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Abbreviation for Office of the Commissioner of Insurance, O C I.
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AMERICAN NATIONAL STANDARDS INSTITUTE (ANSI)
CLAIM ADJUSTMENT REASON CODES

(OCI 17-007 R 07/2008)

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ANSI Claim Adjustment Reason Codes - pdf version


CodeDefinition
1Deductible amount.
Start: 1/1/1995
2Coinsurance amount.
Start: 1/1/1995
3Co-payment amount.
Start: 1/1/1995
4The procedure code is inconsistent with the modifier used or a required modifier is missing.
Start: 1/1/1995
5The procedure code/bill type is inconsistent with the place of service.
Start: 1/1/1995
6The procedure/revenue code is inconsistent with the patient's age.
Start: 1/1/1995 | Last Modified: 6/30/2002
7The procedure/revenue code is inconsistent with the patient's gender.
Start: 1/1/1995 | Last Modified: 6/30/2002
8The procedure code is inconsistent with the provider type/specialty (taxonomy).
Start: 1/1/1995 | Last Modified: 6/30/2002
9The diagnosis is inconsistent with the patient's age.
Start: 1/1/1995
10The diagnosis is inconsistent with the patient's gender.
Start: 1/1/1995 | Last Modified: 2/29/2000
11The diagnosis is inconsistent with the procedure.
Start: 1/1/1995
12The diagnosis is inconsistent with the provider type.
Start: 1/1/1995
13The date of death precedes the date of service.
Start: 1/1/1995
14The date of birth follows the date of service.
Start: 1/1/1995
15Payment adjusted because the submitted authorization number is missing, invalid, or does not apply to the billed services or provider. This change to be effective 4/1/2008: The authorization number is missing, invalid, or does not apply to the billed services or provider.
Start: 01/01/1995 | Last Modified: 09/30/2007
16Claim/service lacks information which is needed for adjudication. At least one Remark Code must be provided (may be comprised of either the Remittance Advice Remark Code or NCPDP Reject Reason Code).
Start: 1/1/1995 | Last Modified: 6/30/2006
17Payment adjusted because requested information was not provided or was insufficient/incomplete. At least one Remark Code must be provided (may be comprised of either the Remittance Advice Remark Code or NCPDP Reject Reason Code). This change to be effective 4/1/2008: Requested information was not provided or was insufficient/incomplete. At least one Remark Code must be provided (may be comprised of either the Remittance Advice Remark Code or NCPDP Reject Reason Code).
Start: 01/01/1995 | Last Modified: 09/30/2007
18Duplicate claim/service.
Start: 1/1/1995
19Claim denied because this is a work-related injury/illness and thus the liability of the worker's compensation carrier. This change to be effective 4/1/2008: This is a work-related injury/illness and thus the liability of the worker's compensation carrier.
Start: 01/01/1995 | Last Modified: 09/30/2007
20Claim denied because this injury/illness is covered by the liability carrier. This change to be effective 4/1/2008: This injury/illness is covered by the liability carrier.
Start: 01/01/1995 | Last Modified: 09/30/2007
21Claim denied because this injury/illness is the liability of the no-fault carrier. This change to be effective 4/1/2008: This injury/illness is the liability of the no-fault carrier.
Start: 01/01/1995 | Last Modified: 09/30/2007
22Payment adjusted because this care may be covered by another payer per coordination of benefits. This change to be effective 4/1/2008: This care may be covered by another payer per coordination of benefits.
Start: 01/01/1995 | Last Modified: 09/30/2007
23Payment adjusted due to the impact of prior payer(s) adjudication including payments and/or adjustments. This change to be effective 4/1/2008: The impact of prior payer(s) adjudication including payments and/or adjustments.
Start: 01/01/1995 | Last Modified: 09/30/2007
24Payment for charges adjusted. Charges are covered under a capitation agreement/managed care plan. This change to be effective 4/1/2008: Charges are covered under a capitation agreement/managed care plan.
Start: 01/01/1995 | Last Modified: 09/30/2007
25Payment denied. Your stop loss deductible has not been met.
Start: 1/1/1995 | Stop: 04/01/2008
26Expenses incurred prior to coverage.
Start: 1/1/1995
27Expenses incurred after coverage terminated.
Start: 1/1/1995
28Coverage not in effect at the time the service was provided.
Start: 1/1/1995 | Stop: 10/16/2003
Note: Redundant to codes 26 & 27.
29The time limit for filing has expired.
Start: 1/1/1995
30Payment adjusted because the patient has not met the required eligibility, spend down, waiting, or residency requirements.
Start: 1/1/1995 | Stop: 2/1/2006
31Claim denied as patient cannot be identified as our insured. This change to be effective 4/1/2008: Patient cannot be identified as our insured.
Start: 01/01/1995 | Last Modified: 09/30/2007
32Our records indicate that this dependent is not an eligible dependent as defined.
Start: 1/1/1995
33Claim denied. Insured has no dependent coverage. This change to be effective 4/1/2008: Insured has no dependent coverage.
Start: 01/01/1995 | Last Modified: 09/30/2007
34Claim denied. Insured has no coverage for newborns. This change to be effective 4/1/2008: Insured has no coverage for newborns.
