ITS SIRF Adjustment Reason Codes by K10Ooh

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									Types of NFs                             Informational Reason Codes                                                      Adjustment Reason Codes
01 Informational Message                 100 COB Question                             Void Only Reason Codes
02 Adjudication Suspense Request         101 EOB Question                             201 Wrong Provider Paid                          211 Medicare
03 Adjudication Suspense Reply           102 Deductible Question                      202 Wrong Sub Paid                               212 Subrogation
04 Payment Suspense Request              103 Coinsurance Question                     203 Wrong Payee                                  213 COB
05 Payment Suspense Reply                104 Cost Containment Question                204 Retro Cancellation                           214 Incorrect Sub ID
06 Adjustment Request                    105 Benefit Period Question                  205 Benefits                                     215 Patient Change
07 Adjustment Reply                      106 Provider Question                        206 Duplicate                                    216 Incorrect Reject
00 Adjustment Closeout                   107 Claim Coding Question                    207 Lost/Damaged Check, Stop Payment             217 Late Managed Care Data Sent
08 Managed Care Information              108 Cancellation Question                    210 Work Comp                                    218 Incorrect Provider/PCP Data
09 MEF Discrepancy                       109 Eligibility Question                                                                      219 One Time Exception
Action Codes                             110 Sanction Question                        Void Reissue Reason Codes                        High Volume ADJ Reason Codes ***
Informational Action Codes               111 Filing Procedure Question                240 Incorrect Reject                             Void Only # / Void Reissue #
100 EOB Sent                             150 Claim Failed Edits                       241 Incorrect Deductible                         208 / 272 HVA Incorrect Reject
101 Forms Sent                           151 Invalid DF Transmission                  242 Incorrect Coinsurance                        209 / 273 HVA Benefit Change
102 Explanation Given                    152 General Information                      243 Incorrect Sanction                           220 / 274 HVA Pricing Change
103 Responded to Provider                153 Additional Information Request           244 Incorrect Group Number Retired 04/19/2004    221 / 259 HVA Wrong Class of Provider
104 Responded to Subscriber              154 Pricing Information Request              245 Incorrect Subscriber ID                      222 / 275 HVA Medicare
105 Additional Information Requested     155 System Problem Occurred                  246 Incorrect Address Retired 04/19/2004         223 / 270 Other HVA Home
106 Additional Information Sent-Fed Ex   156 Payment Information Request              247 Benefit Change                               224 / 271 Other HVA Host
107 Additional Information Sent-FAX      157 Lost Check                               248 Pricing Change                               ***Only to be used as directed by Mgmt
108 Additional Information Sent-Mail     158 Overage Check                            249 Resubmitted Billing                          or NTS. HVA defined as over 1,500 or
109 Claim Data Corrected                 159 Claim Status Inquiry Retired 10/16/03    250 Patient Change                               more claims or 200 claims to one plan.
110 Claim Status Verified                160 Split Claim                              251 Wrong Payee Retired 04/19/2004
111 Processed Delayed Claim              161 COB Speculative Questionnaire Sent       252 Lost/Damaged Check, Stop Payment
112 Name Changed                         162 OPL Payment Information Needed           253 Wrong Subscriber Paid
113 Address Changed                      163 Investigated Claim (NMIS guidelines)     254 Wrong Provider Paid
114 System Updated                       164 Carve-out Claim (NMIS guidelines)        255 Late Charges
115 Bill Sent                            165 Medical Records Requested                256 Wrong Subscriber Information
116 Bill Corrected                       167 Claim Status Inq./ International Only    257 Interim Billing
117 Refund Sent                                       Source Codes                    258 Wrong Classification of Provider
118 Refund Requested                          First Digit     2nd and 3rd Digits      260 Worker’s Compensation
119 Claim Paid                           1 Host/Par           01 Provider Hospital    261 Medicare
120 Claim Denied                         2 Home/Control       02 Provider Other       262 Subrogation
121 Replacement DF Sent                                       03 Group                263 COB
122 Replacement RF Sent                                       04 Subscriber           264 Statistical
123 Check Reissued                                            05 Marketing            265 Incorrect Provider/PCP Data
124 Resubmission Approved                                     06 Other Carrier        266 Incorrect Managed Care Information
125 Resubmission Denied                                       07 Processing Site      267 Incorrect Financial Reimbursement to Prov
126 Additional Information Obtained                           08 Medical Dept         268 Late Managed Care Data Sent by Par Plan
                                                              09 Utilization Review   269 One Time Exception
                                                              10 CFA
                                 Adjustment Action Codes
200 Adjustment Approved
300 Adjustment Denied
301 Adjustment Denied Until Money is Recouped from Provider

								
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