Coinsurance for Professional service rendered in an Institutional setting and billed on an Institutional claim. The impact of prior payer(s) adjudication including payments and/or adjustments. Payment denied because service/procedure was provided outside the United States or as a result of war. 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.) 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 received by the dental plan, but benefits not available under this plan. CO-50, CO-57, CO-151, N-115 - Medical Necessity: An ICD-9 code (s) was submitted that is not covered under a LCD/NCD CMS houses all information for Local Coverage or National Coverage Determinations that have been established. Sequestration - reduction in federal payment. From attempts to insert intelligent design creationism into public schools to climate change denial, efforts to "cure" gay people through conversion therapy . 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). Usage: To be used for pharmaceuticals 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). No available or correlating CPT/HCPCS code to describe this service. This claim has been identified as a readmission. Procedure code was invalid on the date of service. Claim/Service has invalid non-covered days. 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). Identity verification required for processing this and future claims. Procedure modifier was invalid on the date of service. The prescribing/ordering provider is not eligible to prescribe/order the service billed. Service/procedure was provided as a result of terrorism. Information related to the X12 corporation is listed in the Corporate section below. The Claim Adjustment Group Codes are internal to the X12 standard. Online access to all available versions ofX12 products, including The EDI Standard, Code Source Directory, Control Standards, EDI Standard Figures, Guidelines and Technical Reports. The date of death precedes the date of service. This (these) diagnosis(es) is (are) not covered, missing, or are invalid. Submit a request for interpretation (RFI) related to the implementation and use of X12 work. 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). CO150 is associated with the remark code M3: Equipment is the same or similar to equipment already being used. Only one visit or consultation per physician per day is covered. Payment made to patient/insured/responsible party. 100135 . No available or correlating CPT/HCPCS code to describe this service. . CO 19 Denial Code - This is a work-related injury/illness and thus the liability of the Worker's Compensation Carrier; CO 20 and CO 21 Denial Code; CO 23 Denial Code - The impact of prior payer(s) adjudication including payments and/or adjustments; CO 26 CO 27 and CO 28 Denial Codes; CO 31 Denial Code- Patient cannot be identified as our . (Use only with Group Code CO). 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. Payment denied/reduced for absence of, or exceeded, pre-certification/authorization. Anesthesia not covered for this service/procedure. (Use only with Group Code CO). Referral not authorized by attending physician per regulatory requirement. Claim/service not covered by this payer/contractor. Services not provided or authorized by designated (network/primary care) providers. Did you receive a code from a health plan, such as: PR32 or CO286? The rendering provider is not eligible to perform the service billed. Procedure/service was partially or fully furnished by another provider. Claim Status Category Codes and Status Code 7 Inter-plan Program (IPP) and FEP Requests (Blue Exchange) 8 276 Data Element Table 10 277 Data Element Table 13 276-277 Transactions Samples 18 276 Business Scenario 18 276 Data String Example 19 276 File Map 20 Document Change Log 22 Refund issued to an erroneous priority payer for this claim/service. Based on entitlement to benefits. Original payment decision is being maintained. Prior contractual reductions related to a current periodic payment as part of a contractual payment schedule when deferred amounts have been previously reported. 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. 256 Requires REV code with CPT code . If a To be used for Property and Casualty only. If it is an . Claim lacks prior payer payment information. These denials contained 74 unique combinations of RARCs attached to them and were worth $1.9 million. To be used for Property and Casualty only. Submission/billing error(s). The disposition of the claim/service is undetermined during the premium payment grace period, per Health Insurance SHOP Exchange requirements. Procedure code was incorrect. includes situations in which the revenue code is restricted, requires procedure code with pricing, is not covered in an outpatient setting, is not separately reimbursed or is only allowed with a specific list of procedure codes. The claim/service has been transferred to the proper payer/processor for processing. Edward A. Guilbert Lifetime Achievement Award. Internal liaisons coordinate between two X12 groups. 256. The below mention list of EOB codes is as below Use only with Group Code CO. Patient/Insured health identification number and name do not match. 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). Workers' Compensation claim adjudicated as non-compensable. To be used for Property and Casualty only. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. No maximum allowable defined by legislated fee arrangement. Level of subluxation is missing or inadequate. Claim spans eligible and ineligible periods of coverage. Claim/Service missing service/product information. To be used for Property and Casualty only. Payment adjusted based on the Medical Payments Coverage (MPC) and/or Personal Injury Protection (PIP) Benefits jurisdictional regulations, or payment policies. Any adult who requests mental health services under sections 245.461 to 245.486 must be advised of services available and the right to appeal at the time of the request and each time the individual deleted text begin assessment summary deleted text end new text begin community support plan new text end or . Services denied at the time authorization/pre-certification was requested. To apply for an X12 membership, complete and submit an application form which will be reviewed and verified, then you will be notified of the next steps. Denial reason code FAQs. The date of birth follows the date of service. To be used for Workers' Compensation only. To be used for Property & Casualty only. Based on payer reasonable and customary fees. Proposed modifications to the current EDI Standard proceed through a series of ballots and must be approved by impacted subcommittees, the Technical Assessment Subcommittee (TAS), and the Accredited Standards Committee stakeholders in order to be included in the next publication. 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). To be used for Property and Casualty only. Patient is covered by a managed care plan. The CO 4 Denial code stands for when your claim is rejected under the category that the modifier is inconsistent or wrong. For example, using contracted providers not in the member's 'narrow' network. The procedure code is inconsistent with the provider type/specialty (taxonomy). Payment is denied when performed/billed by this type of provider. Prior processing information appears incorrect. Missing or Invalid Service Codes (CPT, HCPCS, Revenue Codes, etc.) Lifetime reserve days. Claim lacks indication that service was supervised or evaluated by a physician. Categories include Commercial, Internal, Developer and more. Claim/service denied based on prior payer's coverage determination. