating physician, the assistant surgeon or the attending physician. (Use only with Group code OA), Payment adjusted because pre-certification/authorization not received in a timely fashion. This claim has been identified as a readmission. Reason Code 42: Charge exceeds fee schedule/maximum allowable or contracted/legislated fee arrangement. 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. The diagnosis is inconsistent with the procedure. 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.). Reason Code 208: National Drug Codes (NDC) not eligible for rebate, are not covered. The diagnosis is inconsistent with the provider type. Treatment was deemed by the payer to have been rendered in an inappropriate or invalid place of service. 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). Claim/service denied based on prior payer's coverage determination. OA : Other adjustments. Upon review, it was determined that this claim was processed properly. Code. Reason Code 173: Prescription is not current. Are you looking for more than one billing quotes? To be used for Property & Casualty only.