DEAN HEALTH PLAN CLAIM ADJUSTMENT REASON CODES - 10/27/10
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code Claim Adj. 835 Claim Adj. 835 Description of ANSI code Group 835 Line Level
Paper Description
(Paper Reason Reason code (note will not print on 835) Codes Adjustment
only) code
Deductible amount Deductible amount
DD 1 1 PR Deductible
Coinsurance Amount. Coinsurance Amount.
MI 2 2 PR Coinsurance
Copayment amount. Copayment amount.
WW 3 3 PR Copay
Copayment amount. Copayment amount.
CJ (Used
only for CU
3 3 PR Non - Covered
hold code
process)
The procedure code is inconsistent w/modifier The procedure code is inconsistent with the
used or req. modifier is misiing. MA does not allow modifier used or required modifier is misiing.
PV 4 svc. 4 OA Non - Covered
The procedure code is inconsistent w/modifier The procedure code is inconsistent with the
used or req. modifier missing. modifier used or a required modifier is missing.
XM 4 4 OA Non - Covered
The procedure code/bill type is inconsistent with The procedure code/bill type is inconsistent
the place of service. with the place of service.
ZJ 5 5 OA Non - Covered
The procedure/revenue code is inconsistent with The procedure/revenue code is inconsistent
the patient's age with the patient's age
XL 6 6 OA Non - Covered
The procedure/revenue code is inconsistent with The procedure/revenue code is inconsistent
the patient's gender with the patient's gender
XT 7 7 OA Non - Covered
The procedure code is inconsistent with the prov. The procedure code is inconsistent with the
type/specialty (taxonomy). provider type/specialty(taxonomy).
PY 8 8 OA Non - Covered
The diagnosis is inconsistent with the patient's age The diagnosis is inconsistent with the patient's
age
XV 9 9 OA Non - Covered
The diagnosis is inconsistent with the patient's The diagnosis is inconsistent with the patient's
gender. gender.
XY 10 10 OA Non - Covered
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DEAN HEALTH PLAN CLAIM ADJUSTMENT REASON CODES - 10/27/10
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code Claim Adj. 835 Claim Adj. 835 Description of ANSI code Group 835 Line Level
Paper Description
(Paper Reason Reason code (note will not print on 835) Codes Adjustment
only) code
The diagnosis is inconsistent with the procedure The diagnosis is inconsistent with the
procedure
DH 11 11 OA Non-Covered
The diagnosis is inconsistent with the provider type The diagnosis is inconsistent with the provider
type
DK 12 12 OA Non-Covered
The date of death precedes the date of service The date of death precedes the date of service
DL 13 13 OA Non-Covered
The date of birth follows the date of service The date of birth follows the date of service
DQ 14 14 OA Non-Covered
Clm/svc lacks info needed for adjudication. Refile Claim/service lacks information which is
w/ correct prov / vend# needed for adjudication. At least one Remark
ZT 16W 16 Code must be provided (may be comprised of OA Non - Covered
either the Remittance Advice Remark Code or
NCPDP Reject Reason Code).
clm/svc lacks info for adjudication - refile with more Claim/service lacks information which is
appropriate CPT/ HCPC's code needed for adjudication. At least one Remark
YI 16V 16 Code must be provided (may be comprised of OA Non - Covered
either the Remittance Advice Remark Code or
NCPDP Reject Reason Code).
Claim/svc lacks info for adjudication. Submit Claim/service lacks information which is
Provider Name & Specialty needed for adjudication. At least one Remark
ZS 16Q 16 Code must be provided (may be comprised of OA Non - Covered
either the Remittance Advice Remark Code or
NCPDP Reject Reason Code).
Claim/svc lacks info for adjudication - refile with Claim/service lacks information which is
itemzation sorted by days needed for adjudication. At least one Remark
ZF 16K 16 Code must be provided (may be comprised of OA Non - Covered
either the Remittance Advice Remark Code or
NCPDP Reject Reason Code).
Claim/svc lacks info for adjudication. Submit Claim/service lacks information which is
description of procedure. needed for adjudication. At least one Remark
X1 16X 16 Code must be provided (may be comprised of OA Non - Covered
either the Remittance Advice Remark Code or
NCPDP Reject Reason Code).