Start: 01/01/1995 | Last Modified: 09/30/2007
35Lifetime benefit maximum has been reached.
Start: 1/1/1995 | Last Modified: 10/31/2002
36Balance does not exceed co-payment amount.
Start: 1/1/1995 | Stop: 10/16/2003
37Balance does not exceed deductible.
Start: 1/1/1995 | Stop: 10/16/2003
38Services not provided or authorized by designated (network/primary care) providers.
Start: 1/1/1995 | Last Modified: 6/30/2003
39Services denied at the time authorization/pre-certification was requested.
Start: 1/1/1995
40Charges do not meet qualifications for emergent/urgent care.
Start: 1/1/1995
41Discount agreed to in Preferred Provider contract.
Start: 1/1/1995 | Stop: 10/16/2003
42Charges exceed our fee schedule or maximum allowable amount. (Use CARC 45)
Start: 1/1/1995 | Stop: 6/1/2007 | Last Modified: 10/31/2006
43Gramm-Rudman reduction.
Start: 1/1/1995 | Stop: 7/1/2006
44Prompt-pay discount.
Start: 1/1/1995
45Charges exceed your contracted/legislated fee arrangement. This change to be effective 6/1/2007: Charge exceeds fee schedule/maximum allowable or contracted/legislated fee arrangement. (Use group codes PR or CO depending upon liability.)
Start: 1/1/1995 | Last Modified: 10/31/2006
46This (these) service(s) is (are) not covered.
Start: 1/1/1995 | Stop: 10/16/2003
Note: Use code 96.
47This (these) diagnosis(es) is (are) not covered, missing, or are invalid.
Start: 1/1/1995 | Stop: 2/1/2006
48This (these) procedure(s) is (are) not covered.
Start: 1/1/1995 | Stop: 10/16/2003
Note: Use code 96.
49These are non-covered services because this is a routine exam or screening procedure done in conjunction with a routine exam.
Start: 1/1/1995
50These are non-covered services because this is not deemed a "medical necessity" by the payer.
Start: 1/1/1995
51These are non-covered services because this is a pre-existing condition.
Start: 1/1/1995
52The referring/prescribing/rendering provider is not eligible to refer/prescribe/order/perform the service billed.
Start: 1/1/1995 | Stop: 2/1/2006
53Services by an immediate relative or a member of the same household are not covered.
Start: 1/1/1995
54Multiple physicians/assistants are not covered in this case.
Start: 1/1/1995
55Claim/service denied because procedure/treatment is deemed experimental/investigational by the payer. This change to be effective 4/1/2008: Procedure/treatment is deemed experimental/investigational by the payer.
Start: 01/01/1995 | Last Modified: 09/30/2007
56Claim/service denied because procedure/treatment has not been deemed "proven to be effective" by the payer. This change to be effective 4/1/2008: Procedure/treatment has not been deemed "proven to be effective" by the payer.
Start: 01/01/1995 | Last Modified: 09/30/2007
57Payment denied/reduced because the payer deems the information submitted does not support this level of service, this many services, this length of service, this dosage, or this day's supply.
Start: 1/1/1995 | Stop: 6/30/2007
Note: Split into codes 150, 151, 152, 153, and 154.
58Payment adjusted because treatment was deemed by the payer to have been rendered in an inappropriate or invalid place of service. This change to be effective 4/1/2008: Treatment was deemed by the payer to have been rendered in an inappropriate or invalid place of service.
Start: 01/01/1995 | Last Modified: 09/30/2007
59Charges are adjusted based on multiple or concurrent procedure rules. (For example, multiple surgery or diagnostic imaging, concurrent anesthesia.) This change to be effective 4/1/2008: Processed based on multiple or concurrent procedure rules. (For example, multiple surgery or diagnostic imaging, concurrent anesthesia.)
Start: 01/01/1995 | Last Modified: 09/30/2007
60Charges for outpatient services with this proximity to inpatient services are not covered. This change to be effective 1/1/2009: 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
61Charges adjusted as penalty for failure to obtain second surgical opinion. This change to be effective 4/1/2008: Penalty for failure to obtain second surgical opinion.
Start: 01/01/1995 | Last Modified: 09/30/2007
62Payment denied/reduced for absence of, or exceeded, pre-certification/authorization.
Start: 1/1/1995 | Stop: 4/1/2007 | Last Modified: 10/31/2006
63Correction to a prior claim.
Start: 1/1/1995 | Stop: 10/16/2003
64Denial reversed per medical review.
Start: 1/1/1995 | Stop: 10/16/2003
65Procedure code was incorrect. This payment reflects the correct code.
Start: 1/1/1995 | Stop: 10/16/2003
66Blood deductible.
Start: 1/1/1995
67Lifetime reserve days. (Handled in QTY, QTY01=LA)
Start: 1/1/1995 | Stop: 10/16/2003
68DRG weight. (Handled in CLP12)
Start: 1/1/1995 | Stop: 10/16/2003
69Day outlier amount.
Start: 1/1/1995
70Cost outlier - adjustment to compensate for additional costs.
Start: 1/1/1995 | Last Modified: 6/30/2001
71Primary payer amount.
