eob by liwenting

VIEWS: 30 PAGES: 377

									                                                            277 Claim Status Codes Master




277 CLAIM
STATUS    277 CLAIM STATUS CODE DESCRIPTION                                 NOTES
0           CANNOT PROVIDE FURTHER STATUS ELECTRONICALLY.

1           FOR MORE DETAILED INFORMATION, SEE REMITTANCE ADVICE.
2           MORE DETAILED INFORMATION IN LETTER.

3           CLAIM HAS BEEN ADJUDICATED AND IS AWAITING PAYMENT CYCLE.
            THIS IS A SUBSEQUENT REQUEST FOR INFORMATION FROM THE
4           ORIGINAL REQUEST.
5           THIS IS A FINAL REQUEST FOR INFORMATION.
6           BALANCE DUE FROM THE SUBSCRIBER.
7           CLAIM MAY BE RECONSIDERED AT A FUTURE DATE.


                                                                            Inactive as of ASC X12
                                                                            Version 4020. Refer to
8           NO PAYMENT DUE TO CONTRACT/PLAN PROVISIONS                      107 for new verbiage.
9           NO PAYMENT WILL BE MADE FOR THIS CLAIM.


                                                                            Inactive as of ASC X12
                                                                            Version 4020. Refer to
10          ALL ORIGINALLY SUBMITTED PROCEDURE CODES HAVE BEEN COMBINED.    12 for new verbiage.


                                                                          Inactive as of ASC X12
                                                                          Version 4020. Refer to
11          SOME ORIGINALLY SUBMITTED PROCEDURE CODES HAVE BEEN COMBINED. 12 for new verbiage.
            ONE OR MORE ORIGINALLY SUBMITTED PROCEDURE CODES HAVE BEEN
12          COMBINED.                                                       Changed as of 6/01


                                                                            Inactive as of ASC X12
                                                                            Version 4020. Refer to
13          ALL ORIGINALLY SUBMITTED PROCEDURE CODES HAVE BEEN MODIFIED.    15 for new verbiage.


                                                                            Inactive as of ASC X12
            SOME ALL ORIGINALLY SUBMITTED PROCEDURE CODES HAVE BEEN         Version 4020. Refer to
14          MODIFIED.                                                       15 for new verbiage.
            ONE OR MORE ORIGINALLY SUBMITTED PROCEDURE CODES HAVE BEEN
15          MODIFIED.                                                       Changed as of 6/01
16          CLAIM/ENCOUNTER HAS BEEN FORWARDED TO ENTITY.
            CLAIM/ENCOUNTER HAS BEEN FORWARDED BY THIRD PARTY ENTITY TO
17          ENTITY.

18          ENTITY RECEIVED CLAIM/ENCOUNTER, BUT RETURNED INVALID STATUS.




5/16/2012                                                               Page 1
                                                             277 Claim Status Codes Master




277 CLAIM
STATUS    277 CLAIM STATUS CODE DESCRIPTION                                 NOTES
19          ENTITY ACKNOWLEDGES RECEIPT OF CLAIM/ENCOUNTER                  Changed as of 6/01
20          ACCEPTED FOR PROCESSING.                                        Changed as of 6/01
21          MISSING OR INVALID INFORMATION.                                 Changed as of 6/01

22          …BEFORE ENTERING THE ADJUDICATION SYSTEM.                       Inactive as of 01/01/08
23          RETURNED TO ENTITY.                                             Changed as of 6/01
24          ENTITY NOT APPROVED AS AN ELECTRONIC SUBMITTER.                 Changed as of 6/01
25          ENTITY NOT APPROVED.                                            Changed as of 6/01
26          ENTITY NOT FOUND.                                               Changed as of 6/01
27          POLICY CANCELED.                                                Changed as of 6/01


                                                                            Inactive as of ASC X12
                                                                            Version 4020. Refer to
28          CLAIM SUBMITTED TO WRONG PAYER.                                 116 for new verbiage.

29          SUBSCRIBER AND POLICY NUMBER/CONTRACT NUMBER MISMATCHED.
30          SUBSCRIBER AND SUBSCRIBER ID MISMATCHED.
31          SUBSCRIBER AND POLICYHOLDER NAME MISMATCHED.

32          SUBSCRIBER AND POLICY NUMBER/CONTRACT NUMBER NOT FOUND.
33          SUBSCRIBER AND SUBSCRIBER ID NOT FOUND.
34          SUBSCRIBER AND POLICYHOLDER NAME NOT FOUND.
35          CLAIM/ENCOUNTER NOT FOUND.

37          PREDETERMINATION IS ON FILE, AWAITING COMPLETION OF SERVICES.
38          AWAITING NEXT PERIODIC ADJUDICATION CYCLE.
39          CHARGES FOR PREGNANCY DEFERRED UNTIL DELIVERY.
40          WAITING FOR FINAL APPROVAL.
41          SPECIAL HANDLING REQUIRED AT PAYER SITE.
42          AWAITING RELATED CHARGES.
44          CHARGES PENDING PROVIDER AUDIT.
45          AWAITING BENEFIT DETERMINATION.
46          INTERNAL REVIEW/AUDIT.
47          INTERNAL REVIEW/AUDIT - PARTIAL PAYMENT MADE.
48          REFERRAL/AUTHORIZATION.                                       Changed as of 2/01
49          PENDING PROVIDER ACCREDITATION REVIEW.
50          CLAIM WAITING FOR INTERNAL PROVIDER VERIFICATION.
51          INVESTIGATING OCCUPATIONAL ILLNESS/ACCIDENT.

52          INVESTIGATING EXISTENCE OF OTHER INSURANCE COVERAGE.




5/16/2012                                                               Page 2
                                                          277 Claim Status Codes Master




277 CLAIM
STATUS    277 CLAIM STATUS CODE DESCRIPTION                                NOTES
            CLAIM BEING RESEARCHED FOR INSURED ID/GROUP POLICY NUMBER
53          ERROR.
54          DUPLICATE OF A PREVIOUSLY PROCESSED CLAIM/LINE.
55          CLAIM ASSIGNED TO AN APPROVER/ANALYST.
56          AWAITING ELIGIBILITY DETERMINATION.
57          PENDING COBRA INFORMATION REQUESTED.
59          NON-ELECTRONIC REQUEST FOR INFORMATION.
60          ELECTRONIC REQUEST FOR INFORMATION.
61          ELIGIBILITY FOR EXTENDED BENEFITS.
64          RE-PRICING INFORMATION.
65          CLAIM/LINE HAS BEEN PAID.
66          PAYMENT REFLECTS USUAL AND CUSTOMARY CHARGES.
67          PAYMENT MADE IN FULL.
68          PARTIAL PAYMENT MADE FOR THIS CLAIM.


                                                                           Inactive as of ASC X12
                                                                           Version 4020. Refer to
69          PAYMENT REFLECTS PLAN PROVISIONS.                              107 for new verbiage.


                                                                           Inactive as of ASC X12
                                                                           Version 4020. Refer to
70          PAYMENT REFLECTS CONTRACT PROVISIONS.                          107 for new verbiage.
71          PERIODIC INSTALLMENT RELEASED.
72          CLAIM CONTAINS SPLIT PAYMENT.

73          PAYMENT MADE TO ENTITY, ASSIGNMENT OF BENEFITS NOT ON FILE.

78          DUPLICATE OF AN EXISTING CLAIM/LINE, AWAITING PROCESSING.

81          CONTRACT/PLAN DOES NOT COVER PRE-EXISTING CONDITIONS.
83          NO COVERAGE FOR NEWBORNS.
84          SERVICE NOT AUTHORIZED.
85          ENTITY NOT PRIMARY.
86          DIAGNOSIS AND PATIENT GENDER MISMATCH.                         Changed as of 2/00
                                                                           Inactive as of
                                                                           01/01/2008. Refer to
87          DENIED: ENTITY NOT FOUND.                                      code 26.
            ENTITY NOT ELIGIBLE FOR BENEFITS FOR SUBMITTED DATES OF
88          SERVICE.
            ENTITY NOT ELIGIBLE FOR DENTAL BENEFITS FOR SUBMITTED DATES
89          OF SERVICE




5/16/2012                                                               Page 3
                                                           277 Claim Status Codes Master




277 CLAIM
STATUS    277 CLAIM STATUS CODE DESCRIPTION                                NOTES
            ENTITY NOT ELIGIBLE FOR MEDICAL BENEFITS FOR SUBMITTED DATES
90          OF SERVICE.

91          ENTITY NOT ELIGIBLE/NOT APPROVED FOR DATES OF SERVICE.

92          ENTITY DOES NOT MEET DEPENDENT OR STUDENT QUALIFICATION.
93          ENTITY IS NOT SELECTED PRIMARY CARE PROVIDER.

94          ENTITY NOT REFERRED BY SELECTED PRIMARY CARE PROVIDER.
95          REQUESTED ADDITIONAL INFORMATION NOT RECEIVED.
96          NO AGREEMENT WITH ENTITY.
97          PATIENT ELIGIBILITY NOT FOUND WITH ENTITY.
98          CHARGES APPLIED TO DEDUCTIBLE.
99          PRE-TREATMENT REVIEW.
100         PRE-CERTIFICATION PENALTY TAKEN.

101         CLAIM WAS PROCESSED AS ADJUSTMENT TO PREVIOUS CLAIM.
102         NEWBORN'S CHARGES PROCESSED ON MOTHER'S CLAIM.
103         CLAIM COMBINED WITH OTHER CLAIM(S).
104         PROCESSED ACCORDING TO PLAN PROVISIONS.
105         CLAIM/LINE IS CAPITATED.
106         THIS AMOUNT IS NOT ENTITY'S RESPONSIBILITY.
107         PROCESSED ACCORDING TO CONTRACT/PLAN PROVISIONS.               Changed as of 6/01
                                                                           Inactive as of
                                                                           01/01/2008. Refer to
108         COVERAGE HAS BEEN CANCELED FOR THIS ENTITY.                    code 27.
109         ENTITY NOT ELIGIBLE.
110         CLAIM REQUIRES PRICING INFORMATION.
            AT THE POLICYHOLDER'S REQUEST THESE CLAIMS CANNOT BE
111         SUBMITTED ELECTRONICALLY.
112         POLICYHOLDER PROCESSES THEIR OWN CLAIMS.
                                                                           Inactive as of
113         CANNOT PROCESS INDIVIDUAL INSURANCE POLICY CLAIMS.             07/01/2008.

114         CLAIM/SERVICE SHOULD BE PROCESSED BY ENTITY.                   Changed as of 07/01/2008.
                                                                           Inactive as of
115         CANNOT PROCESS HMO CLAIMS                                      07/01/2008.
116         CLAIM SUBMITTED TO INCORRECT PAYER.
117         CLAIM REQUIRES SIGNATURE-ON-FILE INDICATOR.




5/16/2012                                                              Page 4
                                                            277 Claim Status Codes Master




277 CLAIM
STATUS    277 CLAIM STATUS CODE DESCRIPTION                                 NOTES
                                                                            Inactive as   of
                                                                            01/01/2008.   Refer to
                                                                            code 21 and   125 with
118         TPO REJECTED CLAIM/LINE BECAUSE PAYER NAME IS MISSING.          entity code   IN.
                                                                            Inactive as of
            TPO REJECTED CLAIM/LINE BECAUSE CERTIFICATION INFORMATION IS    01/01/2008. Refer to
119         MISSING.                                                        code 21 and 252.
                                                                            Inactive as of
            TPO REJECTED CLAIM/LINE BECAUSE CLAIM DOES NOT CONTAIN          01/01/2008. Refer to
120         ENOUGH INFORMATION.                                             code 21.

121         SERVICE LINE NUMBER GREATER THAN MAXIMUM ALLOWABLE FOR PAYER.
                                                                            Inactive as of
                                                                            01/01/2008. Refer to
122         MISSING/INVALID DATA PREVENTS PAYER FROM PROCESSING CLAIM.      code 21.
123         ADDITIONAL INFORMATION REQUESTED FROM ENTITY.
124         ENTITY'S NAME, ADDRESS, PHONE AND ID NUMBER.
125         ENTITY'S NAME.
126         ENTITY'S ADDRESS.
127         ENTITY'S PHONE NUMBER.
128         ENTITY'S TAX ID.
129         ENTITY'S BLUE CROSS PROVIDER ID.
130         ENTITY'S BLUE SHIELD PROVIDER ID.
131         ENTITY'S MEDICARE PROVIDER ID.
132         ENTITY'S MEDICAID PROVIDER ID.
133         ENTITY'S UPIN.
134         ENTITY'S CHAMPUS PROVIDER ID.
135         ENTITY'S COMMERCIAL PROVIDER ID.
136         ENTITY'S HEALTH INDUSTRY ID NUMBER.
137         ENTITY'S PLAN NETWORK ID.
138         ENTITY'S SITE ID.
139         ENTITY'S HEALTH MAINTENANCE PROVIDER ID (HMO).
140         ENTITY'S PREFERRED PROVIDER ORGANIZATION ID (PPO).

141         ENTITY'S   ADMINISTRATIVE SERVICES ORGANIZATION ID (ASO).
142         ENTITY'S   LICENSE/CERTIFICATION NUMBER.
143         ENTITY'S   STATE LICENSE NUMBER.
144         ENTITY'S   SPECIALTY LICENSE NUMBER.

145         ENTITY'S SPECIALTY/TAXONOMY CODE.                               Changed as of 04/01/2008.
146         ENTITY'S ANESTHESIA LICENSE NUMBER.




5/16/2012                                                               Page 5
                                                          277 Claim Status Codes Master




277 CLAIM
STATUS    277 CLAIM STATUS CODE DESCRIPTION                               NOTES

147         ENTITY'S QUALIFICATION DEGREE/DESIGNATION (E.G. RN,PHD, MD)
148         ENTITY'S SOCIAL SECURITY NUMBER.
149         ENTITY'S EMPLOYER ID.
150         ENTITY'S DRUG ENFORCEMENT AGENCY (DEA) NUMBER.
152         PHARMACY PROCESSOR NUMBER.
153         ENTITY'S ID NUMBER.
154         RELATIONSHIP OF SURGEON & ASSISTANT SURGEON.
155         ENTITY'S RELATIONSHIP TO PATIENT.
156         PATIENT RELATIONSHIP TO SUBSCRIBER.
157         ENTITY'S GENDER.
158         ENTITY'S DATE OF BIRTH.
159         ENTITY'S DATE OF DEATH.
160         ENTITY'S MARITAL STATUS.
161         ENTITY'S EMPLOYMENT STATUS.
162         ENTITY'S HEALTH INSURANCE CLAIM NUMBER (HICN).
163         ENTITY'S POLICY NUMBER.
164         ENTITY'S CONTRACT/MEMBER NUMBER.
165         ENTITY'S EMPLOYER NAME, ADDRESS AND PHONE.
166         ENTITY'S EMPLOYER NAME.
167         ENTITY'S EMPLOYER ADDRESS.
168         ENTITY'S EMPLOYER PHONE NUMBER.
                                                                          Inactive for version
                                                                          004060. Duplicates code
169         ENTITY'S EMPLOYER ID.                                         149.
170         ENTITY'S EMPLOYEE ID.
            OTHER INSURANCE COVERAGE INFORMATION (HEALTH, LIABILITY,
171         AUTO, ETC).
172         OTHER EMPLOYER NAME, ADDRESS AND TELEPHONE NUMBER.