Clm/svc lacks info.needed for adjudication. Claim/service lacks information which is
Consent form does not meet age requirements. needed for adjudication. At least one Remark
CF 16Z 16 Code must be provided (may be comprised of OA Non-Covered
either the Remittance Advice Remark Code or
NCPDP Reject Reason Code).
Clm /svc lacks info for adjudication. Submit Claim/service lacks information which is
Medicaid Consent Form. needed for adjudication. At least one Remark
GF 16J 16 Code must be provided (may be comprised of OA Non-Covered
either the Remittance Advice Remark Code or
NCPDP Reject Reason Code).
Duplicate claim/service. Duplicate claim/service.
XD 18 18 OA Non - Covered
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DEAN HEALTH PLAN CLAIM ADJUSTMENT REASON CODES - 10/27/10
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code Claim Adj. 835 Claim Adj. 835 Description of ANSI code Group 835 Line Level
Paper Description
(Paper Reason Reason code (note will not print on 835) Codes Adjustment
only) code
This is a work-related injury/illness and thus the This is a work-related injury/illness and thus
liability of the worker's compensation carrier. the liability of the worker's compensation
S1 19 19 carrier. OA Non - Covered
This care may be covered by another payer This care may be covered by another payer
(Medicare) per coordination of benefits.
MP 22B 22 OA Non- Covered
This care may be covered by another payer. This care may be covered by another payer
per coordination of benefits.
OI 22 22 OA Non - Covered
The impact of prior payer adj. Including payments The impact of prior payer(s) adjudication
and/ or adjustments. including payments and / or adjustments.
S5 23 23 OA COB Savings
Expenses incurred prior to coverage. Expenses incurred prior to coverage.
CV 26 26 PR Non-Covered
Expenses incurred after coverage terminated. Expenses incurred after coverage terminated.
CX 27 27 PR Non-Covered
Time limit for filing has expired. Per review, service Time limit for filing has expired.
remains denied.
YU 29B 29 (1) CO, (2) PR Non - Covered
The time limit for filing has expired. The time limit for filing has expired.
TF 29 29 PR Non - Covered
The time limit for filing has expired. The time limit for filing has expired.
X6 29 29 (1) CO, (2) PR Non - Covered
Patient cannot be identified as our insured Patient cannot be identified as our insured
FF 31 31 PR Non- Covered
Our records indicate that this dependent is not an Our records indicate that this dependent is not
eligible dependent as defined an eligible dependent as defined
CW 32 32 PR Non - Covered
Insured has no dependent coverage Insured has no dependent coverage
CZ 33 33 PR Non - Covered
Insured has no coverage for newborns. Insured has no coverage for newborns.
C2 34 34 PR Non - Covered
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DEAN HEALTH PLAN CLAIM ADJUSTMENT REASON CODES - 10/27/10
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code Claim Adj. 835 Claim Adj. 835 Description of ANSI code Group 835 Line Level
Paper Description
(Paper Reason Reason code (note will not print on 835) Codes Adjustment
only) code
Lifetime Benefit maximum has been reached Lifetime Benefit maximum has been reached
BM 35 35 PR Non-Covered
Services not provided or authorized by designated Services not provided or authorized by
network/primary care prov. designated (network/primary care) providers.
NA 38 38 PR Non - Covered
Services denied at the time Services denied at the time
authorization/precertification was req authorization/precertification was requested
NZ 39 39 PR Non - Covered
Charges do not meet qualifications for Charges do not meet qualifications for
emergent/urgent care. emergent/urgent care.
NE 40 40 PR Non - Covered
Charge exceeds fee schedule/maximum allowable. Charge exceeds fee schedule/maximum
Discount applied. allowable or contracted /legislated fee
arrangement. Difference between charged and
50 45 45 (1.) CO, (2) PR
allowed amount
Charge exceeds contracted fee arrangement. No Charge exceeds fee schedule/maximum
HPSA Incentive applied allowable or contracted /legislated fee
arrangement. Difference between charged and
SE 45A 45 CO
allowed amount
Charge exceeds contracted fee arrangement. Charge exceeds fee schedule/maximum
HPSA Incentive applied allowable or contracted /legislated fee
arrangement. Difference between charged and
SB 45B 45 CO
allowed amount
Charge exceeds contracted fee arrangement. No Charge exceeds fee schedule/maximum
Discount applied allowable or contracted /legislated fee
arrangement. Difference between charged and
BE 45C 45 CO
allowed amount
Charge exceeds contracted fee arrangement. Charge exceeds fee schedule/maximum
Reduced by Managed care. allowable or contracted /legislated fee
arrangement. Difference between charged and
BX 45D 45 (1) CO, (2) PR
allowed amount
Charge exceeds contracted fee arrangement. Svc Charge exceeds fee schedule/maximum
not on your fee sched. allowable or contracted /legislated fee
arrangement.
