Another Set of Codes?
Written by Editor   
Wednesday, October 21, 2015 12:00 AM

Now that we have officially transitioned to coding with ICD-10-CM, there is another set of codes you will want your billing staff to be acquainted with, that is the Claim Adjustment Reason Codes (CARC).

These codes communicate "why a claim or service line was paid differently than it was billed." This is important information as your clinic looks for ways to speed up the process of managing probable denials.

In the weeks following ICD-10 transition, ACA encourages clinics to make a top ten list of denial codes and keep it handy as you monitor claim status daily.

A complete list of CARCs can be found here and are reproduced below.

Payer examples are provided below:

  • Enhanced Claim Edits -The Claims Payer List for UnitedHealthcare

  • Aetna's list of ICD-10 reject codes: C34-The ICD-9 or ICD-10 procedure code is invalid; C35-ICD procedure code is a mixed code set-ICD-9/ICD-10; C36-ICD-9 code set is submitted.

  • Anthem's EDI ICD-10 Edits Communications- a list of ICD-10 related edits by transaction can be found here.

Claim Adjustment Reason Codes

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.

Start: 01/01/1995 | Last Modified: 09/20/2009

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.

Start: 01/01/1995 | Last Modified: 09/20/2009

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.

Start: 01/01/1995 | Last Modified: 09/20/2009

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.

Start: 01/01/1995 | Last Modified: 09/20/2009

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.

Start: 01/01/1995 | Last Modified: 09/20/2009

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.

Start: 01/01/1995 | Last Modified: 09/20/2009

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.

Start: 01/01/1995 | Last Modified: 09/20/2009

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.

Start: 01/01/1995 | Last Modified: 09/20/2009

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.

Start: 01/01/1995 | Last Modified: 09/20/2009

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.

Start: 01/01/1995 | Last Modified: 11/01/2013

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.

Start: 01/01/1995 | Last Modified: 09/20/2009

44

Prompt-pay discount.

Start: 01/01/1995

45

Charge exceeds fee schedule/maximum allowable or contracted/legislated fee arrangement. (Use only with Group Codes PR or CO depending upon liability) This change effective 11/1/2015: Charge exceeds fee schedule/maximum allowable or contracted/legislated fee arrangement. Note: this 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: 03/01/2015

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.

Start: 01/01/1995 | Last Modified: 11/01/2013

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.

Start: 01/01/1995 | Last Modified: 09/20/2009

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.

Start: 01/01/1995 | Last Modified: 09/20/2009

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.

Start: 01/01/1995 | Last Modified: 09/20/2009

55

Procedure/treatment 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 9/1/2015: 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.

Start: 01/01/1995 | Last Modified: 04/01/2015

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.

Start: 01/01/1995 | Last Modified: 09/20/2009

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.

Start: 01/01/1995 | Last Modified: 09/20/2009

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.

Start: 01/01/1995 | Last Modified: 09/20/2009

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

Penalty for failure to obtain second surgical opinion. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

Start: 01/01/1995 | Last Modified: 09/20/2009

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.

Start: 01/01/1995 | Last Modified: 07/01/2009

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.

Start: 01/01/1995 | Last Modified: 09/20/2009

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.

Start: 01/01/1995 | Last Modified: 09/20/2009

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.

Start: 01/01/1995 | Last Modified: 09/20/2009

108

Rent/purchase guidelines were not met. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

Start: 01/01/1995 | Last Modified: 09/20/2009

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).

Start: 07/01/2014 | Last Modified: 03/01/2015

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.

Start: 10/31/2002 | Last Modified: 09/20/2009

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.

Start: 06/30/2005 | Last Modified: 09/20/2009

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.

Start: 06/30/2005 | Last Modified: 09/20/2009

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.

Start: 06/30/2005 | Last Modified: 09/20/2009

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.

Start: 06/30/2005 | Last Modified: 09/20/2009

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.

Start: 06/30/2005 | Last Modified: 09/20/2009

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.

Start: 06/30/2005 | Last Modified: 09/20/2009

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.

Start: 06/30/2005 | Last Modified: 09/20/2009

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.

Start: 06/30/2005 | Last Modified: 09/20/2009

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.

Start: 10/31/2005 | Last Modified: 09/30/2007

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).

Start: 01/27/2008 | Last Modified: 10/17/2010

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.

Start: 06/01/2008 | Last Modified: 09/20/2009

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)

Start: 01/25/2009 | Last Modified: 07/01/2013

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.

Start: 07/01/2009 | Last Modified: 09/20/2009

232

Institutional Transfer Amount. Note - Applies to institutional claims only and explains the DRG amount difference when the patient care crosses multiple institutions.

Start: 11/01/2009

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.

Start: 06/03/2012

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.

Start: 11/01/2014

263

Adjustment for shipping cost. Note: To be used for pharmaceuticals only.

Start: 11/01/2014

264

Adjustment for postage cost. Note: To be used for pharmaceuticals only.

Start: 11/01/2014

265

Adjustment for administrative cost. Note: To be used for pharmaceuticals only.

Start: 11/01/2014

266

Adjustment for compound preparation cost. Note: To be used for pharmaceuticals only.

Start: 11/01/2014

267

Claim/service spans multiple months. Rebill as separate claim/service. This change effective 9/1/2015: 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.

Start: 03/01/2015

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

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

B5

Coverage/program guidelines were not met or were exceeded.

Start: 01/01/1995 | Last Modified: 09/30/2007

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.

Start: 01/01/1995 | Last Modified: 09/20/2009

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.

Start: 01/01/1995 | Last Modified: 09/20/2009

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.

Start: 01/01/1995 | Last Modified: 09/20/2009

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.

Start: 11/01/2013

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

Start: 11/01/2013

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.

Start: 11/01/2013

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.

Start: 11/01/2013

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.

Start: 11/01/2013

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.

Start: 11/01/2013

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.

Start: 11/01/2013

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.

Start: 11/01/2013

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.

Start: 11/01/2013

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.

Start: 11/01/2013

Notes: This code replaces deactivated code Y3