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. To be used for Property and Casualty Auto only. ), Information requested from the patient/insured/responsible party was not provided or was insufficient/incomplete. (Use only with Group Code OA). Code Reason Description Remark Code Remark Description SAIF Code Adjustment Description 150 Payer deems the information submitted does not support this level of service. Consumer Spending Account payments (includes but is not limited to Flexible Spending Account, Health Savings Account, Health Reimbursement Account, etc.). Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. To enable us to present you with customized content that focuses on your area of interest, please select your preferences below: Select which best describes you: Person (s) with Medicare. (Use only with Group Code OA). Allowed amount has been reduced because a component of the basic procedure/test was paid. Claim did not include patient's medical record for the service. The disposition of the related Property & Casualty claim (injury or illness) is pending due to litigation. X12 defines and maintains transaction sets that establish the data content exchanged for specific business purposes. Care beyond first 20 visits or 60 days requires authorization. To be used for Property and Casualty only. Charges for outpatient services are not covered when performed within a period of time prior to or after inpatient services. Please resubmit one claim per calendar year. EX Code CARC RARC DESCRIPTION Type EX*1 95 N584 DENY: SHP guidelines for submitting corrected claim were not followed DENY EX*2 A1 N473 DENY: ASSESSMENT, FILLING AND/OR DME CERTIFICATION NOT ON FILE DENY . We have created a list of EOB reason codes for the help of people who are working on denials, AR-follow-up, medical coding, etc. Payment adjusted because the payer deems the information submitted does not support this many/frequency of services. Procedure/product not approved by the Food and Drug Administration. 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. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. 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. Claim spans eligible and ineligible periods of coverage. Workers' Compensation Medical Treatment Guideline Adjustment. Provider promotional discount (e.g., Senior citizen discount). Revenue code and Procedure code do not match. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Prior payer's (or payers') patient responsibility (deductible, coinsurance, co-payment) not covered. These codes describe why a claim or service line was paid differently than it was billed. Fee/Service not payable per patient Care Coordination arrangement. 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. The "PR" is a Claim Adjustment Group Code and the description for "32" is below. Enter your search criteria (Adjustment Reason Code) 4. Description ## SYSTEM-MORE ADJUSTMENTS. Payment adjusted because the patient has not met the required eligibility, spend down, waiting, or residency requirements. National Drug Codes (NDC) not eligible for rebate, are not covered. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Refund to patient if collected. Referral not authorized by attending physician per regulatory requirement. The necessary information is still needed to process the claim. Exceeds the contracted maximum number of hours/days/units by this provider for this period. 3. 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. paired with HIPAA Remark Code 256 Service not payable per managed care contract. 2 Invalid destination modifier. Here you could find Group code and denial reason too. Attachment/other documentation referenced on the claim was not received. co 256 denial code descriptions dublin south constituency 2021-05-27 The service provided. This list was formerly published as Part 6 of the administrative and billing instructions in Subchapter 5 of your MassHealth provider manual. 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. Adjustment Group Code Description CO Contractual Obligation CR Corrections and Reversal OA Other Adjustment PI Payer Initiated Reductions PR Patient Responsibility Reason Code Description 1 Deductible Amount 2 Coinsurance Amount 3 Co-payment Amount (Use only with Group Code PR), Workers' Compensation claim adjudicated as non-compensable. The related or qualifying claim/service was not identified on this claim. The Benefit for this Service is included in the payment/allowance for another service/procedure that has been performed on the same day. Predetermination: anticipated payment upon completion of services or claim adjudication. Service not payable per managed care contract. This list has been stable since the last update. Select the Reason or Remark code link below to review supplier solutions to the denial and/or how to avoid the same denial in the future. The diagnosis is inconsistent with the patient's birth weight. The colleagues have kindly dedicated me a volume to my 65th anniversary. 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. 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.). 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). On a particular claim, you might receive the reason code CO-16 (Claim/service lacks information which is needed for adjudication. The list below shows the status of change requests which are in process. This (these) procedure(s) is (are) not covered. One of our 25-bed hospital clients received 2,012 claims with CO16 from 1/1/2022 - 9/1/2022. The hospital must file the Medicare claim for this inpatient non-physician service. To be used for Property and Casualty only. 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). 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). This claim/service will be reversed and corrected when the grace period ends (due to premium payment or lack of premium payment). Set a password, place your documents in encrypted folders, and enable recipient authentication to control who accesses your documents. More information is available in X12 Liaisons (CAP17). To be used for Property and Casualty only. Use only with Group Code CO. ZU The audit reflects the correct CPT code or Oregon Specific Code. 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. Did you receive a code from a health plan, such as: PR32 or CO286? Previous payment has been made. The EDI Standard is published onceper year in January. The diagnosis is inconsistent with the procedure. Per regulatory or other agreement. Ingredient cost adjustment. Phase 1 - Behavior Health Co-Pays Applied Behavioral Health 8/7/2017 8/21/2017 8/25/2017 317783 DNNPR/CL062/C L068/CL069 The denial code CO 18 revolves around a duplicate service or claim while the denial code CO 22 revolves around the fact that the care can be covered by any other payer for coordination of the benefits involved. Allow Wi-Fi/cell tiles to co-exist with provider model (fix for WiFI and Data QS tiles) SystemUI: DreamTile: Enable for everyone . (Note: To be used for Workers' Compensation only) - Temporary code to be added for timeframe only until 01/01/2009. Cost outlier - Adjustment to compensate for additional costs. This non-payable code is for required reporting only. Code Description 01 Deductible amount. Diagnosis was invalid for the date(s) of service reported. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. 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