X7 45W 45 CO Non - Covered
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DEAN HEALTH PLAN CLAIM ADJUSTMENT REASON CODES - 10/27/10
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code Claim Adj. 835 Claim Adj. 835 Description of ANSI code Group 835 Line Level
Paper Description
(Paper Reason Reason code (note will not print on 835) Codes Adjustment
only) code
Charge exceeds contracted fee schedule. Submit Charge exceeds fee schedule/maximum
notes to rev for add'l $ allowable or contracted /legislated fee
arrangement. Difference between charged and
YQ 45X 45 CO
allowed amount
Charge exceeds contracted fee arrangement. Charge exceeds fee schedule/maximum
Provider discount applied. allowable or contracted /legislated fee
arrangement.
DT 45Z 45 CO Discount field
These are noncovered services because this is not These are noncovered services because this
deemed a "medical necessity" is not deemed a "medical necessity" by the
payer
MT 50 50 PR Non - Covered
These are noncovered services because this is a These are noncovered services because this
preexisting condition is a preexisting condition
DP 51 51 PR Non- Covered
Services by an immediate relative or member of Services by an immediate relative or a member
same household are not covered of the same household are not covered
N1 53 53 PR Non - Covered
Multiple physicians/assistants are not covered in Multiple physicians/assistants are not covered
this case. in this case.
X4 54 54 OA Non - Covered
Procedure/treatment is deemed Procedure/treatment is deemed
experimental/investigational by the payer experimental/investigational by the payer
EV 55 55 PR Non-Covered
Treatment deemed to have been rendered in Treatment was deemed by the payer to have
inappro. or invalid POS been rendered in an inappropriate or invalid
place of service.
ZX 58 58 OA Non -covered
Processed based on mulitple or concurrent Processed based on mulitple or concurrent
procedure rules. procedure rules.
Difference between charged and
2X 59 59 OA
allowed amount
Noncovered days/room charge adjustment Noncovered days/room charge adjustment
PN 78 78 PR Non-covered
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DEAN HEALTH PLAN CLAIM ADJUSTMENT REASON CODES - 10/27/10
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code Claim Adj. 835 Claim Adj. 835 Description of ANSI code Group 835 Line Level
Paper Description
(Paper Reason Reason code (note will not print on 835) Codes Adjustment
only) code
Transfer Amount Transfer Amount
C1 87 87 PR Copay
Plan procedures not followed. Plan procedures not followed.
XP 95 95 PR Non - Covered
Plan procedures not followed.Penalty applied Plan procedures not followed.
P5 95E 95 PR Non - Covered
Plan procedures not followed. S/B enrolled w/ Plan procedures not followed.
Medicare Part B
RB 95C 95 PR Non- Covered
Noncovered charges. Noncovered per policy Noncovered charges
NC 96 96 PR Non - Covered
Noncovered charges. Service covered at 50%. Noncovered charges.
C5 96J 96 PR Non-covered
Payment included in the allowance for another Payment included in the allowance for another
service. Svc pd at DRG/PerDiem service/procedure
Difference between charged and
LO 97E 97 CO
allowed amount
Payment made to patient/insured/responsible party Payment made to patient/insured/responsible
party
PJ 100 100 PR Non - Covered
Managed care withholding ***note should only be Managed care withholding
on Provider EOP, not printed on Member EOB
WH 104 104 CO With hold
The related claim/service was not identified on this The related or qualifying claim/service was not
claim. identified on this claim
N2 107 107 OA Non-Covered
Rent/purchase guidelines were not met Rent/purchase guidelines were not met
RT 108 108 PR Non -covered
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DEAN HEALTH PLAN CLAIM ADJUSTMENT REASON CODES - 10/27/10
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code Claim Adj. 835 Claim Adj. 835 Description of ANSI code Group 835 Line Level
Paper Description
(Paper Reason Reason code (note will not print on 835) Codes Adjustment
only) code
Claim not covered by this payer. You must send Claim not covered by this payer/contractor.