Start: 1/1/1995 | Stop: 6/30/2000
Note: Use code 23.
72Coinsurance day. (Handled in QTY, QTY01=CD)
Start: 1/1/1995 | Stop: 10/16/2003
73Administrative days.
Start: 1/1/1995 | Stop: 10/16/2003
74Indirect medical education adjustment.
Start: 1/1/1995
75Direct medical education adjustment.
Start: 1/1/1995
76Disproportionate share adjustment.
Start: 1/1/1995
77Covered days. (Handled in QTY, QTY01=CA)
Start: 1/1/1995 | Stop: 10/16/2003
78Non-covered days/room charge adjustment.
Start: 1/1/1995
79Cost report days. (Handled in MIA15)
Start: 1/1/1995 | Stop: 10/16/2003
80Outlier days. (Handled in QTY, QTY01=OU)
Start: 1/1/1995 | Stop: 10/16/2003
81Discharges.
Start: 1/1/1995 | Stop: 10/16/2003
82PIP days.
Start: 1/1/1995 | Stop: 10/16/2003
83Total visits.
Start: 1/1/1995 | Stop: 10/16/2003
84Capital adjustment. (Handled in MIA)
Start: 1/1/1995 | Stop: 10/16/2003
85Patient interest adjustment (Use only group code PR)
Start: 01/01/1995 | Last Modified: 01/01/2008
Note: Only use when the payment of interest is the responsibility of the patient.
86Statutory adjustment.
Start: 1/1/1995 | Stop: 10/16/2003
Note: Duplicative of code 45.
87Transfer amount.
Start: 1/1/1995
88Adjustment amount represents collection against receivable created in prior overpayment.
Start: 1/1/1995 | Stop: 6/30/2007
89Professional fees removed from charges.
Start: 1/1/1995
90Ingredient cost adjustment.
Start: 1/1/1995
91Dispensing fee adjustment.
Start: 1/1/1995
92Claim paid in full.
Start: 1/1/1995 | Stop: 10/16/2003
93No claim level adjustments.
Start: 1/1/1995 | Stop: 10/16/2003
Note: As of 004010, CAS at the claim level is optional.
94Processed in excess of charges.
Start: 1/1/1995
95Benefits adjusted. Plan procedures not followed. This change to be effective 4/1/2008: Plan procedures not followed.
Start: 01/01/1995 | Last Modified: 09/30/2007
96Non-covered charge(s). At least one Remark Code must be provided (may be comprised of either the Remittance Advice Remark Code or NCPDP Reject Reason Code).
Start: 1/1/1995 | Last Modified: 6/30/2006
97Payment adjusted because the benefit for this service is included in the payment/allowance for another service/procedure that has already been adjudicated. This change to be effective 4/1/2008: The benefit for this service is included in the payment/allowance for another service/procedure that has already been adjudicated.
Start: 01/01/1995 | Last Modified: 09/30/2007
98The hospital must file the Medicare claim for this inpatient non-physician service.
Start: 1/1/1995 | Stop: 10/16/2003
99Medicare secondary payer adjustment amount.
Start: 1/1/1995 | Stop: 10/16/2003
100Payment made to patient/insured/responsible party/employer.
Start: 1/1/1995 | Last Modified: 01/27/2008
101Predetermination: anticipated payment upon completion of services or claim adjudication.
Start: 1/1/1995 | Last Modified: 2/28/1999
102Major medical adjustment.
Start: 1/1/1995
103Provider promotional discount (e.g., senior citizen discount).
Start: 1/1/1995 | Last Modified: 6/30/2001
104Managed care withholding.
Start: 1/1/1995
105Tax withholding.
Start: 1/1/1995
106Patient payment option/election not in effect.
Start: 1/1/1995
107Claim/service adjusted because the related or qualifying claim/service was not identified on this claim. This change to be effective 4/1/2008: The related or qualifying claim/service was not identified on this claim.
Start: 01/01/1995 | Last Modified: 09/30/2007
108Payment adjusted because rent/purchase guidelines were not met. This change to be effective 4/1/2008: Rent/purchase guidelines were not met.
Start: 01/01/1995 | Last Modified: 09/30/2007
109Claim not covered by this payer/contractor. You must send the claim to the correct payer/contractor.
Start: 1/1/1995
110Billing date predates service date.
Start: 1/1/1995
111Not covered unless the provider accepts assignment.
Start: 1/1/1995
112Payment adjusted as not furnished directly to the patient and/or not documented. This change to be effective 4/1/2008: Service not furnished directly to the patient and/or not documented.
Start: 01/01/1995 | Last Modified: 09/30/2007
113Payment denied because service/procedure was provided outside the United States or as a result of war.
Start: 1/1/1995 | Stop: 6/30/2007 | Last Modified: 2/28/2001
Note: Use codes 157, 158, or 159.
114Procedure/product not approved by the Food and Drug Administration.
Start: 1/1/1995
115Payment adjusted as procedure postponed, canceled, or delayed. This change to be effective 4/1/2008: Procedure postponed, canceled, or delayed.