            ENTITY'S NAME, ADDRESS, PHONE, GENDER, DOB, MARITAL STATUS,
173         EMPLOYMENT STATUS AND RELATION TO SUBSCRIBER.                 Changed as of 2/00
174         ENTITY'S STUDENT STATUS.
175         ENTITY'S SCHOOL NAME.
176         ENTITY'S SCHOOL ADDRESS.
            TRANSPLANT RECIPIENT'S NAME, DATE OF BIRTH, GENDER,
177         RELATIONSHIP TO INSURED.                                      Changed as of 2/00
178         SUBMITTED CHARGES.
179         OUTSIDE LAB CHARGES.
180         HOSPITAL'S SEMI-PRIVATE ROOM RATE.
181         HOSPITAL'S ROOM RATE.




5/16/2012                                                              Page 6
                                                          277 Claim Status Codes Master




277 CLAIM
STATUS    277 CLAIM STATUS CODE DESCRIPTION                                NOTES
182         ALLOWABLE/PAID FROM PRIMARY COVERAGE.
183         AMOUNT ENTITY HAS PAID.

184         PURCHASE PRICE FOR THE RENTED DURABLE MEDICAL EQUIPMENT.
185         RENTAL PRICE FOR DURABLE MEDICAL EQUIPMENT.

186         PURCHASE AND RENTAL PRICE OF DURABLE MEDICAL EQUIPMENT.
187         DATE(S) OF SERVICE.
188         STATEMENT FROM-THROUGH DATES.
189         HOSPITAL ADMISSION DATE.
190         HOSPITAL DISCHARGE DATE.
191         DATE OF LAST MENSTRUAL PERIOD (LMP).                           New as of 2/97

192         DATE OF FIRST SERVICE FOR CURRENT SERIES/SYMPTOM/ILLNESS.
193         FIRST CONSULTATION/EVALUATION DATE.                            New as of 2/97
194         CONFINEMENT DATES.
195         UNABLE TO WORK DATES.
196         RETURN TO WORK DATES.
197         EFFECTIVE COVERAGE DATE(S).
198         MEDICARE EFFECTIVE DATES.
199         DATE OF CONCEPTION AND EXPECTED DATE OF DELIVERY.
200         DATE OF EQUIPMENT RETURN.
201         DATE OF DENTAL APPLIANCE PRIOR PLACEMENT.

202         DATE OF DENTAL PRIOR REPLACEMENT/REASON FOR REPLACEMENT.
203         DATE OF DENTAL APPLIANCE PLACED.

204         DATE DENTAL CANAL(S) OPENED AND DATE SERVICE COMPLETED.

205         DATE(S) DENTAL ROOT CANAL THERAPY PREVIOUSLY PERFORMED.
            MOST RECENT DATE OF CURETTAGE, ROOT PLANNING, OR PERIODONTAL
206         SURGERY.
207         DENTAL IMPRESSION AND SEATING DATE.
208         MOST RECENT DATE PACEMAKER WAS IMPLANTED.
209         MOST RECENT PACEMAKER BATTERY CHANGE DATE.
210         DATE OF THE LAST X-RAY.
211         DATE(S) OF DIALYSIS TRAINING PROVIDED TO PATIENT.
212         DATE OF LAST ROUTINE DIALYSIS.
213         DATE OF FIRST ROUTINE DIALYSIS.
214         ORIGINAL DATE OF PRESCRIPTION/ORDERS/REFERRAL.                 New as of 2/97
215         DATE OF TOOTH EXTRACTION/EVOLUTION.




5/16/2012                                                               Page 7
                                                          277 Claim Status Codes Master




277 CLAIM
STATUS    277 CLAIM STATUS CODE DESCRIPTION                               NOTES
216         DRUG INFORMATION.
217         DRUG NAME, STRENGTH AND DOSAGE FORM.
218         NDC NUMBER.
219         PRESCRIPTION NUMBER.
220         DRUG PRODUCTION ID NUMBER.
221         DRUG DAYS SUPPLY AND DOSAGE.

222         DRUG DISPENSING UNITS AND AVERAGE WHOLESALE PRICE (AWP).
223         ROUTINE OF DRUG/MYELOGRAM ADMINISTRATION.
224         ANATOMICAL LOCATION FOR JOINT INJECTION.
225         ANATOMICAL LOCATION.
226         JOINT INJECTION SITE.
227         HOSPITAL INFORMATION.
228         TYPE OF BILL FOR UB CLAIM.                                    Changed as of 6/01
229         HOSPITAL ADMISSION SOURCE.
230         HOSPITAL ADMISSION HOUR.
231         HOSPITAL ADMISSION TYPE.
232         ADMITTING DIAGNOSIS.
233         HOSPITAL DISCHARGE HOUR.
234         PATIENT DISCHARGE STATUS.
235         UNITS OF BLOOD FURNISHED.
236         UNITS OF BLOOD REPLACED.
237         UNITS OF DEDUCTIBLE BLOOD.
238         SEPARATE CLAIM FOR MOTHER/BABY CHARGES.
239         DENTAL INFORMATION.
240         TOOTH SURFACE(S) INVOLVED.
241         LIST OF ALL MISSING TEETH (UPPER AND LOWER).
242         TOOTH NUMBERS, SURFACES, AND/OR QUADRANTS INVOLVED.
243         MONTHS OF DENTAL TREATMENT REMAINING.
244         TOOTH NUMBER OR LETTER.
245         DENTAL QUADRANT/ARCH.
            TOTAL ORTHODONTIC SERVICE FEE, INITIAL APPLIANCE FEE,
246         MONTHLY FEE, LENGTH OF SERVICE.
247         LINE INFORMATION.
248         ACCIDENT DATE, STATE, DESCRIPTION AND CAUSE.
249         PLACE OF SERVICE.
250         TYPE OF SERVICE.
251         TOTAL ANESTHESIA MINUTES.
252         AUTHORIZATION/CERTIFICATION NUMBER.




5/16/2012                                                              Page 8
                                                          277 Claim Status Codes Master




277 CLAIM
STATUS    277 CLAIM STATUS CODE DESCRIPTION                                NOTES
                                                                           Deleted as of 2/97.
                                                                           Please use codes 454 or
253         PROCEDURE/REVENUE CODE FOR SERVICES(S) RENDERED.               455.
254         PRIMARY DIAGNOSIS CODE.
255         DIAGNOSIS CODE.
256         DRG CODE(S).
257         ADSM-III-R CODE FOR SERVICES RENDERED.
258         DAYS/UNITS FOR PROCEDURE/REVENUE CODE.
259         FREQUENCY OF SERVICE.
260         LENGTH OF MEDICAL NECESSITY, INCLUDING BEGIN DATE.             New as of 2/97
261         OBESITY MEASUREMENTS.
            TYPE OF SURGERY/SERVICE FOR WHICH ANESTHESIA WAS
262         ADMINISTERED.
263         LENGTH OF TIME FOR SERVICES RENDERED.
            NUMBER OF LITERS/MINUTE & TOTAL HOURS/DAY FOR RESPIRATORY
264         SUPPORT.
265         NUMBER OF LESIONS EXCISED.

266         FACILITY POINT OF ORIGIN AND DESTINATION - AMBULANCE.
267         NUMBER OF MILES PATIENT WAS TRANSPORTED.
268         LOCATION OF DURABLE MEDICAL EQUIPMENT USE.
269         LENGTH/SIZE OF LACERATION/TUMOR.
270         SUBLUXATION LOCATION.
271         NUMBER OF SPINE SEGMENTS.
272         OXYGEN CONTENTS FOR OXYGEN SYSTEM RENTAL.
273         WEIGHT.
274         HEIGHT.
275         CLAIM.
276         UB-04/HCFA-1450/HCFA-1500 CLAIM FORM                           Changed as of 6/01
277         PAPER CLAIM.
278         SIGNED CLAIM FORM.
279         ITEMIZED CLAIM.
280         ITEMIZED CLAIM BY PROVIDER.
281         RELATED CONFINEMENT CLAIM.
282         COPY OF PRESCRIPTION.
            MEDICARE ENTITLEMENT INFORMATION IS REQUIRED TO DETERMINE
283         PRIMARY COVERAGE.                                              Changed as of 7/01/08.
284         COPY OF MEDICARE ID CARD.
285         VOUCHERS/EXPLANATION OF BENEFITS (EOB).

286         OTHER PAYER'S EXPLANATION OF BENEFITS/PAYMENT INFORMATION.




5/16/2012                                                               Page 9
                                                          277 Claim Status Codes Master




277 CLAIM
STATUS    277 CLAIM STATUS CODE DESCRIPTION                               NOTES
287         MEDICAL NECESSITY FOR SERVICE.
288         REASON FOR LATE HOSPITAL CHARGES.
289         REASON FOR LATE DISCHARGE.
290         PRE-EXISTING INFORMATION.
291         REASON FOR TERMINATION OF PREGNANCY.
292         PURPOSE OF FAMILY CONFERENCE/THERAPY.
293         REASON FOR PHYSICAL THERAPY.
294         SUPPORTING DOCUMENTATION.
295         ATTENDING PHYSICIAN REPORT.
296         NURSE'S NOTES.
297         MEDICAL NOTES/REPORT.                                        New as of 2/97
298         OPERATIVE REPORT.
299         EMERGENCY ROOM NOTES/REPORT.
300         LAB/TEST REPORT/NOTES/RESULTS.                               New as of 2/97
301         MRI REPORT.

302         REFER TO CODES 300 FOR LAB NOTES AND 311 FOR PATHOLOGY NOTES. Removed prior to 2/97


                                                                         Deleted as of 2/97.
                                                                         Please use code 297:6O
303         PHYSICAL THERAPY NOTES.                                      (6 'OH' - not zero)
304         REPORTS FOR SERVICE.
305         X-RAY REPORTS/INTERPRETATION.
306         DETAILED DESCRIPTION OF SERVICE.
307         NARRATIVE WITH POCKET DEPTH CHART.
308         DISCHARGE SUMMARY.

309         CODE WAS DUPLICATE OF CODE 299.                              Removed prior to 2/97.

310         PROGRESS NOTES FOR THE SIX MONTHS PRIOR TO STATEMENT DATE.
311         PATHOLOGY NOTES/REPORTS.
312         DENTAL CHARTING.
313         BRIDGEWORK INFORMATION.
314         DENTAL RECORDS FOR THIS SERVICE.
315         PAST PERIO TREATMENT HISTORY.
316         COMPLETE MEDICAL HISTORY.
317         PATIENT'S MEDICAL RECORDS.
318         X-RAYS.
319         PRE/POST-OPERATIVE X-RAYS/PHOTOGRAPHS.                       New as of 2/97
320         STUDY MODELS.
321         RADIOGRAPHS OR MODELS.




5/16/2012                                                            Page 10
                                                          277 Claim Status Codes Master




277 CLAIM
STATUS    277 CLAIM STATUS CODE DESCRIPTION                               NOTES
322         RECENT FM X-RAYS.
323         STUDY MODELS, X-RAYS, AND/OR NARRATIVE.
324         RECENT X-RAY OF TREATMENT AREA AND/OR NARRATIVE.
325         RECENT FM X-RAYS AND/OR NARRATIVE.
326         COPY OF TRANSPLANT ACQUISITION INVOICE.
            PERIODONTAL CASE TYPE DIAGNOSIS AND RECENT POCKET DEPTH
327         CHART WITH NARRATIVE.

                                                                          Deleted as of 2/97.
328         SPEECH THERAPY NOTES.                                         Please use code 297:6R
329         EXERCISE NOTES.
330         OCCUPATIONAL NOTES.
331         HISTORY AND PHYSICAL.

                                                                          Inactive as of 01/01/08.
332         AUTHORIZATION/CERTIFICATION (INCLUDE PERIOD COVERED).         Use code 252.
333         PATIENT RELEASE OF INFORMATION AUTHORIZATION.
334         OXYGEN CERTIFICATION.
335         DURABLE MEDICAL EQUIPMENT CERTIFICATION.
336         CHIROPRACTIC CERTIFICATION.
337         AMBULANCE CERTIFICATION/DOCUMENTATION.

                                                                          Deleted as of 2/97.
338         HOME HEALTH CERTIFICATION.                                    Please use code 332:4Y
339         ENTERAL/PARENTERAL CERTIFICATION.
340         PACEMAKER CERTIFICATION.
341         PRIVATE DUTY NURSING CERTIFICATION.
342         PODIATRIC CERTIFICATION.
            DOCUMENTATION THAT FACILITY IS STATE LICENSED AND MEDICARE
343         APPROVED AS A SURGICAL FACILITY.
            DOCUMENTATION THAT PROVIDER OF PHYSICAL THERAPY IS MEDICARE
344         PART B APPROVED.
345         TREATMENT PLAN FOR SERVICE/DIAGNOSIS.
346         PROPOSED TREATMENT PLAN FOR NEXT 6 MONTHS.

347         REFER TO CODE 345 FOR TREATMENT PLAN AND 282 FOR PRESCRIPTION Removed prior to 2/97

                                                                          Inactive as of 01/01/08.
348         CHIROPRACTIC TREATMENT PLAN.                                   Use code 345:QL.




5/16/2012                                                             Page 11
                                                            277 Claim Status Codes Master




277 CLAIM
STATUS    277 CLAIM STATUS CODE DESCRIPTION                                NOTES

                                                                           Deleted as of 2/97.
                                                                           Please use codes 345:5I,
                                                                           5J, 5K, 5L, 5M, 5N, 5O
349         PSYCHIATRIC TREATMENT PLAN.                                    (5 'OH' - not zero), 5P

                                                                           Deleted as of 2/97.
350         SPEECH PATHOLOGY TREATMENT PLAN.                               Please use code 345:6R


                                                                           Deleted as of 2/97.
                                                                           Please use codes 345:6O
351         PHYSICAL/OCCUPATIONAL THERAPY TREATMENT PLAN.                  (6 'OH' - not zero), 6N
352         DURATION OF TREATMENT PLAN.
353         ORTHODONTICS TREATMENT PLAN.