the clm to North Central Opthalmology. You must send the claim to the correct
Y1 109 109 payor/contractor OA Non - Covered
Claim not covered by this payor. You must send Claim not covered by this payer/contractor.
the claim to contracted repricer. You must send the claim to the correct
RW 109 109 payor/contractor OA Non - Covered
Claim not covered by this payor. You must send Claim not covered by this payer/contractor.
the claim to Interlink. You must send the claim to the correct
Z1 109 109 payor/contractor OA Non-Covered
Claim not covered by this payor. You must send Claim not covered by this payer/contractor.
the claim to URN. You must send the claim to the correct
Z2 109 109 payor/contractor OA Non - Covered
Claim not covered by this payer. You must send Claim not covered by this payer/contracter.
the claim to the correct payer You must send the claim to the correct
TI 109 109 payer/contracter OA Non - Covered
Billing date predates service date. Resubmit Billing date predates service date
w/correct DOS
YF 110 110 OA Non - Covered
Not covered unless the provider accepts Not covered unless the provider accepts
assignment assignment
AA 111 111 OA Non-Covered
Procedure postponed, cancelled or delayed Procedure postponed, cancelled or delayed
C6 115 115 PR Non-Covered
Transportation is only covered to the closest Transportation is only covered to the closest
facility. facility that can provide the necessary care
TV 117 117 PR Non-Covered
Benefit max for this period/occurrence is reached. Benefit maximum for this time period or
2 Yr Eyeglass benefit met. occurrence has been reached
EG 119 119 PR Non- Covered
12/12/2011 a4ae9100-c808-4019-b682-de1e2f7dc910.xls 7
DEAN HEALTH PLAN CLAIM ADJUSTMENT REASON CODES - 10/27/10
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code Claim Adj. 835 Claim Adj. 835 Description of ANSI code Group 835 Line Level
Paper Description
(Paper Reason Reason code (note will not print on 835) Codes Adjustment
only) code
Benefit max for this period/occurrence is reached. Benefit maximum for this time period or
Benefit maximum met occurrence has been reached
BN 119 119 PR Non - Covered
Benefit max for this period/occurrence is Benefit maximum for this time period or
reached.Benefit maximum met occurrence has been reached
MX 119 119 PR Non - Covered
Submission/billing error(s). At least one
Remark Code must be provided (may be
Submission/billing error(s). Submit HCFA for add'l
Z3 125 125 comprised of either the Remittance Advice OA Non - Covered
$
Remark Code or NCPDP Reject Reason
Code).
Prior processing information appears incorrect. Prior processing information appears incorrect.
Need EOB.
OC 129 129 OA Non - Covered
Claim specific negotiated discount. Negotiated fee Claim specific negotiated discount
with prov.
Difference between charged and
NF 131 131 CO
allowed amount
Claim specific negotiated discount. TRPN/HFN Claim specific negotiated discount
Difference between charged and
R1 131 131 CO
allowed amount
Claim specific negotiated discount. First Choice Claim specific negotiated discount
Health Netwk.
Difference between charged and
R2 131 131 CO
allowed amount
Claim specific negotiated discount. PPO Claim specific negotiated discount
Next/PHN/Healthstar
Difference between charged and
R3 131 131 CO
allowed amount
Claim specific negotiated discount. HFNID Claim specific negotiated discount
Difference between charged and
R4 131 131 CO
allowed amount
Claim specific negotiated discount. Primary Health Claim specific negotiated discount
Services
Difference between charged and
R5 131 131 CO
allowed amount
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DEAN HEALTH PLAN CLAIM ADJUSTMENT REASON CODES - 10/27/10
Hold Paper
code Claim Adj. 835 Claim Adj. 835 Description of ANSI code Group 835 Line Level
Paper Description
(Paper Reason Reason code (note will not print on 835) Codes Adjustment
only) code
Claim specific negotiated discount. Novanet Claim specific negotiated discount
Difference between charged and
R6 131 131 CO
allowed amount
Claim specific negotiated discount. Galaxy Health Claim specific negotiated discount
Network
Difference between charged and
R7 131 131 CO
allowed amount
Claim specific negotiated discount. Claim specific negotiated discount
NPPN/Accountable
Difference between charged and
R8 131 131 CO
allowed amount
Claim specific negotiated discount. Hygeia Claim specific negotiated discount
Corporation
Difference between charged and
R9 131 131 CO
allowed amount
Claim specific negotiated discount. TRPN/FPN Claim specific negotiated discount
Difference between charged and
RA 131 131 CO
allowed amount
Claim specific negotiated discount. PHCS Healthy Claim specific negotiated discount
Directions contract
Difference between charged and
RE 131 131 CO
allowed amount
Claim specific negotiated discount.Health Payors Claim specific negotiated discount
organization contract
Difference between charged and
RF 131 131 CO
allowed amount
Claim specific negotiated discount. PPO Next Claim specific negotiated discount
contract.