Start: 01/01/1995 | Last Modified: 09/30/2007
116Payment denied. The advance indemnification notice signed by the patient did not comply with requirements. This change to be effective 4/1/2008: The advance indemnification notice signed by the patient did not comply with requirements.
Start: 01/01/1995 | Last Modified: 09/30/2007
117Payment adjusted because transportation is only covered to the closest facility that can provide the necessary care. This change to be effective 4/1/2008: Transportation is only covered to the closest facility that can provide the necessary care.
Start: 01/01/1995 | Last Modified: 09/30/2007
118Charges reduced for ESRD network support. This change to be effective 4/1/2008: ESRD network support adjustment.
Start: 01/01/1995 | Last Modified: 09/30/2007
119Benefit maximum for this time period or occurrence has been reached.
Start: 1/1/1995 | Last Modified: 2/29/2004
120Patient is covered by a managed care plan.
Start: 1/1/1995 | Stop: 6/30/2007
Note: Use code 24.
121Indemnification adjustment. This change effective 4/1/2008: Indemnification adjustment - compensation for outstanding member responsibility.
Start: 01/01/1995 | Last Modified: 09/30/2007
122Psychiatric reduction.
Start: 1/1/1995
123Payer refund due to overpayment.
Start: 1/1/1995 | Stop: 6/30/2007
Note: Refer to implementation guide for proper handling of reversals.
124Payer refund amount - not our patient.
Start: 1/1/1995 | Stop: 6/30/2007 | Last Modified: 6/30/1999
Note: Refer to implementation guide for proper handling of reversals.
125Payment adjusted due to a submission/billing error(s). At least one Remark Code must be provided (may be comprised of either the Remittance Advice Remark Code or NCPDP Reject Reason Code). This change to be effective 4/1/2008: Submission/billing error(s). At least one Remark Code must be provided (may be comprised of either the Remittance Advice Remark Code or NCPDP Reject Reason Code).
Start: 01/01/1995 | Last Modified: 09/30/2007
126Deductible -- Major Medical
Start: 02/28/1997 | Stop: 04/01/2008 | Last Modified: 09/30/2007
Note: Use group code PR and code 1.
127Coinsurance -- Major Medical
Start: 02/28/1997 | Stop: 04/01/2008 | Last Modified: 09/30/2007
Note: Use group code PR and code 2.
128Newborn's services are covered in the mother's allowance.
Start: 2/28/1997
129Payment denied - Prior processing information appears incorrect. This change to be effective 4/1/2008: Prior processing information appears incorrect.
Start: 02/28/1997 | Last Modified: 09/30/2007
130Claim submission fee.
Start: 2/28/1997 | Last Modified: 6/30/2001
131Claim specific negotiated discount.
Start: 2/28/1997
132Prearranged demonstration project adjustment.
Start: 2/28/1997
133The disposition of this claim/service is pending further review.
Start: 2/28/1997 | Last Modified: 10/31/1999
134Technical fees removed from charges.
Start: 10/31/1998
135Claim denied. Interim bills cannot be processed. This change to be effective 4/1/2008: Interim bills cannot be processed.
Start: 10/31/1998 | Last Modified: 09/30/2007
136Claim adjusted based on failure to follow prior payer's coverage rules. (Use group code OA.) This change to be effective 4/1/2008: Failure to follow prior payer's coverage rules. (Use group code OA.)
Start: 10/31/1998 | Last Modified: 09/30/2007
137Payment/reduction for regulatory surcharges, assessments, allowances, or health related taxes. This change to be effective 4/1/2008: Regulatory surcharges, assessments, allowances, or health related taxes.
Start: 02/28/1999 | Last Modified: 09/30/2007
138Claim/service denied. Appeal procedures not followed or time limits not met. This change to be effective 4/1/2008: Appeal procedures not followed or time limits not met.
Start: 06/30/1999 | Last Modified: 09/30/2007
139Contracted funding agreement - subscriber is employed by the provider of services.
Start: 6/30/1999
140Patient/insured health identification number and name do not match.
Start: 6/30/1999
141Claim adjustment because the claim spans eligible and ineligible periods of coverage. This change to be effective 4/1/2008: Claim spans eligible and ineligible periods of coverage.
Start: 06/30/1999 | Last Modified: 09/30/2007
142Claim adjusted by the monthly Medicaid patient liability amount. This change to be effective 4/1/2008: Monthly Medicaid patient liability amount.
Start: 06/30/2000 | Last Modified: 09/30/2007
143Portion of payment deferred.
Start: 2/28/2001
144Incentive adjustment, e.g. preferred product/service.
Start: 6/30/2001
145Premium payment withholding.
Start: 06/30/2002 | Stop: 04/01/2008 | Last Modified: 09/30/2007
Note: Use group code CO and code 45.
146Payment denied because the diagnosis was invalid for the date(s) of service reported. This change to be effective 4/1/2008: Diagnosis was invalid for the date(s) of service reported.
Start: 06/30/2002 | Last Modified: 09/30/2007
147Provider contracted/negotiated rate expired or not on file.
Start: 6/30/2002
148Claim/service rejected at this time because information from another provider was not provided or was insufficient/incomplete. This change to be effective 4/1/2008: Information from another provider was not provided or was insufficient/incomplete.