354         TREATMENT PLAN FOR REPLACEMENT OF REMAINING MISSING TEETH.
355         HAS CLAIM BEEN PAID?
356         WAS BLOOD FURNISHED?
357         HAS OR WILL BLOOD BE REPLACED?
358         DOES PROVIDER ACCEPT ASSIGNMENT OF BENEFITS?

359         IS THERE A RELEASE OF INFORMATION SIGNATURE ON FILE?

360         IS THERE AN ASSIGNMENT OF BENEFITS SIGNATURE ON FILE?
361         IS THERE OTHER INSURANCE?
362         IS THE DENTAL PATIENT COVERED BY MEDICAL INSURANCE?
363         WILL WORKER'S COMPENSATION COVER SUBMITTED CHARGES?
364         IS ACCIDENT/ILLNESS/CONDITION EMPLOYMENT RELATED?
365         IS SERVICE THE RESULT OF AN ACCIDENT?
366         IS INJURY DUE TO AUTO ACCIDENT?
            IS SERVICE PERFORMED FOR A RECURRING CONDITION OR NEW
367         CONDITION?
            IS MEDICAL DOCTOR (MD) OR DOCTOR OF OSTEOPATH (DO) ON STAFF
368         OF THIS FACILITY?

369         DOES PATIENT CONDITION PRECLUDE USE OF ORDINARY BED?
370         CAN PATIENT OPERATE CONTROLS OF BED?
371         IS PATIENT CONFINED TO ROOM?
372         IS PATIENT CONFINED TO BED?
373         IS PATIENT AN INSULIN DIABETIC?
374         IS PRESCRIBED LENSES A RESULT OF CATARACT SURGERY?




5/16/2012                                                             Page 12
                                                            277 Claim Status Codes Master




277 CLAIM
STATUS    277 CLAIM STATUS CODE DESCRIPTION                                 NOTES
375         WAS REFRACTION PERFORMED?
376         WAS CHARGE FOR AMBULANCE FOR A ROUND-TRIP?

377         WAS DURABLE MEDICAL EQUIPMENT PURCHASED NEW OR USED?
378         IS PACEMAKER TEMPORARY OR PERMANENT?
379         WERE SERVICES PERFORMED SUPERVISED BY A PHYSICIAN?
            WERE SERVICES PERFORMED BY A CRNA UNDER APPROPRIATE MEDICAL
380         DIRECTION?                                                      Changed as of 10/99
381         IS DRUG GENERIC?

382         DID PROVIDER AUTHORIZE GENERIC OR BRAND NAME DISPENSING?
            WAS NERVE BLOCK USED FOR SURGICAL PROCEDURE OR PAIN
383         MANAGEMENT?
            IS PROSTHESIS/CROWN/INLAY PLACEMENT AN INITIAL PLACEMENT OR
384         A REPLACEMENT?
            IS APPLIANCE UPPER OR LOWER ARCH & IS APPLIANCE FIXED OR
385         REMOVABLE?
386         IS SERVICE FOR ORTHODONTIC PURPOSES?
387         DATE PATIENT LAST EXAMINED BY ENTITY.                           New as of 2/97
388         DATE POST-OPERATIVE CARE ASSUMED.                               New as of 2/97
389         DATE POST-OPERATIVE CARE RELINQUISHED.                          New as of 2/97

390         DATE OF   MOST RECENT MEDICAL EVENT NECESSITATING SERVICE(S).   New   as   of   2/97
391         DATE(S)   DIALYSIS CONDUCTED.                                   New   as   of   2/97
392         DATE(S)   OF BLOOD TRANSFUSION(S).                              New   as   of   2/97
393         DATE OF   PREVIOUS PACEMAKER                                    New   as   of   2/97

394         DATE(S) OF MOST RECENT HOSPITALIZATION RELATED TO SERVICE.      New   as   of   2/97
395         DATE ENTITY SIGNED CERTIFICATION/RECERTIFICATION                New   as   of   2/97
396         DATE HOME DIALYSIS BEGAN.                                       New   as   of   2/97
397         DATE OF ONSET/EXACERBATION OF ILLNESS/CONDITION.                New   as   of   2/97
398         VISUAL FIELD TEST RESULTS.                                      New   as   of   2/97
            REPORT OF PRIOR TESTING RELATED TO THIS SERVICE, INCLUDING
399         DATES.                                                          New   as   of   2/97
400         CLAIM IS OUT OF BALANCE.                                        New   as   of   2/97
401         SOURCE OF PAYMENT IS NOT VALID                                  New   as   of   2/97
402         AMOUNT MUST BE GREATER THAN ZERO.                               New   as   of   2/97
403         ENTITY REFERRAL NOTES/ORDERS/PRESCRIPTION.                      New   as   of   2/97
            SPECIFIC FINDINGS, COMPLAINTS, OR SYMPTOMS NECESSITATING
404         SERVICE.                                                        New as of 2/97
405         SUMMARY OF SERVICES.                                            New as of 2/97




5/16/2012                                                              Page 13
                                                          277 Claim Status Codes Master




277 CLAIM
STATUS    277 CLAIM STATUS CODE DESCRIPTION                                 NOTES
406         BRIEF MEDICAL HISTORY AS RELATED TO SERVICES(S).                New as of 2/97
407         COMPLICATIONS/MITIGATING CIRCUMSTANCES.                         New as of 2/97
408         INITIAL CERTIFICATION.                                          New as of 2/97

409         MEDICATION LOGS/RECORDS (INCLUDING MEDICATION THERAPY).         New as of 2/97
            EXPLAIN DIFFERENCES BETWEEN TREATMENT PLAN AND PATIENT'S
410         CONDITION.                                                      New as of 2/97
411         MEDICAL NECESSITY FOR NON-ROUTINE SERVICES(S).                  New as of 2/97

412         MEDICAL RECORDS TO SUBSTANTIATE DECISION OF NON-COVERAGE.       New as of 2/97
            EXPLAIN/JUSTIFY DIFFERENCES BETWEEN TREATMENT PLAN AND
413         SERVICES RENDERED.                                              New as of 2/97
414         NEED FOR MORE THAN ONE PHYSICIAN TO TREAT PATIENT.              New as of 2/97
415         JUSTIFY SERVICES OUTSIDE COMPOSITE RATE.                        New as of 2/97
            VERIFICATION OF PATIENT'S ABILITY TO RETAIN AND USE
416         INFORMATION.                                                    New as of 2/97
            PRIOR TESTING, INCLUDING RESULT(S) AND DATE(S) AS RELATED TO
417         SERVICE(S).                                                     New as of 2/97
418         INDICATING WHY MEDICATIONS CANNOT BE TAKEN ORALLY.              New as of 2/97
            INDIVIDUAL TEST(S) COMPRISING THE PANEL AND THE CHARGES FOR
419         EACH TEST.                                                      New as of 2/97
            NAME, DOSAGE AND MEDICAL JUSTIFICATION OF CONTRAST MATERIAL
420         USED FOR RADIOLOGY PROCEDURE.                                   New as of 2/97

421         MEDICAL REVIEW ATTACHMENT/INFORMATION FOR SERVICE(S).           New as of 2/97
422         HOMEBOUND STATUS.                                               New as of 2/97


                                                                            Inactive for 004030,
                                                                            since 10/99. LOINC
                                                                            codes have the ability
423         PROGNOSIS.                                                      to ask for prognosis.
424         STATEMENT OF NON-COVERAGE INCLUDING ITEMIZED BILL.              New as of 2/97
425         ITEMIZE NON-COVERED SERVICES.                                   New as of 2/97
426         ALL CURRENT DIAGNOSES.                                          New as of 2/97
427         EMERGENCY CARE PROVIDED DURING TRANSPORT.                       New as of 2/97
428         REASON FOR TRANSPORT BY AMBULANCE.                              New as of 2/97
            LOADED MILES AND CHARGES FOR TRANSPORT TO NEAREST FACILITY
429         WITH APPROPRIATE SERVICES.                                      New as of 2/97
430         NEAREST APPROPRIATE FACILITY.                                   New as of 2/97

431         PROVIDE CONDITION/FUNCTIONAL STATUS AT TIME OF SERVICE.         New as of 2/97




5/16/2012                                                               Page 14
                                                          277 Claim Status Codes Master




277 CLAIM
STATUS    277 CLAIM STATUS CODE DESCRIPTION                                NOTES
432         DATE BENEFITS EXHAUSTED.                                       New as of 2/97
433         COPY OF PATIENT REVOCATION OF HOSPICE BENEFITS.                New as of 2/97

434         REASONS FOR MORE THAN ONE TRANSFER PER ENTITLEMENT PERIOD.     New   as   of   2/97
435         NOTICE OF ADMISSION.                                           New   as   of   2/97
436         SHORT TERM GOALS.                                              New   as   of   2/97
437         LONG TERM GOALS.                                               New   as   of   2/97
438         NUMBER OF PATIENTS ATTENDING SESSION.                          New   as   of   2/97
439         SIZE, DEPTH, AMOUNT, AND TYPE OF DRAINAGE WOUNDS.              New   as   of   2/97

440         WHY NON-SKILLED CAREGIVER HAS NOT BEEN TAUGHT PROCEDURE.       New   as   of   2/97
441         ENTITY PROFESSIONAL QUALIFICATION FOR SERVICE(S).              New   as   of   2/97
442         MODALITIES OF SERVICE.                                         New   as   of   2/97
443         INITIAL EVALUATION REPORT.                                     New   as   of   2/97
444         METHOD USED TO OBTAIN TEST SAMPLE.                             New   as   of   2/97

445         EXPLAIN WHY HEARING LOSS NOT CORRECTABLE BY HEARING AID.       New as of 2/97

446         DOCUMENTATION FROM PRIOR CLAIM(S) RELATED TO SERVICE(S).       New as of 2/97
447         PLAN OF TEACHING.                                              New as of 2/97


            INVALID BILLING COMBINATION. SEE STC12 FOR DETAILS. THIS
            CODE SHOULD ONLY BE USED TO INDICATE AN INCONSISTENCY
            BETWEEN TWO OR MORE DATA ELEMENTS ON THE CLAIM. A DETAILED
448         EXPLANATION IS REQUIRED IN STC12 WHEN THIS CODE IS USED.       New   as   of   2/97
449         PROJECTED DATE TO DISCONTINUE SERVICE(S).                      New   as   of   2/97
450         AWAITING SPEND DOWN DETERMINATION.                             New   as   of   2/97
451         PREOPERATIVE AND POST-OPERATIVE DIAGNOSIS.                     New   as   of   2/97
            TOTAL VISITS IN TOTAL NUMBER OF HOURS/DAY AND TOTAL NUMBER
452         OF HOURS/WEEK.                                                 New   as   of   2/97
453         PROCEDURE CODE MODIFIER(S) FOR SERVICE(S) RENDERED.            New   as   of   2/97
454         PROCEDURE CODE FOR SERVICES RENDERED.                          New   as   of   2/97
455         REVENUE CODE FOR SERVICES RENDERED.                            New   as   of   2/97
456         COVERED DAY(S).                                                New   as   of   2/97
457         NON-COVERED DAY(S).                                            New   as   of   2/97
458         COINSURANCE DAYS(S).                                           New   as   of   2/97
459         LIFETIME RESERVE DAY(S).                                       New   as   of   2/97
460         NUBC CONDITION CODE(S).                                        New   as   of   2/97
461         NUBC OCCURRENCE CODE(S) AND DATES(S)                           New   as   of   2/97
462         NUBC OCCURRENCE SPAN CODE(S) AND DATE(S).                      New   as   of   2/97
463         NUBC VALUE CODE(S) AND/OR AMOUNT(S).                           New   as   of   2/97




5/16/2012                                                              Page 15
                                                          277 Claim Status Codes Master




277 CLAIM
STATUS    277 CLAIM STATUS CODE DESCRIPTION                                NOTES

464         PAYER ASSIGNED CLAIM CONTROL NUMBER.                           Changed as of 10/31/04.
465         PRINCIPAL PROCEDURE CODE FOR SERVICE(S) RENDERED.              New as of 2/97
466         ENTITIES ORIGINAL SIGNATURE.                                   New as of 2/97
467         ENTITY SIGNATURE DATE.                                         New as of 2/97
468         PATIENT SIGNATURE SOURCE.                                      New as of 2/97
469         PURCHASE SERVICE CHARGE.                                       New as of 2/97
470         WAS SERVICE PURCHASED FROM ANOTHER ENTITY?                     New as of 2/97
471         WERE SERVICES RELATED TO AN EMERGENCY?                         New as of 2/97
472         AMBULANCE RUN SHEET.                                           New as of 2/97
473         MISSING OR INVALID LAB INDICATOR.                              New as of 2/97
474         PROCEDURE CODE AND PATIENT GENDER MISMATCH.                    Changed as of 2/00
475         PROCEDURE CODE NOT VALID FOR PATIENT AGE.                      Changed as of 2/00
476         MISSING OR INVALID UNITS OF SERVICE.                           New as of 6/98
477         DIAGNOSIS CODE POINTER IS MISSING OR INVALID.                  New as of 6/98
            CLAIM SUBMITTER'S IDENTIFIER (PATIENT ACCOUNT NUMBER) IS
478         MISSING.                                                       New as of 6/98
479         OTHER CARRIER PAYER ID IS MISSING OR INVALID.                  New as of 6/98

480         OTHER CARRIER CLAIM FILING INDICATOR IS MISSING OR INVALID.    New as of 6/98
481         CLAIM/SUBMISSION FORMAT IS INVALID.                            New as of 10/98
482         DATE ERROR, CENTURY MISSING.                                   New as of 2/99

483         MAXIMUM COVERAGE AMOUNT MET OR EXCEEDED FOR BENEFIT PERIOD.    New as of 6/99
484         BUSINESS APPLICATION CURRENTLY NOT AVAILABLE.                  New as of 2/00

            MORE INFORMATION AVAILABLE THAN CAN BE RETURNED IN REAL TIME
485         MODE. NARROW YOU CURRENT SEARCH CRITERIA.                      New as of 2/01
486         PRINCIPLE PROCEDURE DATE.                                      New as of 10/01
            CLAIM NOT FOUND, CLAIM SHOULD HAVE BEEN SUBMITTED TO/THROUGH
487         'ENTITY'.                                                      New   as   of   2/02
488         DIAGNOSIS CODE(S) FOR THE SERVICES RENDERED.                   New   as   of   6/02
489         ATTACHMENT CONTROL NUMBER.                                     New   as   of   10/02
490         OTHER PROCEDURE CODE FOR SERVICE(S) RENDERED.                  New   as   of   2/03
491         ENTITY NOT ELIGIBLE FOR ENCOUNTER SUBMISSION.                  New   as   of   2/03
492         OTHER PROCEDURE DATE.                                          New   as   of   2/03
            VERSION/RELEASE/INDUSTRY ID CODE NOT CURRENTLY SUPPORTED BY
493         INFORMATION HOLDER.                                            New as of 2/03
            REAL-TIME REQUESTS NOT SUPPORTED BY THE INFORMATION HOLDER,
494         RESUBMIT AS BATCH REQUEST.                                     New as of 2/03