Difference between charged and
RG 131 131 CO
allowed amount
Claim specific negotiated discount. PHCS contract Claim specific negotiated discount
Difference between charged and
RH 131 131 CO
allowed amount
Claim specific negotiated discount. Hygeia Corp Claim specific negotiated discount
contract
Difference between charged and
RI 131 131 CO
allowed amount
Claim specific negotiated discount. Multiplan Claim specific negotiated discount
contract
Difference between charged and
RJ 131 131 CO
allowed amount
Claim specific negotiated discount. HealthEOS Claim specific negotiated discount
contract
Difference between charged and
RK 131 131 CO
allowed amount
12/12/2011 a4ae9100-c808-4019-b682-de1e2f7dc910.xls 9
DEAN HEALTH PLAN CLAIM ADJUSTMENT REASON CODES - 10/27/10
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code Claim Adj. 835 Claim Adj. 835 Description of ANSI code Group 835 Line Level
Paper Description
(Paper Reason Reason code (note will not print on 835) Codes Adjustment
only) code
Claim specific negotiated discount Accountable Claim specific negotiated discount
Health Plans.
Difference between charged and
RL 131 131 CO
allowed amount
Claim specific negotiated discount. NPPN Claim specific negotiated discount
Community Health Partners.
Difference between charged and
RN 131 131 CO
allowed amount
Claim specific negotiated discount. URN Network Claim specific negotiated discount
contract)
Difference between charged and
RO 131 131 CO
allowed amount
Claim specific negotiated discount. ARAZ/Americas Claim specific negotiated discount
PPO
Difference between charged and
RP 131 131 CO
allowed amount
Claim specific negotiated discount. Coalition Claim specific negotiated discount
America contract
Difference between charged and
RQ 131 131 CO
allowed amount
Claim specific negotiated discount. Provider Select Claim specific negotiated discount
Difference between charged and
RU 131 131 CO
allowed amount
Claim specific negotiated discount. HMN/RAN/AMN Claim specific negotiated discount
Difference between charged and
RX 131 131 CO
allowed amount
Claim specific negotiated discount. NPPN Direct Claim specific negotiated discount
Difference between charged and
RY 131 131 CO
allowed amount
Claim specific negotiated discount. Medical Claim specific negotiated discount
Resource/Natl Prvd
Difference between charged and
RZ 131 131 CO
allowed amount
Claim specific negotiated discount. PlanCare Claim specific negotiated discount
America.
Difference between charged and
T1 131 131 CO
allowed amount
Claim specific negotiated discount. Negotiated fee Claim specific negotiated discount
Difference between charged and
Y6 131 131 CO
allowed amount
12/12/2011 a4ae9100-c808-4019-b682-de1e2f7dc910.xls 10
DEAN HEALTH PLAN CLAIM ADJUSTMENT REASON CODES - 10/27/10
Hold Paper
code Claim Adj. 835 Claim Adj. 835 Description of ANSI code Group 835 Line Level
Paper Description
(Paper Reason Reason code (note will not print on 835) Codes Adjustment
only) code
The disposition of the clm/svc is pending review. The disposition of the claim/service is pending
Submit NDC/ name of RX drug. further review.
YA 133 133 OA Non - Covered
The disposition of the clm/svc is pending further The disposition of the claim/service is pending
review. Submit office notes/ records. further review.
XO 133 133 OA Non - Covered
The disposition of the clm/svc is pending review. The disposition of the claim/service is pending
Notes req. w/ medical need. further review.
ZY 133 133 OA Non - Covered
Interim bills cannot be processed Interim bills cannot be processed
I2 135 135 CO Non-Covered
Failure to follow prior payer's coverage rules. Failure to follow prior payer's coverage rules.