Start: 06/30/2002 | Last Modified: 09/30/2007
149Lifetime benefit maximum has been reached for this service/benefit category.
Start: 10/31/2002
150Payment adjusted because the payer deems the information submitted does not support this level of service. This change to be effective 4/1/2008: Payer deems the information submitted does not support this level of service.
Start: 10/31/2002 | Last Modified: 09/30/2007
151Payment 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
152Payment adjusted because the payer deems the information submitted does not support this length of service. This change to be effective 4/1/2008: Payer deems the information submitted does not support this length of service.
Start: 10/31/2002 | Last Modified: 09/30/2007
153Payment adjusted because the payer deems the information submitted does not support this dosage. This change to be effective 4/1/2008: Payer deems the information submitted does not support this dosage.
Start: 10/31/2002 | Last Modified: 09/30/2007
154Payment adjusted because the payer deems the information submitted does not support this day's supply. This change to be effective 4/1/2008: Payer deems the information submitted does not support this day's supply.
Start: 10/31/2002 | Last Modified: 09/30/2007
155This claim is denied because the patient refused the service/procedure. This change to be effective 4/1/2008: Patient refused the service/procedure.
Start: 06/30/2003 | Last Modified: 09/30/2007
156Flexible spending account payments.
Start: 9/30/2003
157Payment denied/reduced because service/procedure was provided as a result of an act of war. This change to be effective 4/1/2008: Service/procedure was provided as a result of an act of war.
Start: 09/30/2003 | Last Modified: 09/30/2007
158Payment denied/reduced because the service/procedure was provided outside of the United States. This change to be effective 4/1/2008: Service/procedure was provided outside of the United States.
Start: 09/30/2003 | Last Modified: 09/30/2007
159Payment denied/reduced because the service/procedure was provided as a result of terrorism. This change to be effective 4/1/2008: Service/procedure was provided as a result of terrorism.
Start: 09/30/2003 | Last Modified: 09/30/2007
160Payment denied/reduced because injury/illness was the result of an activity that is a benefit exclusion. This change to be effective 4/1/2008: Injury/illness was the result of an activity that is a benefit exclusion.
Start: 09/30/2003 | Last Modified: 09/30/2007
161Provider performance bonus.
Start: 2/29/2004
162State-mandated requirement for property and casualty; see Claim Payment Remarks Code for specific explanation.
Start: 2/29/2004
163Claim/service adjusted because the attachment referenced on the claim was not received. This change to be effective 4/1/2008: Attachment referenced on the claim was not received.
Start: 06/30/2004 | Last Modified: 09/30/2007
164Claim/service adjusted because the attachment referenced on the claim was not received in a timely fashion. This change to be effective 4/1/2008: Attachment referenced on the claim was not received in a timely fashion.
Start: 06/30/2004 | Last Modified: 09/30/2007
165Payment denied /reduced for absence of, or exceeded, referral. This change to be effective 4/1/2008: Referral absent or exceeded.
Start: 10/31/2004 | Last Modified: 09/30/2007
166These services were submitted after this payer's responsibility for processing claims under this plan ended.
Start: 2/28/2005
167This (these) diagnosis(es) is (are) not covered.
Start: 6/30/2005
168Payment denied as service(s) have been considered under the patient's medical plan. Benefits are not available under this dental plan. This change to be effective 4/1/2008: Service(s) have been considered under the patient's medical plan. Benefits are not available under this dental plan.
Start: 06/30/2005 | Last Modified: 09/30/2007
169Payment adjusted because an alternate benefit has been provided. This change to be effective 4/1/2008: Alternate benefit has been provided.
Start: 06/30/2005 | Last Modified: 09/30/2007
170Payment is denied when performed/billed by this type of provider.
Start: 6/30/2005
171Payment is denied when performed/billed by this type of provider in this type of facility.
Start: 6/30/2005
172Payment is adjusted when performed/billed by a provider of this specialty.
Start: 6/30/2005
173Payment adjusted because this service was not prescribed by a physician. This change to be effective 4/1/2008: Service was not prescribed by a physician.
Start: 06/30/2005 | Last Modified: 09/30/2007
174Payment denied because this service was not prescribed prior to delivery. This change to be effective 4/1/2008: Service was not prescribed prior to delivery.
Start: 06/30/2005 | Last Modified: 09/30/2007
175Payment denied because the prescription is incomplete. This change to be effective 4/1/2008: Prescription is incomplete.
Start: 06/30/2005 | Last Modified: 09/30/2007
176Payment denied because the prescription is not current. This change to be effective 4/1/2008: Prescription is not current.
Start: 06/30/2005 | Last Modified: 09/30/2007
177Payment denied because the patient has not met the required eligibility requirements. This change to be effective 4/1/2008: Patient has not met the required eligibility requirements.
Start: 06/30/2005 | Last Modified: 09/30/2007
178Payment adjusted because the patient has not met the required spend down requirements. This change to be effective 4/1/2008: Patient has not met the required spend down requirements.
Start: 06/30/2005 | Last Modified: 09/30/2007
179Payment adjusted because the patient has not met the required waiting requirements. This change to be effective 4/1/2008: Patient has not met the required waiting requirements.