5/16/2012                                                              Page 16
                                                          277 Claim Status Codes Master




277 CLAIM
STATUS    277 CLAIM STATUS CODE DESCRIPTION                                NOTES
            REQUESTS FOR RE-ADJUDICATION MUST REFERENCE THE NEWLY
            ASSIGNED PAYER CLAIM CONTROL NUMBER FOR THIS PREVIOUSLY
            ADJUSTED CLAIM. CORRECT THE PAYER CLAIM CONTROL NUMBER AND
495         RE-SUBMIT.                                                     New as of 9/03
            SUBMITTER NOT APPROVED FOR ELECTRONIC CLAIM SUBMISSIONS ON
496         BEHALF OF THIS ENTITY.                                         New as of 2/04
497         SALES TAX NOT PAID                                             New as of 6/04
498         MAXIMUM LEAVE DAYS EXHAUSTED.                                  New as of 6/04
            NO RATE ON FILE WITH THE PAYER FOR THIS SERVICE FOR THIS
499         ENTITY.                                                        New   as   of   6/04
500         ENTITY'S POSTAL/ZIP CODE                                       New   as   of   6/04
501         ENTITY'S STATE/PROVINCE                                        New   as   of   6/04
502         ENTITY'S CITY                                                  New   as   of   6/04
503         ENTITY'S STREET ADDRESS                                        New   as   of   6/04
504         ENTITY'S LAST NAME                                             New   as   of   6/04
505         ENTITY'S FIRST NAME                                            New   as   of   6/04

            ENTITY IS CHANGING PROCESSOR/CLEARINGHOUSE. THIS CLAIM MUST
506         BE SUBMITTED TO THE NEW PROCESSOR/CLEARINGHOUSE.               New   as   of   6/04
507         HCPCS                                                          New   as   of   10/04
508         ICD9                                                           New   as   of   10/04
509         E-CODE                                                         New   as   of   10/04
510         FUTURE DATE                                                    New   as   of   10/04
511         INVALID CHARACTER                                              New   as   of   10/04
512         LENGTH INVALID FOR RECEIVER'S APPLICATION SYSTEM               New   as   of   10/04
513         HIPPS RATE CODE FOR SERVICES RENDERED                          New   as   of   10/04
514         ENTITIES MIDDLE NAME                                           New   as   of   10/04
515         MANAGED CARE REVIEW                                            New   as   of   10/04
516         ADJUDICATION OR PAYMENT DATE                                   New   as   of   10/04
517         ADJUSTED REPRICED CLAIM REFERENCE NUMBER                       New   as   of   10/04
518         ADJUSTED REPRICED LINE ITEM REFERENCE NUMBER                   New   as   of   10/04
519         ADJUSTMENT AMOUNT                                              New   as   of   10/04
520         ADJUSTMENT QUANTITY                                            New   as   of   10/04
521         ADJUSTMENT REASON CODE                                         New   as   of   10/04
522         ANESTHESIA MODIFYING UNITS                                     New   as   of   10/04
523         ANESTHESIA UNIT COUNT                                          New   as   of   10/04
524         ARTERIAL BLOOD GAS QUANTITY                                    New   as   of   10/04
525         BEGIN THERAPY DATE                                             New   as   of   10/04
526         BUNDLED OR UNBUNDLED LINE NUMBER                               New   as   of   10/04
527         CERTIFICATION CONDITION INDICATOR                              New   as   of   10/04
528         CERTIFICATION PERIOD PROJECTED VISIT COUNT                     New   as   of   10/04




5/16/2012                                                              Page 17
                                                          277 Claim Status Codes Master




277 CLAIM
STATUS    277 CLAIM STATUS CODE DESCRIPTION                              NOTES
529         CERTIFICATION REVISION DATE                                  New   as   of   10/04
530         CLAIM ADJUSTMENT INDICATOR                                   New   as   of   10/04
531         CLAIM DISPROPORTINATE SHARE AMOUNT                           New   as   of   10/04
532         CLAIM DRG AMOUNT                                             New   as   of   10/04
533         CLAIM DRG OUTLIER AMOUNT                                     New   as   of   10/04
534         CLAIM ESRD PAYMENT AMOUNT                                    New   as   of   10/04
535         CLAIM FREQUENCY CODE                                         New   as   of   10/04
536         CLAIM INDIRECT TEACHING AMOUNT                               New   as   of   10/04
537         CLAIM MSP PASS-THROUGH AMOUNT                                New   as   of   10/04
538         CLAIM OR ENCOUNTER IDENTIFIER                                New   as   of   10/04
539         CLAIM PPS CAPITAL AMOUNT                                     New   as   of   10/04
540         CLAIM PPS CAPITAL OUTLIER AMOUNT                             New   as   of   10/04
541         CLAIM SUBMISSION REASON CODE                                 New   as   of   10/04
542         CLAIM TOTAL DENIED CHARGE AMOUNT                             New   as   of   10/04
543         CLEARINGHOUSE OR VALUE ADDED NETWORK TRACE                   New   as   of   10/04
544         CLINICAL LABORATORY IMPROVEMENT AMENDMENT                    New   as   of   10/04
545         CONTRACT AMOUNT                                              New   as   of   10/04
546         CONTRACT CODE                                                New   as   of   10/04
547         CONTRACT PERCENTAGE                                          New   as   of   10/04
548         CONTRACT TYPE CODE                                           New   as   of   10/04
549         CONTRACT VERSION IDENTIFIER                                  New   as   of   10/04
550         COORDINATION OF BENEFITS CODE                                New   as   of   10/04
551         COORDINATION OF BENEFITS TOTAL SUBMITTED CHARGE              New   as   of   10/04
552         COST REPORT DAY COUNT                                        New   as   of   10/04
553         COVERED AMOUNT                                               New   as   of   10/04
554         DATE CLAIM PAID                                              New   as   of   10/04
555         DELAY REASON CODE                                            New   as   of   10/04
556         DEMONSTRATION PROJECT IDENTIFIER                             New   as   of   10/04
557         DIAGNOSIS DATE                                               New   as   of   10/04
558         DISCOUNT AMOUNT                                              New   as   of   10/04
559         DOCUMENT CONTROL IDENTIFIER                                  New   as   of   10/04
560         ENTITY'S ADDITIONAL/SECONDARY IDENTIFIER                     New   as   of   10/04
561         ENTITY'S CONTACT NAME                                        New   as   of   10/04
562         ENTITY'S NATIONAL PROVIDER IDENTIFIER (NPI)                  New   as   of   10/04
563         ENTITY'S TAX AMOUNT                                          New   as   of   10/04
564         EPSDT INDICATOR                                              New   as   of   10/04
565         ESTIMATED CLAIM DUE AMOUNT                                   New   as   of   10/04
566         EXCEPTION CODE                                               New   as   of   10/04
567         FACILITY CODE QUALIFIER                                      New   as   of   10/04
568         FAMILY PLANNING INDICATOR                                    New   as   of   10/04
569         FIXED FORMAT INFORMATION                                     New   as   of   10/04




5/16/2012                                                           Page 18
                                                          277 Claim Status Codes Master




277 CLAIM
STATUS    277 CLAIM STATUS CODE DESCRIPTION                              NOTES
570         FREE FORM MESSAGE TEXT                                       New   as   of   10/04
571         FREQUENCY COUNT                                              New   as   of   10/04
572         FREQUENCY PERIOD                                             New   as   of   10/04
573         FUNCTIONAL LIMITATION CODE                                   New   as   of   10/04
574         HCPCS PAYABLE AMOUNT HOME HEALTH                             New   as   of   10/04
575         HOMEBOUND INDICATOR                                          New   as   of   10/04
576         IMMUNIZATION BATCH NUMBER                                    New   as   of   10/04
577         INDUSTRY CODE                                                New   as   of   10/04
578         INSURANCE TYPE CODE                                          New   as   of   10/04
579         INVESTIGATIONAL DEVICE EXEMPTION IDENTIFIER                  New   as   of   10/04
580         LAST CERTIFICATION DATE                                      New   as   of   10/04
581         LAST WORKED DATE                                             New   as   of   10/04
582         LIFETIME PSYCHIATRIC DAYS COUNT                              New   as   of   10/04
583         LINE ITEM CHARGE AMOUNT                                      New   as   of   10/04
584         LINE ITEM CONTROL NUMBER                                     New   as   of   10/04

585         DENIED CHARGE OR NON-COVERED CHARGE                          Changed as of 07/09/07.
586         LINE NOTE TEXT                                               New as of 10/04
587         MEASUREMENT REFERENCE IDENTIFICATION CODE                    New as of 10/04
588         MEDICAL RECORD NUMBER                                        New as of 10/04
589         MEDICARE ASSIGNMENT CODE                                     New as of 10/04
590         MEDICARE COVERAGE INDICATOR                                  New as of 10/04
591         MEDICARE PAID AT 100% AMOUNT                                 New as of 10/04
592         MEDICARE PAID AT 80% AMOUNT                                  New as of 10/04
593         MEDICARE SECTION 4081 INDICATOR                              New as of 10/04
594         MENTAL STATUS CODE                                           New as of 10/04
595         MONTHLY TREATMENT COUNT                                      New as of 10/04
596         NON-COVERED CHARGE AMOUNT                                    New as of 10/04
597         NON-PAYABLE PROFESSIONAL COMPONENT AMOUNT                    New as of 10/04
598         NON-PAYABLE PROFESSIONAL COMPONENT BILLED AMOUNT             New as of 10/04
599         NOTE REFERENCE CODE                                          New as of 10/04
600         OXYGEN SATURATION QTY                                        New as of 10/04
601         OXYGEN TEST CONDITION CODE                                   New as of 10/04
602         OXYGEN TEST DATE                                             New as of 10/04
603         OLD CAPITAL AMOUNT                                           New as of 10/04
604         ORIGINATOR APPLICATION TRANSACTION IDENTIFIER                New as of 10/04
605         ORTHODONTIC TREATMENT MONTHS COUNT                           New as of 10/04
606         PAID FROM PART A MEDICARE TRUST FUND AMOUNT                  New as of 10/04
607         PAID FROM PART B MEDICARE TRUST FUND AMOUNT                  New as of 10/04
608         PAID SERVICE UNIT COUNT                                      New as of 10/04
609         PARTICIPATION AGREEMENT                                      New as of 10/04




5/16/2012                                                           Page 19
                                                         277 Claim Status Codes Master




277 CLAIM
STATUS    277 CLAIM STATUS CODE DESCRIPTION                             NOTES
610         PATIENT DISCHARGE FACILITY TYPE CODE                        New   as   of   10/04
611         PEER REVIEW AUTHORIZATION NUMBER                            New   as   of   10/04
612         PER DAY LIMIT AMOUNT                                        New   as   of   10/04
613         PHYSICIAN CONTACT DATE                                      New   as   of   10/04
614         PHYSICIAN ORDER DATE                                        New   as   of   10/04
615         POLICY COMPLIANCE CODE                                      New   as   of   10/04
616         POLICY NAME                                                 New   as   of   10/04
617         POSTAGE CLAIMED AMOUNT                                      New   as   of   10/04
618         PPS-CAPITAL DSH DRG AMOUNT                                  New   as   of   10/04
619         PPS-CAPITAL EXCEPTION AMOUNT                                New   as   of   10/04
620         PPS-CAPITAL FSP DRG AMOUNT                                  New   as   of   10/04
621         PPS-CAPITAL HSP DRG AMOUNT                                  New   as   of   10/04
622         PPS-CAPITAL IME AMOUNT                                      New   as   of   10/04
623         PPS-OPERATING FEDERAL SPECIFIC DRG AMOUNT                   New   as   of   10/04
624         PPS-OPERATING HOSPITAL SPECIFIC DRG AMOUNT                  New   as   of   10/04
625         PREDETERMINATION OF BENEFITS IDENTIFIER                     New   as   of   10/04
626         PREGNANCY INDICATOR                                         New   as   of   10/04
627         PRE-TAX CLAIM AMOUNT                                        New   as   of   10/04
628         PRICING METHODOLOGY                                         New   as   of   10/04
629         PROPERTY CASUALTY CLAIM NUMBER                              New   as   of   10/04
630         REFERRING CLIA NUMBER                                       New   as   of   10/04
631         REIMBURSEMENT RATE                                          New   as   of   10/04
632         REJECT REASON CODE                                          New   as   of   10/04
633         RELATED CAUSES CODE                                         New   as   of   10/04
634         REMARK CODE                                                 New   as   of   10/04
635         REPRICED APPROVED AMBULATORY PATIENT GROUP                  New   as   of   10/04
636         REPRICED LINE ITEM REFERENCE NUMBER                         New   as   of   10/04
637         REPRICED SAVING AMOUNT                                      New   as   of   10/04
638         REPRICING PER DIEM OR FLAT RATE AMOUNT                      New   as   of   10/04
639         RESPONSIBILITY AMOUNT                                       New   as   of   10/04
640         SALES TAX AMOUNT                                            New   as   of   10/04
641         SERVICE ADJUDICATION OR PAYMENT DATE                        New   as   of   10/04
642         SERVICE AUTHORIZATION EXCEPTION CODE                        New   as   of   10/04
643         SERVICE LINE PAID AMOUNT                                    New   as   of   10/04
644         SERVICE LINE RATE                                           New   as   of   10/04
645         SERVICE TAX AMOUNT                                          New   as   of   10/04
646         SHIP, DELIVERY OR CALENDAR PATTERN CODE                     New   as   of   10/04
647         SHIPPED DATE                                                New   as   of   10/04
648         SIMILAR ILLNESS OR SYMPTOM DATE                             New   as   of   10/04
649         SKILLED NURSING FACILITY INDICATOR                          New   as   of   10/04
650         SPECIAL PROGRAM INDICATOR                                   New   as   of   10/04




5/16/2012                                                          Page 20
                                                          277 Claim Status Codes Master