GG 136 136 OA Non-Covered
Appeal procedures not followed or time limits not Appeal procedures not followed or time limits
met not met
TL 138 138 CO Non-Covered
Patient/insured health identification number and allowed amt reduced because component of
name do not match. the basic prodcedure/test was paid. The
beneficiary is not liable for more than the
N3 140 140 charge limit for the basic procedure/test PR Non-Covered
Claim spans eligible & ineligible periods of Claim spans eligible & ineligible periods of
coverage. coverage.
N4 141 141 PR Non-Covered
Monthly Medicaid patient liability amount. Monthly Medicaid patient liability amount.
N5 142 142 PR Non-Covered
Diagnosis was invalid for date(s) of service Diagnosis was invalid for date(s) of service
reported. reported.
N7 146 146 OA Non-Covered
12/12/2011 a4ae9100-c808-4019-b682-de1e2f7dc910.xls 11
DEAN HEALTH PLAN CLAIM ADJUSTMENT REASON CODES - 10/27/10
Hold Paper
code Claim Adj. 835 Claim Adj. 835 Description of ANSI code Group 835 Line Level
Paper Description
(Paper Reason Reason code (note will not print on 835) Codes Adjustment
only) code
Diagnosis was invalid for date(s) of service Diagnosis was invalid for date(s) of
reported. service reported.
XX 146 146 OA Non - Covered
Provider contracted/negotiated rate expired or rate Provider contracted/negotiated rate expired or
not on file. rate not on file.
N9 147 147 CO Non-Covered
Information from another provider was not provided Information from another provider was not
or was incomplete. provided or was insufficient/incomplete.
FA 148 148 PR Non-Covered
Lifetime benefit maximum has been reached for Lifetime benefit maximum has been reached
this service/benefit category. for this service/benefit category.
M5 149 149 PR Non-Covered
Payer deems the information submitted does not Payer deems the information submitted does
support level of svc. not support this level of service.
M7 150 150 OA Non-Covered
Payer deems the information submitted does not Payer deems the information submitted does
support level of svc. not support this level of service.
XC 150 150 OA Non - Covered
Payment adj. because the payer deems the info Payment adjusted because the payer deems
rec'd does not support these svc. the information submitted does not support this
many/frequency of services.
M8 151 151 OA Non-Covered
This (these) diagnosis (es) is (are) not covered This (these) diagnosis(es) is (are) not covered
DX 167 167 PR Non-Covered
Payment is denied when billed by this type of Payment is denied when performed/billed by
provider. Included in NH rate. this type of provider in this type of facility.
ZK 171 171 CO Non - Covered
Payment adjusted when performed/billed by a Payment adjusted when perfomed/billed by a
provider of this specialty provider of this specialty
P4 172 172 OA Non-Covered
12/12/2011 a4ae9100-c808-4019-b682-de1e2f7dc910.xls 12
DEAN HEALTH PLAN CLAIM ADJUSTMENT REASON CODES - 10/27/10
Hold Paper
code Claim Adj. 835 Claim Adj. 835 Description of ANSI code Group 835 Line Level
Paper Description
(Paper Reason Reason code (note will not print on 835) Codes Adjustment
only) code
Procedure code was invalid on the date of service. Procedure code was invalid on the date of
service.
XN 181 181 OA Non-Covered
Procedure modifer was invalid on the date of Procedure modifer was invalid on the date of
service. service.
M9 182 182 OA Non-Covered
The rendering provider is not eligible to perform the The rendering provider is not eligible to
service billed perform the service billed
P1 185 185 1)CO 2) PR Non-Covered
Unlisted procedure code billed when there is a "Not otherwise classified " or "unlisted"
specific code for this svc. procedure code (CPT/HCPCS) was billed
when there is a specific procedure code for
T3 189 189 this procedure/service OA Non-Covered
Precertification/authorization/notification absent. Precertification/authorization/notification
absent.
X8 197 197 1) CO 2) PR Non - Covered
Precertification/authorization/notification absent. Precertification/authorization/notification
Medicaid Member, file w/EDS. absent.
YR 197 197 1) CO 2) PR Non-covered
Noncovered personal comfort or convenience Non covered personal comfort or convenience
services. services.
NP 202 202 PR Non-covered
Information requested from the Information requested from the
patient/insured/responsible party was not provided patient/insured/responsible party was not
or was insufficient/incomplete provided or was insufficient/incomplete. At
FN 227 227 least one Remark Code must be provided PR Non- Covered
(may be comprised of either the Remittance
Advice Remark Code or NCPDP Reject
Reason Code).