Start: 06/30/2005 | Last Modified: 09/30/2007
180Payment adjusted because the patient has not met the required residency requirements. This change to be effective 4/1/2008: Patient has not met the required residency requirements.
Start: 06/30/2005 | Last Modified: 09/30/2007
181Payment adjusted because this procedure code was invalid on the date of service. This change to be effective 4/1/2008: Procedure code was invalid on the date of service.
Start: 06/30/2005 | Last Modified: 09/30/2007
182Payment adjusted because the procedure modifier was invalid on the date of service. This change to be effective 4/1/2008: Procedure modifier was invalid on the date of service.
Start: 06/30/2005 | Last Modified: 09/30/2007
183The referring provider is not eligible to refer the service billed.
Start: 6/30/2005
184The prescribing/ordering provider is not eligible to prescribe/order the service billed.
Start: 6/30/2005
185The rendering provider is not eligible to perform the service billed.
Start: 6/30/2005
186Payment adjusted since the level of care changed. This change to be effective 4/1/2008: Level of care change adjustment.
Start: 06/30/2005 | Last Modified: 09/30/2007
187Health savings account payments.
Start: 6/30/2005
188This product/procedure is only covered when used according to FDA recommendations.
Start: 6/30/2005
189"Not otherwise classified" or "unlisted" procedure code (CPT/HCPCS) was billed when there is a specific procedure code for this procedure/service.
Start: 6/30/2005
190Payment is included in the allowance for a skilled nursing facility (SNF) qualified stay.
Start: 10/31/2005
191Claim denied because this is not a work related injury/illness and thus not the liability of the worker's compensation carrier. This change to be effective 4/1/2008: Not a work related injury/illness and thus not the liability of the worker's compensation carrier.
Start: 10/31/2005 | Last Modified: 09/30/2007
192Non-standard adjustment code from paper remittance advice. This change to be effective 4/1/2008: Non-standard adjustment code from paper remittance.
Note: This code is to be used by providers/payers providing coordination of benefits information to another payer in the 837 transaction only. This code is only used when the non-standard code cannot be reasonably mapped to an existing Claim Adjustment Reason Code, specifically Deductible, Coinsurance, and Copayment.
Start: 10/31/2005 | Last Modified: 09/30/2007
193Original payment decision is being maintained. Upon review, it was determined that this claim was processed properly.
Start: 2/28/2006 | Last Modified: 01/27/2008
194Payment adjusted when anesthesia is performed by the operating physician, the assistant surgeon, or the attending physician. This change to be effective 4/1/2008: Anesthesia performed by the operating physician, the assistant surgeon, or the attending physician.
Start: 02/28/2006 | Last Modified: 09/30/2007
195Payment denied/reduced due to a refund issued to an erroneous priority payer for this claim/service. This change to be effective 4/1/2008: Refund issued to an erroneous priority payer for this claim/service.
Start: 02/28/2006 | Last Modified: 09/30/2007
196Claim/service denied based on prior payer's coverage determination.
Start: 6/30/2006 | Stop: 2/1/2007
Note: Use code 136.
197Payment adjusted for absence of precertification/authorization/notification. This change effective 4/1/2008: Precertification/authorization/notification absent.
Start: 10/31/2006 | Last Modified: 09/30/2007
198Payment adjusted for exceeding precertification/ authorization. This change to be effective 4/1/2008: Precertification/authorization exceeded.
Start: 10/31/2006 | Last Modified: 09/30/2007
199Revenue code and procedure code do not match.
Start: 10/31/2006
200Expenses incurred during lapse in coverage.
Start: 10/31/2006
201Workers compensation case settled. Patient is responsible for amount of this claim/service through WC "Medicare set aside arrangement" or other agreement. (Use group code PR.)
Start: 10/31/2006
202Payment adjusted due to non-covered personal comfort or convenience services. This change to be effective 4/1/2008: Non-covered personal comfort or convenience services.
Start: 02/28/2007 | Last Modified: 09/30/2007
203Payment adjusted for discontinued or reduced service. This change to be effective 4/1/2008: Discontinued or reduced service.
Start: 02/28/2007 | Last Modified: 09/30/2007
204This service/equipment/drug is not covered under the patient's current benefit plan.
Start: 2/28/2007
205Pharmacy discount card processing fee.
Start: 7/9/2007
206National provider identifier - missing.
Start: 07/09/2007 | Last Modified: 09/30/2007
207National provider identifier - invalid format.
Start: 07/09/2007 | Last Modified: 06/01/2008
208National provider identifier - not matched.
Start: 07/09/2007 | Last Modified: 09/30/2007
209Per regulatory or other agreement. The provider cannot collect this amount from the patient. However, this amount may be billed to subsequent payer. Refund to patient if collected. (Use group code OA.)
Start: 7/9/2007
210Payment adjusted because pre-certification/authorization not received in a timely fashion.
Start: 7/9/2007
211National Drug Codes (NDC) not eligible for rebate; are not covered.
Start: 7/9/2007
212Administrative surcharges are not covered.
Start: 11/05/2007
213Non-compliance with the physician self-referral prohibition legislation or payer policy.