277 CLAIM
STATUS    277 CLAIM STATUS CODE DESCRIPTION                                NOTES
651         STATE INDUSTRIAL ACCIDENT PROVIDER NUMBER                      New   as   of   10/04
652         TERMS DISCOUNT PERCENTAGE                                      New   as   of   10/04
653         TEST PERFORMED DATE                                            New   as   of   10/04
654         TOTAL DENIED CHARGE AMOUNT                                     New   as   of   10/04
655         TOTAL MEDICARE PAID AMOUNT                                     New   as   of   10/04
656         TOTAL VISITS PROJECTED THIS CERTIFICATION COUNT                New   as   of   10/04
657         TOTAL VISITS RENDERED COUNT                                    New   as   of   10/04
658         TREATMENT CODE                                                 New   as   of   10/04
659         UNIT OR BASIS FOR MEASUREMENT CODE                             New   as   of   10/04
660         UNIVERSAL PRODUCT NUMBER                                       New   as   of   10/04
661         VISITS PRIOR TO RECERTIFICATION DATE COUNT CR702               New   as   of   10/04
662         X-RAY AVAILABILITY INDICATOR                                   New   as   of   10/04
663         ENTITY'S GROUP NAME                                            New   as   of   10/04
664         ORTHODONTIC BANDING DATE                                       New   as   of   10/04
665         SURGERY DATE                                                   New   as   of   10/04
666         SURGICAL PROCEDURE CODE                                        New   as   of   10/04
            REAL-TIME REQUESTS NOT SUPPORTED BY THE INFORMATION HOLDER,
667         DO NOT RESUBMIT                                                New as of 02/28/05

668         MISSING ENDODONTICS TREATMENT HISTORY AND PROGNOSIS.           New as of 06/30/05
669         DENTAL SERVICE NARRATIVE NEEDED.                               New as of 10/31/05


            FUNDS APPLIED FROM A CONSUMER SPENDING ACCOUNT SUCH AS
            CONSUMER DIRECTED/DRIVEN HEALTH PLAN (CDHP), HEALTH SAVING
670         ACCOUNT (H S A) AND OR OTHER SIMILAR ACCOUNTS                  New as of 06/30/06


            FUNDS MAY BE AVAILABLE FROM A CONSUMER SPENDING ACCOUNT SUCH
            AS CONSUMER DIRECTED/DRIVEN HEALTH PLAN (CDHP), HEALTH
671         SAVINGS ACCOUNT (H S A) AND OR OTHER SIMILAR ACCOUNTS          New   as   of   06/30/06
672         OTHER PAYER'S PAYMENT INFORMATION IS OUT OF BALANCE            New   as   of   10/31/06
673         PATIENT REASON FOR VISIT                                       New   as   of   10/31/06
674         AUTHORIZATION EXCEEDED                                         New   as   of   10/31/06
675         FACILITY ADMISSION THROUGH DISCHARGE DATES                     New   as   of   10/31/06
676         ENTITY POSSIBLY COMPENSATED BY FACILITY                        New   as   of   10/31/06
677         ENTITY NOT AFFILIATED                                          New   as   of   10/31/06
678         REVENUE CODE AND PATIENT GENDER MISMATCH                       New   as   of   10/31/06
679         SUBMIT NEWBORN SERVICES ON MOTHER'S CLAIM                      New   as   of   10/31/06
680         ENTITY'S COUNTRY                                               New   as   of   10/31/06
681         CLAIM CURRENCY NOT SUPPORTED                                   New   as   of   10/31/06
682         COSMETIC PROCEDURE                                             New   as   of   02/28/07
683         AWAITING ASSOCIATED HOSPITAL CLAIMS                            New   as   of   02/28/07




5/16/2012                                                            Page 21
                                                          277 Claim Status Codes Master




277 CLAIM
STATUS    277 CLAIM STATUS CODE DESCRIPTION                                NOTES

            REJECTED. SYNTAX ERROR NOTED FOR THIS CLAIM/SERVICE/INQUIRY.
             SEE FUNCTIONAL OR IMPLEMENTATION ACKNOWLEDGEMENT FOR
            DETAILS. (NOTE: ONLY FOR USE TO REJECT CLAIMS OR STATUS
            REQUESTS IN TRANSACTIONS THAT WERE 'ACCEPTED WITH ERRORS' ON
684         A 997 OR 999 ACKNOWLEDGEMENT.)                                 New as of 11/05/07

            CLAIM COULD NOT COMPLETE ADJUDICATION IN REAL TIME. CLAIM
685         WILL CONTINUE PROCESSING IN A BATCH MODE. DO NOT RESUBMIT.     New as of 01/27/08
            THE CLAIM/ENCOUNTER HAS COMPLETED THE ADJUDICATION CYCLE AND
686         THE ENTIRE CLAIM HAS BEEN VOIDED.                              New as of 01/27/08
            CLAIM ESTIMATION CAN NOT BE COMPLETETED IN REAL TIME. DO NOT
687         RESUBMIT.                                                      New as of 01/27/08
            PRESENT ON ADMISSION INDICATOR FOR REPORTED DIAGNOSIS
688         CODE(S).                                                       New as of 01/27/08




5/16/2012                                                            Page 22
                                    835 Adjustment Reason Master


835
ADJUSTMENT
 REASON
CODE       835 ADJUSTMENT REASON CODE                                       NOTES
1           DEDUCTIBLE AMOUNT.
2           COINSURANCE AMOUNT.
3           CO-PAYMENT AMOUNT.
            THE PROCEDURE CODE IS INCONSISTENT WITH THE MODIFIER USED OR
4           A REQUIRED MODIFIER IS MISSING.
            THE PROCEDURE CODE/BILL TYPE IS INCONSISTENT WITH THE PLACE
5           OF SERVICE.
            THE PROCEDURE/REVENUE CODE IS INCONSISTENT WITH THE
6           PATIENT'S AGE.                                                  Changed as of 6/02
            THE PROCEDURE/REVENUE CODE IS INCONSISTENT WITH THE
7           PATIENT'S GENDER.                                               Changed as of 6/02
            THE PROCEDURE CODE IS INCONSISTENT WITH THE PROVIDER
8           TYPE/SPECIALTY (TAXONOMY).                                      Changed as of 6/02

9           THE DIAGNOSIS IS INCONSISTENT WITH THE PATIENT'S AGE.

10          THE DIAGNOSIS IS INCONSISTENT WITH THE PATIENT'S GENDER.        Changed as of 2/00
11          THE DIAGNOSIS IS INCONSISTENT WITH THE PROCEDURE.

12          THE DIAGNOSIS IS INCONSISTENT WITH THE PROVIDER TYPE.
13          THE DATE OF DEATH PRECEDES THE DATE OF SERVICE.
14          THE DATE OF BIRTH FOLLOWS THE DATE OF SERVICE.
            THE AUTHORIZATION NUMBER IS MISSING, INVALID, OR DOES NOT
15          APPLY TO THE BILLED SERVICES OR PROVIDER.                       Changed as of 4/1/08.



                                                                            Changed as of 2/02, at
                                                                            least one remark code
            CLAIM/SERVICE LACKS INFORMATION WHICH IS NEEDED FOR             or NCPDP reject reason
16          ADJUDICATION.                                                   code must be provided.



                                                                            Modified. 4/1/08. At
                                                                            least one Remittance
                                                                            Advice Remark Code or
            REQUESTED INFORMATION WAS NOT PROVIDED OR WAS                   NCPDP Reject Reason
17          INSUFFICIENT/INCOMPLETE.                                        Code must be provided.
18          DUPLICATE CLAIM/SERVICE.
            THIS IS A WORK-RELATED INJURY/ILLNESS AND THUS THE LIABILITY
19          OF THE WORKER'S COMPENSATION CARRIER.                           Changed as of 4/1/08.

20          THIS INJURY/ILLNESS IS COVERED BY THE LIABILITY CARRIER.        Changed as of 4/1/08.

21          THIS INJURY/ILLNESS IS THE LIABILITY OF THE NO-FAULT CARRIER. Changed as of 4/1/08.
            THIS CARE MAY BE COVERED BY ANOTHER PAYER PER COORDINATION
22          OF BENEFITS.                                                    Changed as of 4/1/08.
            THE IMPACT OF PRIOR PAYER(S) ADJUDICATION INCLUDING PAYMENTS
23          AND/OR ADJUSTMENTS.                                             Changed as of 4/1/08.
            CHARGES ARE COVERED UNDER A CAPITATION AGREEMENT/MANAGED
24          CARE PLAN.                                                      Changed as of 4/1/08.

25          PAYMENT DENIED.   YOUR STOP LOSS DEDUCTIBLE HAS NOT BEEN MET.   Inactive as of 4/1/08.
26          EXPENSES INCURRED PRIOR TO COVERAGE.




5/16/2012                                     Page 23
                                      835 Adjustment Reason Master


835
ADJUSTMENT
 REASON
CODE       835 ADJUSTMENT REASON CODE                                      NOTES
27          EXPENSES INCURRED AFTER COVERAGE TERMINATED.


                                                                           Inactive for 004010,
                                                                           since 6/98. Redundant
28          COVERAGE NOT IN EFFECT AT THE TIME THE SERVICE WAS PROVIDED.   to codes 26 & 27.
29          THE TIME LIMIT FOR FILING HAS EXPIRED.
            PAYMENT ADJUSTED BECAUSE THE PATIENT HAS NOT MET THE
            REQUIRED ELIGIBILITY, SPEND DOWN, WAITING, OR RESIDENCY
30          REQUIREMENTS.                                                  Inactive as of 2/1/06.

31          PATIENT CANNOT BE IDENTIFIED AS OUR INSURED.                   Changed as of 4/1/08.
            OUR RECORDS INDICATE THAT THIS DEPENDENT IS NOT AN ELIGIBLE
32          DEPENDENT AS DEFINED.

33          INSURED HAS NO DEPENDENT COVERAGE.                             Changed as of 4/1/08.

34          INSURED HAS NO COVERAGE FOR NEWBORNS.                          Changed as of 4/1/08.
35          LIFETIME BENEFIT MAXIMUM HAS BEEN REACHED.
                                                                           Inactive as of
36          BALANCE DOES NOT EXCEED CO-PAYMENT AMOUNT.                     10/16/03.
                                                                           Inactive as of
37          BALANCE DOES NOT EXCEED DEDUCTIBLE.                            10/16/03.
            SERVICES NOT PROVIDED OR AUTHORIZED BY DESIGNATED
38          (NETWORK/PRIMARY CARE) PROVIDERS.                              Changed as of 6/03
            SERVICES DENIED AT THE TIME AUTHORIZATION/PRE-CERTIFICATION
39          WAS REQUESTED.

40          CHARGES DO NOT MEET QUALIFICATIONS FOR EMERGENT/URGENT CARE.
                                                                           Inactive as of
41          DISCOUNT AGREED TO IN PREFERRED PROVIDER CONTRACT.             10/16/03.
                                                                           Inactive as of
                                                                           10/31/06. Use reason
42          CHARGES EXCEED OUR FEE SCHEDULE OR MAXIMUM ALLOWABLE AMOUNT.   code 45.

43          GRAMM-RUDMAN REDUCTION.                                        Inactive as of 7/1/06.
44          PROMPT-PAY DISCOUNT.
            CHARGES EXCEEDS FEE SCHEDULE/MAXIMUM ALLOWABLE OR
            CONTRACTED/LEGISLATED FEE ARRANGMENT. (USE GROUPE CODES PR
45          OR CO DEPENDING ON LIABILITY).                                 Modified. 10/31/06.

                                                                           Inactive as of
46          THIS (THESE) SERVICE(S) IS (ARE) NOT COVERED.                  10/16/03. Use code 96.
            THIS (THESE) DIAGNOSIS(ES) IS (ARE) NOT COVERED, MISSING, OR
47          ARE INVALID.                                                   Inactive as of 2/1/06.

                                                                           Inactive as of
48          THIS (THESE) PROCEDURE(S) IS (ARE) NOT COVERED.                10/16/03. Use code 96.
            THESE ARE NON-COVERED SERVICES BECAUSE THIS IS A ROUTINE
            EXAM OR SCREENING PROCEDURE DONE IN CONJUNCTION WITH A
49          ROUTINE EXAM.
            THESE ARE NON-COVERED SERVICES BECAUSE THIS IS NOT DEEMED A
50          'MEDICAL NECESSITY' BY THE PAYER.
            THESE ARE NON-COVERED SERVICES BECAUSE THIS IS A PRE-
51          EXISTING CONDITION.



5/16/2012                                       Page 24
                                     835 Adjustment Reason Master


835
ADJUSTMENT
 REASON
CODE       835 ADJUSTMENT REASON CODE                                      NOTES

            THE REFERRING/PRESCRIBING/RENDERING PROVIDER IS NOT ELIGIBLE
52          TO REFER/PRESCRIBE/ORDER/PERFORM THE SERVICE BILLED.           Inactive as of 02/1/06.
            SERVICES BY AN IMMEDIATE RELATIVE OR A MEMBER OF THE SAME
53          HOUSEHOLD ARE NOT COVERED.

54          MULTIPLE PHYSICIANS/ASSISTANTS ARE NOT COVERED IN THIS CASE.
            PROCEDURE/TREATMENT IS DEEMED EXPERIMENTAL/INVESTIGATIONAL
55          BY THE PAYER.                                                  Changed as of 4/1/08.
            PROCEDURE/TREATMENT HAS NOT BEEN DEEMED 'PROVEN TO BE
56          EFFECTIVE' BY THE PAYER.                                       Changed as of 4/1/08.


            PAYMENT DENIED/REDUCED BECAUSE THE PAYER DEEMS THE             Inactive as of
            INFORMATION SUBMITTED DOES NOT SUPPORT THIS LEVEL OF           6/30/07. Split into
            SERVICE, THIS MANY SERVICES, THIS LENGTH OF SERVICE, THIS      codes 150, 151, 152,
57          DOSAGE, OR THIS DAY'S SUPPLY.                                  153 and 154.

            TREATMENT WAS DEEMED BY THE PAYER TO HAVE BEEN RENDERED IN
58          AN INAPPROPRIATE OR INVALID PLACE OF SERVICE.                  Changed as of 4/1/08.
            PROCESSED BASED ON MULTIPLE OR CONCURRENT PROCEDURE RULES.
            (FOR EXAMPLE MULTIPLE SURGERY OR DIAGNOSTIC IMAGING,
59          CONCURRENT ANESTHESIA.)                                        Changed as of 4/1/08.
            CHARGES FOR OUTPATIENT SERVICES WITH THIS PROXIMITY TO
60          INPATIENT SERVICES ARE NOT COVERED.

61          PENALTY FOR FAILURE TO OBTAIN SECOND SURGICAL OPINION.         Changed as of 4/1/08.
            PAYMENT DENIED/REDUCED FOR ABSENCE OF, OR EXCEEDED, PRE-
62          CERTIFICATION/AUTHORIZATION.                                   Inactive as of 4/1/07.
                                                                           Inactive as of
63          CORRECTION TO A PRIOR CLAIM.                                   10/16/03.
                                                                           Inactive as of
64          DENIAL REVERSED PER MEDICAL REVIEW.                            10/16/03.
            PROCEDURE CODE WAS INCORRECT.   THIS PAYMENT REFLECTS THE      Inactive as of
65          CORRECT CODE.                                                  10/16/03.
66          BLOOD DEDUCTIBLE.
                                                                           Inactive as of
67          LIFETIME RESERVE DAYS. (HANDLED IN QTY, QTY01=LA)              10/16/03.
                                                                           Inactive as of
68          DRG WEIGHT.   (HANDLED IN CLP12)                               10/16/03.
69          DAY OUTLIER AMOUNT.