Information requested from the Information requested from the
patient/insured/responsible party was not provided patient/insured/responsible party was not
or was insufficient/incomplete. Medical Records provided or was insufficient/incomplete. At
MR 227 Requested. 227 least one Remark Code must be provided PR Non-Covered
(may be comprised of either the Remittance
Advice Remark Code or NCPDP Reject
Reason Code).
Information requested from the Information requested from the
patient/insured/responsible party was not provided patient/insured/responsible party was not
or was insufficient/incomplete provided or was insufficient/incomplete. At
WN 227 227 least one Remark Code must be provided PR Non - Covered
(may be comprised of either the Remittance
Advice Remark Code or NCPDP Reject
Reason Code).
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DEAN HEALTH PLAN CLAIM ADJUSTMENT REASON CODES - 10/27/10
Hold Paper
code Claim Adj. 835 Claim Adj. 835 Description of ANSI code Group 835 Line Level
Paper Description
(Paper Reason Reason code (note will not print on 835) Codes Adjustment
only) code
Mutually exclusive procedures cannot be done in Mutually exclusive procedures cannot be done
the same day/setting. in the same day/setting.
YG 231 231 1) CO 2) PR Non-covered
Ungroupable DRG Ungroupable DRG
UG A8 A8 OA Non - Covered
Non Covered visits. This visit is not covered. Non Covered visits
NV B1 B1 PR Non - Covered
Coverage/program guidelines were not met or were Coverage/program guidelines were not met or
exceeded. were exceeded.
HB B5 B5 PR Non- Covered
Alternative services were available and not used. Alternative services were available and should
have been utilized.
AS B8 B8 PR Non -covered
Allowed amt reduced because component of the Allowed amt reduced because component of
basic prodcedure/test was paid the basic prodcedure/test was paid. The
beneficiary is not liable for more than the
YD B10 B10 charge limit for the basic procedure/test OA Non - Covered
Services not documented in patient's medical Services not documented in patient's medical
records. No documentation for svc. records
ZU B12 B12 OA Non - Covered
Previously paid. Payment for this clm/svc provided Previously paid. Payment for this claim/service
in a previous payment. may have been provided in a previous
payment.
YK B13 B13 OA Non - Covered
Only one visit or consultation per physician per day Only one visit or consultation per physician per
is covered. day is covered.
ZV B14 B14 OA Non - Covered
12/12/2011 a4ae9100-c808-4019-b682-de1e2f7dc910.xls 14
DEAN HEALTH PLAN CLAIM ADJUSTMENT REASON CODES - 10/27/10
Hold Paper
code Claim Adj. 835 Claim Adj. 835 Description of ANSI code Group 835 Line Level
Paper Description
(Paper Reason Reason code (note will not print on 835) Codes Adjustment
only) code
This service requires that a qualifying service be This service/procedure requires that a
received and covered. Included in other service. qualifying service/procedure be received and
covered. The qualifying other
XA B15 B15 service/procedure has not been (1) CO, (2) PR Non - Covered
received/adjudicated.
"New Patient" qualifications were not met "New Patient" qualifications were not met
XK B16 B16 OA Non - Covered
Coinsurance Amount met. Member has reached
their out of pocket maximum.
M2 02G No Set up Used for paper only
Correction to a prior claim
**Do not set up reason code per Cyndy - file
76 63 No Set up Negatives - all buckets
places in bucket
Correction to a prior claim
RV 63C No Set up Used for paper only
Interest amount. Interest payment.
**Do not set up reason code per Cyndy - file
YL 85 No Set up To - Pay
places $'s in bucket
No claim level adjustments. Excluded from
DRG/Flat fee.
93A No Set up Used for paper only
LE
12/12/2011 a4ae9100-c808-4019-b682-de1e2f7dc910.xls 15
DEAN HEALTH PLAN CLAIM ADJUSTMENT REASON CODES - 10/27/10
Hold Paper
code Claim Adj. 835 Claim Adj. 835 Description of ANSI code Group 835 Line Level
Paper Description
(Paper Reason Reason code (note will not print on 835) Codes Adjustment
only) code
12/12/2011 a4ae9100-c808-4019-b682-de1e2f7dc910.xls 16