Start: 01/27/2008
214Worker's compensation claim adjudicated as non-compensable. This payer not liable for claim or service/treatment.
Start: 01/27/2008
Note: To be used for worker's compensation only.
215Based on subrogation of a third party settlement.
Start: 01/27/2008
216Based on the findings of a review organization.
Start: 01/27/2008
217Based on payer reasonable and customary fees. No maximum allowable defined by legislated fee arrangement.
Start: 01/27/2008
Note: To be used for worker's compensation only.
218Based on entitlement to benefits.
Start: 01/27/2008
Note: To be used for worker's compensation only.
219Based on extent of injury.
Start: 01/27/2008
Note: To be used for worker's compensation only.
220The applicable fee schedule does not contain the billed code. Please resubmit a bill with the appropriate fee schedule code(s) that best describe the service(s) provided and supporting documentation if required.
Start: 01/27/2008
Note: To be used for worker's compensation only.
221Worker's compensation claim is under investigation.
Start: 01/27/2008
Note: To be used for worker's compensation only. Claim pending final resolution.
222Exceeds the contracted maximum number of hours/days/units by this provider for this period. This is not patient specific.
Start: 06/01/2008
223Adjustment 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
224Patient identification compromised by identity theft. Identity verification required for processing this and future claims.
Start: 06/01/2008
225Penalty or interest payment by payer. (Only used for plan to plan encounter reporting within the 837.)
Start: 06/01/2008
 
A0Patient refund amount.
Start: 1/1/1995
A1Claim/service denied. At least one Remark Code must be provided (may be comprised of either the Remittance Advice Remark Code or NCPDP Reject Reason Code).
Start: 1/1/1995 | Last Modified: 10/31/2006
A2Contractual adjustment.
Start: 01/01/1995 | Stop: 01/01/2008 | Last Modified: 01/01/2008
Note: Use code 45 with group code 'CO' or use another appropriate specific adjustment code.
A3Medicare secondary payer liability met.
Start: 1/1/1995 | Stop: 10/16/2003
A4Medicare claim PPS capital day outlier amount.
Start: 01/01/1995 | Stop: 04/01/2008 | Last Modified: 09/30/2007
A5Medicare claim PPS capital cost outlier amount.
Start: 1/1/1995
A6Prior hospitalization or 30-day transfer requirement not met.
Start: 1/1/1995
A7Presumptive payment adjustment.
Start: 1/1/1995
A8Claim denied; ungroupable DRG. This change to be effective 4/1/2008: Ungroupable DRG.
Start: 01/01/1995 | Last Modified: 09/30/2007
 
B1Non-covered visits.
Start: 1/1/1995 | Stop: 10/16/2003
B2Covered visits.
Start: 1/1/1995 | Stop: 10/16/2003
B3Covered charges.
Start: 1/1/1995 | Stop: 10/16/2003
B4Late filing penalty.
Start: 1/1/1995
B5Payment adjusted because coverage/program guidelines were not met or were exceeded. This change to be effective 4/1/2008: Coverage/program guidelines were not met or were exceeded.
Start: 01/01/1995 | Last Modified: 09/30/2007
B6This payment is adjusted when performed/billed by this type of provider, by this type of provider in this type of facility, or by a provider of this specialty.
Start: 1/1/1995 | Stop: 2/1/2006
B7This provider was not certified/eligible to be paid for this procedure/service on this date of service.
Start: 1/1/1995 | Last Modified: 10/31/1998
B8Claim/service not covered/reduced because alternative services were available and should have been utilized. This change to be effective 4/1/2008: Alternative services were available and should have been utilized.
Start: 01/01/1995 | Last Modified: 09/30/2007
B9Services not covered because the patient is enrolled in a Hospice. This change to be effective 4/1/2008: Patient is enrolled in a Hospice.
Start: 01/01/1995 | Last Modified: 09/30/2007
B10Allowed 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: 1/1/1995
B11The claim/service has been transferred to the proper payer/processor for processing. Claim/service not covered by this payer/processor.
Start: 1/1/1995
B12Services not documented in patient's medical records.
Start: 1/1/1995
B13Previously paid. Payment for this claim/service may have been provided in a previous payment.
Start: 1/1/1995
B14Payment denied because only one visit or consultation per physician per day is covered. This change to be effective 4/1/2008: Only one visit or consultation per physician per day is covered.
Start: 01/01/1995 | Last Modified: 09/30/2007
B15Payment adjusted because this service/procedure requires that a qualifying service/procedure be received and covered. The qualifying other service/procedure has not been received/adjudicated. This change to be effective 4/1/2008: This service/procedure requires that a qualifying service/procedure be received and covered. The qualifying other service/procedure has not been received/adjudicated.
Start: 01/01/1995 | Last Modified: 09/30/2007
B16Payment adjusted because "new patient" qualifications were not met. This change to be effective 4/1/2008: "New patient" qualifications were not met.
Start: 01/01/1995 | Last Modified: 09/30/2007
B17Payment adjusted because this service was not prescribed by a physician, not prescribed prior to delivery, the prescription is incomplete, or the prescription is not current.