70          COST OUTLIER - ADJUSTMENT TO COMPENSATE FOR ADDITIONAL COSTS. Changed as of 6/01

                                                                           Deleted as of 6/30/00.
71          PRIMARY PAYER AMOUNT.                                           Use code 23.
                                                                           Inactive as of
72          COINSURANCE DAY.    (HANDLED IN QTY, QTY01=CD)                 10/16/03.
                                                                           Inactive as of
73          ADMINISTRATIVE DAYS.                                           10/16/03.
74          INDIRECT MEDICAL EDUCATION ADJUSTMENT.
75          DIRECT MEDICAL EDUCATION ADJUSTMENT.
76          DISPROPORTIONATE SHARE ADJUSTMENT.
                                                                           Inactive as of
77          COVERED DAYS.   (HANDLED IN QTY, QTY01=CA)                     10/16/03.



5/16/2012                                      Page 25
                                     835 Adjustment Reason Master


835
ADJUSTMENT
 REASON
CODE       835 ADJUSTMENT REASON CODE                                      NOTES
78          NON-COVERED DAYS/ROOM CHARGE ADJUSTMENT.
                                                                           Inactive as of
79          COST REPORT DAYS.   (HANDLED IN MIA15)                         10/16/03.
                                                                           Inactive as of
80          OUTLIER DAYS.   (HANDLED IN QTY, QTY01=OU)                     10/16/03.
                                                                           Inactive as of
81          DISCHARGES.                                                    10/16/03.
                                                                           Inactive as of
82          PIP DAYS.                                                      10/16/03.
                                                                           Inactive as of
83          TOTAL VISITS.                                                  10/16/03.
                                                                           Inactive as of
84          CAPITAL ADJUSTMENT.   (HANDLED IN MIA)                         10/16/03.

85          PATIENT INTEREST ADJUSTMENT (USE ONLY GROUP CODE PR)           Modified as of 7/9/07.


                                                                           Inactive as of
                                                                           10/16/03. Duplicative
86          STATUTORY ADJUSTMENT.                                          of code 45.
87          TRANSFER AMOUNT.
            ADJUSTMENT AMOUNT REPRESENTS COLLECTION AGAINST RECEIVABLE
88          CREATED IN PRIOR OVERPAYMENT.                                  Inactive as of 6/30/07.
89          PROFESSIONAL FEES REMOVED FROM CHARGES.
90          INGREDIENT COST ADJUSTMENT.
91          DISPENSING FEE ADJUSTMENT.
                                                                           Inactive as of
92          CLAIM PAID IN FULL.                                            10/16/03.


                                                                           Inactive as of
                                                                           10/16/03. In 004010,
                                                                           CAS at the claim level
93          NO CLAIM LEVEL ADJUSTMENTS.                                    is optional.
94          PROCESSED IN EXCESS OF CHARGES.

95          PLAN PROCEDURES NOT FOLLOWED.                                  Modified as of 4/1/08.
                                                                           At least one
                                                                           Remittance Advice
                                                                           Remark Code or NCPDP
                                                                           Reject Reason Code
96          NON-COVERED CHARGE(S).                                         must be provided.
            THE BENEFIT FOR THIS SERVICE IS INCLUDED IN THE
            PAYMENT/ALLOWANCE FOR ANOTHER SERVICE/PROCEDURE THAT HAS
97          ALREADY BEEN ADJUDICATED.                                      Modified as of 4/1/08.
            THE HOSPITAL MUST FILE THE MEDICARE CLAIM FOR THIS INPATIENT   Inactive as of
98          NON-PHYSICIAN SERVICE.                                         10/16/03.
                                                                           Inactive as of
99          MEDICARE SECONDARY PAYER ADJUSTMENT AMOUNT.                    10/16/03.

100         PAYMENT MADE TO PATIENT/INSURED/RESPONSIBLE PARTY/EMPLOYER.    Modified as of 1/27/08.
            PREDETERMINATION: ANTICIPATED PAYMENT UPON COMPLETION OF
101         SERVICES OR CLAIM ADJUDICATION.                                Changed as of 2/99
102         MAJOR MEDICAL ADJUSTMENT.




5/16/2012                                      Page 26
                                     835 Adjustment Reason Master


835
ADJUSTMENT
 REASON
CODE       835 ADJUSTMENT REASON CODE                                      NOTES
            PROVIDER PROMOTIONAL DISCOUNT (E.G., SENIOR CITIZEN
103         DISCOUNT).                                                     Changed as of 6/01
104         MANAGED CARE WITHHOLDING.
105         TAX WITHHOLDING.
106         PATIENT PAYMENT OPTION/ELECTION NOT IN EFFECT.
            THE RELATED OR QUALIFYING CLAIM/SERVICE WAS NOT IDENTIFIED
107         ON THIS CLAIM.                                                 Changed as of 9/30/07.

108         RENT/PURCHASE GUIDELINES WERE NOT MET.                         Changed as of 9/30/07.

            CLAIM NOT COVERED BY THIS PAYER/CONTRACTOR.   YOU MUST SEND
109         THE CLAIM TO THE CORRECT PAYER/CONTRACTOR.
110         BILLING DATE PREDATES SERVICE DATE.
111         NOT COVERED UNLESS THE PROVIDER ACCEPTS ASSIGNMENT.
            SERVICE NOT FURNISHED DIRECTLY TO THE PATIENT AND/OR NOT
112         DOCUMENTED.                                                    Modified as of 4/1/08.


                                                                           Changed as of 2/01;
                                                                           Inactive as of
            PAYMENT DENIED BECAUSE SERVICE/PROCEDURE WAS PROVIDED          6/30/07. Use codes
113         OUTSIDE THE UNITED STATES OR AS A RESULT OF WAR.               157, 158 or 159.
            PROCEDURE/PRODUCT NOT APPROVED BY THE FOOD AND DRUG
114         ADMINISTRATION.

115         PROCEDURE POSTPONED, CANCELED, OR DELAYED.                     Modified as of 4/1/08.
            THE ADVANCE INDEMNIFICATION NOTICE SIGNED BY THE PATIENT DID
116         NOT COMPLY WITH REQUIREMENTS.                                  Modified as of 4/1/08.
            TRANSPORTATION IS ONLY COVERED TO THE CLOSEST FACILITY THAT
117         CAN PROVIDE THE NECESSARY CARE.                                Modified as of 4/1/08.

118         ESRD NETWORK SUPPORT ADJUSTMENT.                               Modified as of 4/1/08.
            BENEFIT MAXIMUM FOR THE TIME PERIOD OR OCCURRENCE HAS BEEN
119         REACHED.                                                       Changed as of 2/04

                                                                           Inactive as of
120         PATIENT IS COVERED BY A MANAGED CARE PLAN.                     6/30/07. Use code 24.
            INDEMNIFICATION ADJUSTMENT - COMPENSATION FOR OUTSTANDING
121         MEMBER RESPONSIBILITY.                                         Modified as of 4/1/08.
122         PSYCHIATRIC REDUCTION.


                                                                           Inactive as of
                                                                           6/30/07. Refer to
                                                                           implementation guide
                                                                           for proper handling of
123         PAYER REFUND DUE TO OVERPAYMENT.                               reversals.


                                                                           Inactive as of
                                                                           6/30/07. Refer to
                                                                           implementation guide
                                                                           for proper handling of
124         PAYER REFUND AMOUNT - NOT OUR PATIENT.                         reversals.




5/16/2012                                      Page 27
                                    835 Adjustment Reason Master


835
ADJUSTMENT
 REASON
CODE       835 ADJUSTMENT REASON CODE                                      NOTES


                                                                           Modified. 4/1/08. At
                                                                           least one Remittance
                                                                           Advice Remark Code or
                                                                           NCPDP Reject Reason
125         SUBMISSION/BILLING ERROR(S).                                   Code must be provided.
                                                                           Inactive as of 4/1/08.
                                                                            Use group code PR and
126         DEDUCTIBLE -- MAJOR MEDICAL.                                   code 1.
                                                                           Inactive as of 4/1/08.
                                                                            Use group code PR and
127         COINSURANCE -- MAJOR MEDICAL                                   code 2.

128         NEWBORN'S SERVICES ARE COVERED IN THE MOTHER'S ALLOWANCE.      New as of 2/97

129         PRIOR PROCESSING INFORMATION APPEARS INCORRECT.                Modified as of 4/1/08.
130         CLAIM SUBMISSION FEE.                                          Changed as of 6/01
131         CLAIM SPECIFIC NEGOTIATED DISCOUNT.                            New as of 2/97
132         PREARRANGED DEMONSTRATION PROJECT ADJUSTMENT.                  New as of 2/97
            THE DISPOSITION OF THIS CLAIM/SERVICE IS PENDING FURTHER
133         REVIEW.                                                        Changed as of 10/99
134         TECHNICAL FEES REMOVED FROM CHARGES.                           New as of 10/98

135         INTERIM BILLS CANNOT BE PROCESSED.                             Modified as of 4/1/08.
            FAILURE TO FOLLOW PRIOR PAYER'S COVERAGE RULES. (USE GROUP
136         CODE OA).                                                      Modified as of 9/30/07.
            REGULATORY SURCHARGES, ASSESSMENTS, ALLOWANCES OR HEALTH
137         RELATED TAXES.                                                 Modified as of 4/1/08.

138         APPEAL PROCEDURES NOT FOLLOWED OR TIME LIMITS NOT MET.         Modified as of 4/1/08.
            CONTRACTED FUNDING AGREEMENT - SUBSCRIBER IS EMPLOYED BY THE
139         PROVIDER OF SERVICES.                                          New as of 6/99
            PATIENT/INSURED HEALTH IDENTIFICATION NUMBER AND NAME DO NOT
140         MATCH.                                                         New as of 6/99

141         CLAIM SPANS ELIGIBLE AND INELIGIBLE PERIODS OF COVERAGE.       Modified as of 4/1/08.

142         MONTHLY MEDICAID PATIENT LIABILITY AMOUNT.                     Modified as of 4/1/08.
143         PORTION OF PAYMENT DEFERRED.                                   New as of 2/01

144         INCENTIVE ADJUSTMENTS, E.G. PREFERRED PRODUCT/SERVICE.         New as of 6/01


                                                                           Deactivated as of
                                                                           4/1/08. Use group code
145         PREMIUM PAYMENT WITHHOLDING.                                   CO and code 45.

146         DIAGNOSIS WAS INVALID FOR THE DATE(S) OF SERVICE REPORTED.     Modified as of 4/1/08.

147         PROVIDER CONTRACTED/NEGOTIATED RATE EXPIRED OR NOT ON FILE.    New as of 6/02
            INFORMATION FROM ANOTHER PROVIDER WAS NOT PROVIDED OR WAS
148         INSUFFICIENT/INCOMPLETE.                                       Modified as of 4/1/08.
            LIFETIME BENEFIT MAXIMUM HAS BEEN REACHED FOR THIS
149         SERVICE/BENEFIT CATEGORY.                                      New as of 10/02



5/16/2012                                     Page 28
                                   835 Adjustment Reason Master


835
ADJUSTMENT
 REASON
CODE       835 ADJUSTMENT REASON CODE                                      NOTES
            PAYER DEEMS THE INFORMATION SUBMITTED DOES NOT SUPPORT THIS
150         LEVEL OF SERVICE.                                              Modified as of 4/1/08.

            PAYMENT ADJUSTED BECAUSE THE PAYER DEEMS THE INFORMATION
151         SUBMITTED DOES NOT SUPPORT THIS MANY/FREQUENCY OF SERVICES.    Changed as of 1/27/08.
            PAYER DEEMS THE INFORMATION SUBMITTED DOES NOT SUPPORT THIS
152         LENGTH OF SERVICE.                                             Modified as of 4/1/08.
            PAYER DEEMS THE INFORMATION SUBMITTED DOES NOT SUPPORT THIS
153         DOSAGE.                                                        Modified as of 4/1/08.
            PAYER DEEMS THE INFORMATION SUBMITTED DOES NOT SUPPORT THIS
154         DAY'S SUPPLY.                                                  Modified as of 4/1/08.

155         PATIENT REFUSED THE SERVICE/PROCEDURE.                         Modified as of 4/1/08.
156         FLEXIBLE SPENDING ACCOUNT PAYMENTS.                            New as of 9/03

157         SERVICE/PROCEDURE WAS PROVIDED AS A RESULT OF AN ACT OF WAR.   Modified as of 4/1/08.

158         SERVICE/PROCEDURE WAS PROVIDED OUTSIDE OF THE UNITED STATES.   Modified as of 4/1/08.

159         SERVICE/PROCEDURE WAS PROVIDED AS A RESULT OF TERRORISM.       Modified as of 4/1/08.
            INJURY/ILLNESS WAS THE RESULT OF AN ACTIVITY THAT IS A
160         BENEFIT EXCLUSION.                                             Modified as of 4/1/08.
161         PROVIDER PERFORMANCE BONUS.                                    New as of 2/04

            STATE-MANDATED REQUIREMENT FOR PROPERTY AND CASUALTY, SEE
162         CLAIM PAYMENT REMARKS CODE FOR SPECIFIC EXPLANATION.           New as of 2/04

163         ATTACHMENT REFERENCED ON THE CLAIM WAS NOT RECEIVED.           Modified as of 4/1/08.
            ATTACHMENT REFERENCED ON THE CLAIM WAS NOT RECEIVED IN A
164         TIMELY FASHION.                                                Modified as of 4/1/08.

165         REFERRAL ABSENT OR EXCEEDED.                                   Modified as of 4/1/08.

            THESE SERVICES WERE SUBMITTED AFTER THIS PAYERS
166         RESPONSIBILITY FOR PROCESSING CLAIMS UNDER THIS PLAN ENDED.    New as of 2/28/05
167         THIS (THESE) DIANOSIS(ES) IS (ARE) NOT COVERED.                New as of 6/30/05.