Start: 1/1/1995 | Stop: 2/1/2006
B18Payment adjusted because this procedure code and modifier were invalid on the date of service. This change to be effective 4/1/2008: This procedure code and modifier were invalid on the date of service.
Start: 01/01/1995 | Last Modified: 09/30/2007
B19Claim/service adjusted because of the finding of a review organization.
Start: 1/1/1995 | Stop: 10/16/2003
B20Payment adjusted because procedure/service was partially or fully furnished by another provider. This change to be effective 4/1/2008: Procedure/service was partially or fully furnished by another provider.
Start: 01/01/1995 | Last Modified: 09/30/2007
B21The charges were reduced because the service/care was partially furnished by another physician.
Start: 1/1/1995 | Stop: 10/16/2003
B22This payment is adjusted based on the diagnosis.
Start: 1/1/1995 | Last Modified: 2/28/2001
B23Payment denied because this provider has failed an aspect of a proficiency testing program. This change effective 4/1/2008: Procedure billed is not authorized per your Clinical Laboratory Improvement Amendment (CLIA) proficiency test.
Start: 01/01/1995 | Last Modified: 09/30/2007
 
D1Claim/service denied. Level of subluxation is missing or inadequate.
Start: 1/1/1995 | Stop: 10/16/2003
Note: Use code 16 and remark codes if necessary.
D2Claim lacks the name, strength, or dosage of the drug furnished.
Start: 1/1/1995 | Stop: 10/16/2003
Note: Use code 16 and remark codes if necessary.
D3Claim/service denied because information to indicate if the patient owns the equipment that requires the part or supply was missing.
Start: 1/1/1995 | Stop: 10/16/2003
Note: Use code 16 and remark codes if necessary.
D4Claim/service does not indicate the period of time for which this will be needed.
Start: 1/1/1995 | Stop: 10/16/2003
Note: Use code 16 and remark codes if necessary.
D5Claim/service denied. Claim lacks individual lab codes included in the test.
Start: 1/1/1995 | Stop: 10/16/2003
Note: Use code 16 and remark codes if necessary.
D6Claim/service denied. Claim did not include patient's medical record for the service.
Start: 1/1/1995 | Stop: 10/16/2003
Note: Use code 16 and remark codes if necessary.
D7Claim/service denied. Claim lacks date of patient's most recent physician visit.
Start: 1/1/1995 | Stop: 10/16/2003
Note: Use code 16 and remark codes if necessary.
D8Claim/service denied. Claim lacks indicator that "x-ray is available for review."
Start: 1/1/1995 | Stop: 10/16/2003
Note: Use code 16 and remark codes if necessary.
D9Claim/service denied. Claim lacks invoice or statement certifying the actual cost of the lens, less discounts or the type of intraocular lens used.
Start: 1/1/1995 | Stop: 10/16/2003
Note: Use code 16 and remark codes if necessary.
D10Claim/service denied. Completed physician financial relationship form not on file.
Start: 1/1/1995 | Stop: 10/16/2003
Note: Use code 17.
D11Claim lacks completed pacemaker registration form.
Start: 1/1/1995 | Stop: 10/16/2003
Note: Use code 17.
D12Claim/service denied. Claim does not identify who performed the purchased diagnostic test or the amount you were charged for the test.
Start: 1/1/1995 | Stop: 10/16/2003
Note: Use code 17.
D13Claim/service denied. Performed by a facility/supplier in which the ordering/referring physician has a financial interest.
Start: 1/1/1995 | Stop: 10/16/2003
Note: Use code 17.
D14Claim lacks indication that plan of treatment is on file.
Start: 1/1/1995 | Stop: 10/16/2003
Note: Use code 17.
D15Claim lacks indication that service was supervised or evaluated by a physician.
Start: 1/1/1995 | Stop: 10/16/2003
Note: Use code 17.
D16Claim lacks prior payer payment information.
Start: 1/1/1995 | Stop: 6/30/2007
Note: Use code 16 with appropriate claim payment remark code [N4].
D17Claim/service has invalid non-covered days.
Start: 1/1/1995 | Stop: 6/30/2007
Note: Use code 16 with appropriate claim payment remark code.
D18Claim/service has missing diagnosis information.
Start: 1/1/1995 | Stop: 6/30/2007
Note: Use code 16 with appropriate claim payment remark code.
D19Claim/service lacks physician/operative or other supporting documentation.
Start: 1/1/1995 | Stop: 6/30/2007
Note: Use code 16 with appropriate claim payment remark code.
D20Claim/service missing service/product information.
Start: 1/1/1995 | Stop: 6/30/2007
Note: Use code 16 with appropriate claim payment remark code.
D21This (these) diagnosis(es) is (are) missing or invalid.
Start: 1/1/1995 | Stop: 6/30/2007
D22Reimbursement was adjusted for the reasons to be provided in separate correspondence. Temporary code to be added for timeframe only until 01/01/2009. Another code to be established and/or for 06/2008 meeting for a revised code to replace or strategy to use another existing code.
Start: 01/27/2008 | Stop: 01/01/2009
Note: To be used for worker's compensation only.
 
W1Workers compensation state fee schedule adjustment.
Start: 2/29/2000
Updated: July 10, 2008
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