            SERVICE(S) HAVE BEEN CONSIDERED UNDER THE PATIENT'S MEDICAL
168         PLAN. BENEFITS ARE NOT AVAILABLE UNDER THIS DENTAL PLAN.       Modified 4/1/08.
169         ALTERNATE BENEFIT HAS BEEN PROVIDED.                           Modified 4/1/08.
            PAYMENT IS DENIED WHEN PERFORMED/BILLED BY THIS TYPE OF
170         PROVIDER.                                                      New as of 6/30/05.
            PAYMENT IS DENIED WHEN PERFORMED/BILLED BY THIS TYPE OF
171         PROVIDER IN THIS TYPE OF FACILITY.                             New as of 6/30/05.
            PAYMENT IS ADJUSTED WHEN PERFORMED/BILLED BY A PROVIDER OF
172         THIS SPECIALTY.                                                New as of 6/30/05.
173         SERVICE WAS NOT PRESCRIBED BY A PHYSICIAN.                     Modified 4/1/08.
174         SERVICE WAS NOT PRESCRIBED PRIOR TO DELIVERY.                  Modified 4/1/08.
175         PRESCRIPTION IS INCOMPLETE.                                    Modified 4/1/08.
176         PRESCRIPTION IS NOT CURRENT.                                   Modified 4/1/08.

177         PATIENT HAS NOT MET THE REQUIRED ELIGIBILITY REQUIREMENTS.     Modified 4/1/08.




5/16/2012                                    Page 29
                                   835 Adjustment Reason Master


835
ADJUSTMENT
 REASON
CODE       835 ADJUSTMENT REASON CODE                                      NOTES

178         PATIENT HAS NOT MET THE REQUIRED SPEND DOWN REQUIREMENTS.      Modified 4/1/08.

179         PATIENT HAS NOT MET THE REQUIRED WAITING REQUIREMENTS.         Modified 4/1/08.

180         PATIENT HAS NOT MET THE REQUIRED RESIDENCY REQUIREMENTS.       Modified 4/1/08.
181         PROCEDURE CODE WAS INVALID ON THE DATE OF SERVICE.             Modified 4/1/08.

182         PROCEDURE MODIFIER WAS INVALID ON THE DATE OF SERVICE.         Modified 4/1/08.
            THE REFERRING PROVIDER IS NOT ELIGIBLE TO REFER THE SERVICE
183         BILLED.                                                        New as of 6/30/05.
            THE PRESCRIBING/ORDERING PROVIDER IS NOT ELIGIBLE TO
184         PRESCRIBE/ORDER THE SERVICE BILLED.                            New as of 6/30/05.
            THE RENDERING PROVIDER IS NOT ELIGIBILE TO PERFORM THE
185         SERVICE BILLED.                                                New as of 6/30/05.

186         LEVEL OF CARE CHANGE ADJUSTMENT.                               Modified as of 9/30/07.
187         HEALTH SAVINGS ACCOUNT PAYMENTS.                               New as of 6/30/05.
            THIS PRODUCT/PROCEDURE IS ONLY COVERED WHEN USED ACCORDING
188         TO FDA RECOMMENDATIONS.                                        New as of 6/30/05.
            NOT OTHERWISE CLASSIFIED' OR 'UNLISTED' PROCEDURE CODE
            (CPT/HCPCS) WAS BILLED WHEN THERE IS A SPECIFIC PROCEDURE
189         CODE FOR THIS PROCEDURE/SERVICE.                               New as of 6/30/05.
            PAYMENT IS INCLUDED IN THE ALLOWANCE FOR A SKILLED NURSING
190         FACILITY (SNF) QUALIFIED STAY.                                 New as of 10/31/05.
            NOT A WORK RELATED INJURY/ILLNESS AND THUS NOT THE LIABILITY
191         OF THE WORKERS' COMPENSATION CARRIER.                          Modified 4/1/08.




                                                                           Modified 4/1/08. This
                                                                           code is only used when
                                                                           the non-standard code
                                                                           cannot be reasonably
                                                                           mapped to an existing
                                                                           Claims Adjustment
                                                                           Reason Code,
            NON STANDARD ADJUSTMENT CODE FROM PAPER REMITTANCE. NOTE:      specifically
            THIS CODE IS TO BE USED BY PROVIDERS/PAYERS PROVIDING          Deductible,
            COORDINATION OF BENEFITS INFORMATION TO ANOTHER RPAYER IN      Coinsurance and Co-
192         THE 837 TRANSACTION ONLY.                                      payment.

            ORIGINAL PAYMENT DECISION IS BEING MAINTAINED. UPON REVIEW,
193         IT WAS DETERMINED THAT THIS CLAIM WAS PROCESSED PROPERLY.      Modified as of 1/27/08.
            ANESTHESIA PERFORMED BY THE OPERATING PHYSICIAN, THE
194         ASSISTANT SURGEON OR THE ATTENDING PHYSICIAN.                  Modified 4/1/08.
            REFUND ISSUED TO AN ERRONEOUS PRIORITY PAYER FOR THIS
195         CLAIM/SERVICE.                                                 Modified 4/1/08.

            CLAIM/SERVICE DENIED BASED ON PRIOR PAYER'S COVERAGE           Deactivated as of
196         DETERMINATION.                                                 2/1/07. Use code 136
197         PRECERTIFICATION/AUTHORIZATION/NOTIFICATION ABSENT.            Modified 4/1/08.
198         PRECERTIFICATION/AUTHORIZATION EXCEEDED.                       Modified 4/1/08.
199         REVENUE CODE AND PROCEDURE CODE DO NOT MATCH.                  New as of 10/31/06




5/16/2012                                      Page 30
                                     835 Adjustment Reason Master


835
ADJUSTMENT
 REASON
CODE       835 ADJUSTMENT REASON CODE                                      NOTES
200         EXPENSES INCURRED DURING LAPSE IN COVERAGE.                    New as of 10/31/06


            WORKERS COMPENSATION CASE SETTLED. PATIENT IS RESPONSIBLE
            FOR AMOUNT OF THIS CLAIM/SERVICE THROUGH WC 'MEDICARE SET
201         ASIDE ARRANGEMENT' OR OTHER AGREEMENT. (USE GROUP CODE PR).    New as of 10/31/06

202         NON-COVERED PERSONAL COMFORT OR CONVENIENCE SERVICES.          Modified 4/1/08.
203         DISCONTINUED OR REDUCED SERVICE.                               Modified 4/1/08.
            THIS SERVICE/EQUIPMENT/DRUG IS NOT COVERED UNDER THE
204         PATIENT'S CURRENT BENEFIT PLAN.                                New as of 2/28/07
205         PHARMACY DISCOUNT CARD PROCESSING FEE.                         New as of 7/9/07
206         NATIONAL PROVIDER IDENTIFIER - MISSING.                        Modified 4/1/08.
                                                                           Deactivated as of
207         NATIONAL PROVIDER IDENTIFIER - INVALID FORMAT.                 5/23/08.
208         NATIONAL PROVIDER IDENTIFIER - NOT MATCHED.                    Modified 4/1/08.


            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
209         COLLECTED. (USE GROUP CODE OA).                                New as of 7/9/07.

            PAYMENT ADJUSTED BECAUSE PRE-CERTIFICATION/AUTHORIZATION NOT
210         RECEIVED IN A TIMELY FASHION.                                  New as of 7/9/07.
            NATIONAL DRUG CODES (NDC) NOT ELIGIBLE FOR REBATE, ARE NOT
211         COVERED.                                                       New as of 7/9/07.
212         ADMINISTRATIVE SURCHARGES ARE NOT COVERED.                     New as of 11/05/07.
            NON-COMPLIANCE WITH THE PHYSICIAN SELF REFERRAL PROHIBITION
213         LEGISLATION OR PAYER POLICY.                                   New as of 1/27/08.


            WORKERS' COMPENSATION CLAIM ADJUDICATED AS NON-COMPENSABLE.
            THIS PAYER NOT LIABLE FOR CLAIM OR SERVICE/TREATMENT.
214         (NOTE: TO BE USED FOR WORKERS' COMPENSATION ONLY).             New as of 1/27/08.
215         BASED ON SUBROGATION OF A THIRD PARTY SETTLEMENT.              New as of 1/27/08.
216         BASED ON THE FINDINGS OF A REVIEW ORGANIZATION.                New as of 1/27/08.


            BASED ON PAYER REASONABLE AND CUSTOMARY FEES. NO MAXIMUM
            ALLOWABLE DEFINED BY LEGISLATED FEE ARRANGEMENT. (NOTE: TO
217         BE USED FOR WORKERS' COMPENSATION ONLY).                       New as of 1/27/08.
            BASED ON ENTITLEMENT TO BENEFITS (NOTE: TO BE USED FOR
218         WORKERS' COMPENSATION ONLY).                                   New as of 1/27/08.
            BASED ON EXTENT OF INJURY (NOTE: TO BE USED FOR WORKERS'
219         COMPENSATION ONLY).                                            New as of 1/27/08.


            THE 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. (NOTE: TO BE USED
220         FOR WORKERS' COMPENSATION ONLY).                               New as of 1/27/08.
            WORKERS' COMPENSATION CLAIM IS UNDER INVESTIGATION. (NOTE:
            TO BE USED FOR WORKERS' COMPENSATION ONLY. CLAIM PENDING
221         FINAL RESOLUTION).                                             New as of 1/27/08.
A0          PATIENT REFUND AMOUNT.




5/16/2012                                      Page 31
                                      835 Adjustment Reason Master


835
ADJUSTMENT
 REASON
CODE       835 ADJUSTMENT REASON CODE                                       NOTES

                                                                            At least one
                                                                            Remittance Advice
                                                                            Remark Code or NCPDP
                                                                            Reject Reason Code
A1          CLAIM DENIED CHARGES.                                           must be provided.



                                                                            Inactive as of 1/1/08.
                                                                            Use Code 45 with Group
                                                                            Code 'CO' or use
                                                                            another appropriate
                                                                            specific adjustment
A2          CONTRACTUAL ADJUSTMENT.                                         code.
                                                                            Inactive as of
A3          MEDICARE SECONDARY PAYER LIABILITY MET.                         10/16/03.

A4          MEDICARE CLAIM PPS CAPITAL DAY OUTLIER AMOUNT.                  Inactive as of 4/1/08.
A5          MEDICARE CLAIM PPS CAPITAL COST OUTLIER AMOUNT.

A6          PRIOR HOSPITALIZATION OR 30 DAY TRANSFER REQUIREMENT NOT MET.
A7          PRESUMPTIVE PAYMENT ADJUSTMENT.

A8          UNGROUPABLE DRG.                                                Modified as of 4/1/08.
B1          NON-COVERED VISITS.
                                                                            Inactive as of
B2          COVERED VISITS.                                                 10/16/03.
                                                                            Inactive as of
B3          COVERED CHARGES.                                                10/16/03.
B4          LATE FILING PENALTY.

B5          COVERAGE/PROGRAM GUIDELINES WERE NOT MET OR WERE EXCEEDED.      Modified as of 4/1/08.


            THIS PAYMENT IS ADJUSTED WHEN PERFORMED/BILLED BY THIS TYPE
            OF PROVIDER, BY THIS TYPE OF PROVIDER IN THIS TYPE OF
B6          FACILITY, OR BY A PROVIDER OF THIS SPECIALTY.                   Inactive as of 2/1/06.

            THIS PROVIDER WAS NOT CERTIFIED/ELIGIBLE TO BE PAID FOR THIS
B7          PROCEDURE/SERVICE ON THIS DATE OF SERVICE.                      Changes as of 10/98
            ALTERNATIVE SERVICES WERE AVAILABLE, AND SHOULD HAVE BEEN
B8          UTILIZED.                                                       Modified as of 4/1/08.

B9          PATIENT IS ENROLLED IN A HOSPICE.                               Modified as of 4/1/08.
            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
B10         PROCEDURE/TEST.
            THE CLAIM/SERVICE HAS BEEN TRANSFERRED TO THE PROPER
            PAYER/PROCESSOR FOR PROCESSING. CLAIM/SERVICE NOT COVERED
B11         BY THIS PAYER/PROCESSOR.

B12         SERVICES NOT DOCUMENTED IN PATIENT'S MEDICAL RECORDS.
            PREVIOUSLY PAID. PAYMENT FOR THIS CLAIM/SERVICE MAY HAVE
B13         BEEN PROVIDED IN A PREVIOUS PAYMENT.



5/16/2012                                       Page 32
                                    835 Adjustment Reason Master


835
ADJUSTMENT
 REASON
CODE       835 ADJUSTMENT REASON CODE                                      NOTES
            ONLY ONE VISIT OR CONSULTATION PER PHYSICIAN PER DAY IS
B14         COVERED.                                                       Modified as of 4/1/08.


            THIS SERVICE/PROCEDURE REQUIRES THAT A QUALIFYING
            SERVICE/PROCEDURE BE RECEIVED AND COVERED. THE QUALIFYING
B15         OTHER SERVICE/PROCEDURE HAS NOT BEEN RECEIVED/ADJUDICATED.     Modified as of 4/1/08.

B16         NEW PATIENT' QUALIFICATIONS WERE NOT MET.                      Modified as of 4/1/08.
            PAYMENT ADJUSTED BECAUSE THIS SERVICE WAS NOT PRESCRIBED BY
            A PHYSICIAN, NOT PRESCRIBED PRIOR TO DELIVERY, THE
            PRESCRIPTION IS INCOMPLETE, OR THE PRESCRIPTION IS NOT
B17         CURRENT.                                                       Inactive as of 2/1/06.
            THIS PROCEDURE CODE AND MODIFIER WERE INVALID ON THE DATE OF
B18         SERVICE.                                                       Modified as of 4/1/08.
            CLAIM/SERVICE ADJUSTED BECAUSE OF THE FINDING OF A REVIEW
B19         ORGANIZATION.                                                  Inactive for 10/16/03.
            PROCEDURE/SERVICE WAS PARTIALLY OR FULLY FURNISHED BY
B20         ANOTHER PROVIDER.                                              Modified as of 4/1/08.
            THE CHARGES WERE REDUCED BECAUSE THE SERVICE/CARE WAS
B21         PARTIALLY FURNISHED BY ANOTHER PHYSICIAN.                      Inactive for 10/16/03.
B22         THIS PAYMENT IS ADJUSTED BASED ON THE DIAGNOSIS.               Changed as of 2/01

            PROCEDURE BILLED IS NOT AUTHORIZED PER YOUR CLINICAL
B23         LABORATORY IMPROVEMENT AMENDMENT (CLIA) PROFECIENCY TEST.      Modified as of 4/1/08.


                                                                           Inactive for 004010,
                                                                           since 2/99. Use code
            CLAIM/SERVICE DENIED.   LEVEL OF SUBLUXATION IS MISSING OR     16 and remark codes if
D1          INADEQUATE.                                                    necessary.


                                                                           Inactive for 004010,
                                                                           since 2/99. Use code
            CLAIM LACKS THE NAME, STRENGTH, OR DOSAGE OF THE DRUG          16 and remark codes if
D2          FURNISHED.                                                     necessary.


                                                                           Inactive for 004010,
            CLAIM/SERVICE DENIED BECAUSE INFORMATION TO INDICATE IF THE    since 2/99. Use code
            PATIENT OWNS THE EQUIPMENT THAT REQUIRES THE PART OR SUPPLY    16 and remark codes if
D3          WAS MISSING.                                                   necessary.


                                                                           Inactive for 004010,
                                                                           since 2/99. Use code
            CLAIM/SERVICE DOES NOT INDICATE THE PERIOD OF TIME FOR WHICH   16 and remark codes if
D4          THIS WILL BE NEEDED.                                           necessary.


                                                                           Inactive for 004010,
                                                                           since 2/99. Use code
            CLAIM/SERVICE DENIED.   CLAIM LACKS INDIVIDUAL LAB CODES       16 and remark codes if
D5          INCLUDED IN THE TEST.                                          necessary.


                                                                           Inactive for 004010,
                                                                           since 2/99. Use code
            CLAIM/SERVICE DENIED. CLAIM DID NOT INCLUDE PATIENT'S          16 and remark codes if
D6          MEDICAL RECORD FOR THE SERVICE.                                necessary.




5/16/2012                                     Page 33
                                   835 Adjustment Reason Master


835
ADJUSTMENT
 REASON
CODE       835 ADJUSTMENT REASON CODE                                     NOTES

                                                                          Inactive for 004010,
                                                                          since 2/99. Use code
            CLAIM/SERVICE DENIED. CLAIM LACKS DATE OF PATIENT'S MOST      16 and remark codes if
D7          RECENT PHYSICIAN VISIT.                                       necessary.


                                                                          Inactive for 004010,
                                                                          since 2/99. Use code
            CLAIM/SERVICE DENIED. CLAIM LACKS INDICATOR THAT 'X-RAY IS    16 and remark codes if
D8          AVAILABLE FOR REVIEW'.                                        necessary.


                                                                          Inactive for 004010,
            CLAIM/SERVICE DENIED. CLAIM LACKS INVOICE OR STATEMENT        since 2/99. Use code
            CERTIFYING THE ACTUAL COST OF THE LENS, LESS DISCOUNTS OR     16 and remark codes if
D9          THE TYPE OF INTRAOCULAR LENS USED.                            necessary.
                                                                          Inactive for 003070,
            CLAIM/SERVICE DENIED. COMPLETED PHYSICIAN FINANCIAL           since 8/97. Use code
D10         RELATIONSHIP FORM NOT ON FILE.                                17.
                                                                          Inactive for 003070,
                                                                          since 8/97. Use code
D11         CLAIM LACKS COMPLETED PACEMAKER REGISTRATION FORM             17.
            CLAIM/SERVICE DENIED. CLAIM DOES NOT IDENTIFY WHO PERFORMED   Inactive for 003070,
            THE PURCHASED DIAGNOSTIC TEST OR THE AMOUNT YOUR WERE         since 8/97. Use code
D12         CHARGED FOR THE TEST.                                         17.
            CLAIM/SERVICE DENIED. PERFORMED BY A FACILITY/SUPPLIER IN     Inactive for 003070,
            WHICH THE ORDERING/REFERRING PHYSICIAN HAS A FINANCIAL        since 8/97. Use code
D13         INTEREST.                                                     17.
                                                                          Inactive for 003070,
                                                                          since 8/97. Use code
D14         CLAIM LACKS INDICATION THAT PLAN OF TREATMENT IS ON FILE.     17.
                                                                          Inactive for 003070,
            CLAIM LACKS INDICATION THAT SERVICE WAS SUPERVISED OR         since 8/97. Use code
D15         EVALUATED BY A PHYSICIAN.                                     17.


                                                                          Inactive as of version
                                                                          5010. Use code 16
                                                                          with appropriate claim
                                                                          payment remark code
D16         CLAIM LACKS PRIOR PAYER PAYMENT INFORMATION                   [N4].


                                                                          Inactive as of version
                                                                          5010. Use code 16
                                                                          with appropriate claim
                                                                          payment remard code
D17         CLAIM/SERVICE HAS INVALID NON-COVERED DAYS.                   [M32, M33].


                                                                          Inactive as of version
                                                                          5010. use code 16
                                                                          with appropriate claim
                                                                          payment remark code
D18         CLAIM/SERVICE HAS MISSING DIAGNOSIS INFORMATION.              [MA63, MA65].




5/16/2012                                    Page 34
                                   835 Adjustment Reason Master


835
ADJUSTMENT
 REASON
CODE       835 ADJUSTMENT REASON CODE                                      NOTES


                                                                           Inactive as of version
                                                                           5010. Use code 16
                                                                           with appropriate claim
            CLAIM/SERVICE LACKS PHYSICIAN/OPERATIVE OR OTHER SUPPORTING    payment remark code
D19         DOCUMENTATION.                                                 [M29, M30, M35, M66].



                                                                           Inactive as of version
                                                                           5010. Use code 16
                                                                           with appropriate claim
                                                                           payment remark code
D20         CLAIM/SERVICE MISSING SERVICE/PRODUCT INFORMATION.             [M20, M67, M19, MA67].

D21         THIS (THESE) DIAGNOSIS(ES) IS (ARE) MISSING OR ARE INVALID.    Inactive as of 6/30/07


            REIMBURSEMENT WAS ADJUSTED FOR THE REASONS TO BE PROVIDED IN
            SEPARATE CORRESPONDENCE. (NOTE: TO BE USED FOR WORKERS'
            COMPENSATION ONLY) - TEMPORARY CODE TO BE ADDED FOR
            TIMEFRAME ONLY UNTIL 01/01/2009. ANOTHER CODE TO BE
            ESTABLISHED AND/OR FOR 6/2008 MEETING FOR A REVISED CODE TO    Inactive as of
D22         REPLACE OR STRATEGY TO USE ANOTHER EXISTING CODE.              01/01/09.
W1          WORKERS COMPENSATION STATE FEE SCHEDULE ADJUSTMENT.            New as of 2/00




5/16/2012                                    Page 35
                             835 Adjustment Reason Master


835
ADJUSTMENT
 REASON
CODE       835 ADJUSTMENT REASON CODE                       NOTES




5/16/2012                               Page 36
                             835 Adjustment Reason Master


835
ADJUSTMENT
 REASON
CODE       835 ADJUSTMENT REASON CODE                       NOTES




5/16/2012                               Page 37
                             835 Adjustment Reason Master


835
ADJUSTMENT
 REASON
CODE       835 ADJUSTMENT REASON CODE                       NOTES




5/16/2012                               Page 38
                             835 Adjustment Reason Master


835
ADJUSTMENT
 REASON
CODE       835 ADJUSTMENT REASON CODE                       NOTES




5/16/2012                               Page 39
                             835 Adjustment Reason Master


835
ADJUSTMENT
 REASON
CODE       835 ADJUSTMENT REASON CODE                       NOTES




5/16/2012                               Page 40
                             835 Adjustment Reason Master


835
ADJUSTMENT
 REASON
CODE       835 ADJUSTMENT REASON CODE                       NOTES




5/16/2012                               Page 41
                             835 Adjustment Reason Master


835
ADJUSTMENT
 REASON
CODE       835 ADJUSTMENT REASON CODE                       NOTES




5/16/2012                               Page 42
                             835 Adjustment Reason Master


835
ADJUSTMENT
 REASON
CODE       835 ADJUSTMENT REASON CODE                       NOTES




5/16/2012                               Page 43
                             835 Adjustment Reason Master


835
ADJUSTMENT
 REASON
CODE       835 ADJUSTMENT REASON CODE                       NOTES




5/16/2012                               Page 44
                             835 Adjustment Reason Master


835
ADJUSTMENT
 REASON
CODE       835 ADJUSTMENT REASON CODE                       NOTES




5/16/2012                               Page 45
                             835 Adjustment Reason Master


835
ADJUSTMENT
 REASON
CODE       835 ADJUSTMENT REASON CODE                       NOTES




5/16/2012                               Page 46
                             835 Adjustment Reason Master


835
ADJUSTMENT
 REASON
CODE       835 ADJUSTMENT REASON CODE                       NOTES




5/16/2012                               Page 47
                             835 Adjustment Reason Master


835
ADJUSTMENT
 REASON
CODE       835 ADJUSTMENT REASON CODE                       NOTES




5/16/2012                               Page 48
                             835 Adjustment Reason Master


835
ADJUSTMENT
 REASON
CODE       835 ADJUSTMENT REASON CODE                       NOTES




5/16/2012                               Page 49
            835 Adjustment Reason Master




5/16/2012             Page 50
            835 Adjustment Reason Master




5/16/2012             Page 51
            835 Adjustment Reason Master




5/16/2012             Page 52
            835 Adjustment Reason Master




5/16/2012             Page 53
            835 Adjustment Reason Master




5/16/2012             Page 54
            835 Adjustment Reason Master




5/16/2012             Page 55
            835 Adjustment Reason Master




5/16/2012             Page 56
            835 Adjustment Reason Master




5/16/2012             Page 57
            835 Adjustment Reason Master




5/16/2012             Page 58
            835 Adjustment Reason Master




5/16/2012             Page 59
            835 Adjustment Reason Master




5/16/2012             Page 60
            835 Adjustment Reason Master




5/16/2012             Page 61
            835 Adjustment Reason Master




5/16/2012             Page 62
            835 Adjustment Reason Master




5/16/2012             Page 63
            835 Adjustment Reason Master




5/16/2012             Page 64
            835 Adjustment Reason Master




5/16/2012             Page 65
            835 Adjustment Reason Master




5/16/2012             Page 66
            835 Adjustment Reason Master




5/16/2012             Page 67
            835 Adjustment Reason Master




5/16/2012             Page 68
            835 Adjustment Reason Master




5/16/2012             Page 69
            835 Adjustment Reason Master




5/16/2012             Page 70
            835 Adjustment Reason Master




5/16/2012             Page 71
            835 Adjustment Reason Master




5/16/2012             Page 72
            835 Adjustment Reason Master




5/16/2012             Page 73
            835 Adjustment Reason Master




5/16/2012             Page 74
            835 Adjustment Reason Master




5/16/2012             Page 75
            835 Adjustment Reason Master




5/16/2012             Page 76
                                      835 Remittance Remark Master




              EOB Remittance Remarks                                                                 Arkansas Medicaid Revis
835 REMIT
REMARK CODE   835 REMITTANCE REMARK CODE                                        NOTES
              X-RAY NOT TAKEN WITHIN THE PAST 12 MONTHS OR NEAR ENOUGH TO
M1            THE START OF TREATMENT.
M2            NOT PAID SEPARATELY WHEN THE PATIENT IS AN INPATIENT.
              EQUIPMENT IS THE SAME OR SIMILAR TO EQUIPMENT ALREADY BEING
M3            USED.
              ALERT: THIS IS THE LAST MONTHLY INSTALLMENT PAYMENT FOR THIS
M4            DURABLE MEDICAL EQUIPMENT.                                        Modified 04/01/07.
              MONTHLY RENTAL PAYMENTS CAN CONTINUE UNTIL THE EARLIER OF
              THE 15TH MONTH FROM THE FIRST RENTAL MONTH, OR THE MONTH
M5            WHEN THE EQUIPMENT IS NO LONGER NEEDED.

              ALERT: YOU MUST FURNISH AND SERVICE THIS ITEM FOR AS LONG AS
              THE PATIENT CONTINUES TO NEED IT. WE CAN PAY FOR MAINTENANCE
              AND/OR SERVICING FOR EVERY 6 MONTH PERIOD AFTER THE END OF
M6            THE 15TH PAID RENTAL MONTH OR THE END OF THE WARRANTY PERIOD. Modified 04/01/07.
              NO RENTAL PAYMENTS AFTER THE ITEM IS PURCHASED, OR AFTER THE
M7            TOTAL OF ISSUED RENTAL PAYMENTS EQUALS THE PURCHASE PRICE.
              WE DO NOT ACCEPT BLOOD GAS TESTS RESULTS WHEN THE TEST WAS
              CONDUCTED BY A MEDICAL SUPPLIER OR TAKEN WHILE THE PATIENT IS
M8            ON OXYGEN.
              ALERT: THIS IS THE TENTH RENTAL MONTH. YOU MUST OFFER THE
              PATIENT THE CHOICE OF CHANGING THE RENTAL TO A PURCHASE
M9            AGREEMENT.                                                        Modified 04/01/07.
              EQUIPMENT PURCHASES ARE LIMITED TO THE FIRST OR THE TENTH
M10           MONTH OF MEDICAL NECESSITY.
              DME, ORTHOTICS AND PROSTHETICS MUST BE BILLED TO THE DME
M11           CARRIER WHO SERVICES THE PATIENT'S ZIP CODE.
              DIAGNOSTIC TESTS PERFORMED BY A PHYSICIAN MUST INDICATE
M12           WHETHER PURCHASED SERVICES ARE INCLUDED ON THE CLAIM.
              ONLY ONE INITIAL VISIT IS COVERED PER SPECIALTY PER MEDICAL
M13           GROUP.                                                            (Modified 6/30/03)
              NO SEPARATE PAYMENT FOR AN INJECTION ADMINISTERED DURING AN
              OFFICE VISIT, AND NO PAYMENT FOR A FULL OFFICE VISIT IF THE
M14           PATIENT ONLY RECEIVED AN INJECTION.
              SEPARATELY BILLED SERVICES/TESTS HAVE BEEN BUNDLED AS THEY
              ARE CONSIDERED COMPONENTS OF THE SAME PROCEDURE. SEPARATE
M15           PAYMENT IS NOT ALLOWED.
              ALERT: PLEASE SEE OUR WEB SITE, MAILING, OR BULLETINS FOR MORE
M16           DETAILS CONCERNING THIS POLICY/PROCEDURE/DECISION.             Modified 04/01/07.
              ALERT: PAYMENT APPROVED AS YOU DID NOT KNOW, AND COULD NOT
              REASONABLY HAVE BEEN EXPECTED TO KNOW, THAT THIS WOULD NOT
              NORMALLY HAVE BEEN COVERED FOR THIS PATIENT. IN THE FUTURE,
              YOU WILL BE LIABLE FOR CHARGES FOR THE SAME SERVICE(S) UNDER
M17           THE SAME OR SIMILAR CONDITIONS.                                   Modified 04/01/07.
              CERTAIN SERVICES MAY BE APPROVED FOR HOME USE. NEITHER A
              HOSPITAL NOR A SKILLED NURSING FACILITY (SNF) IS CONSIDERED TO
M18           BE A PATIENT'S HOME.                                              (Modified 6/30/03)
M19           MISSING OXYGEN CERTIFICATION/RE-CERTIFICATION.                    (Modified 2/28/03)
M20           MISSING/INCOMPLETE/INVALID HCPCS.                                 (Modified 2/28/03)
              MISSING/INCOMPLETE/INVALID PLACE OF RESIDENCE FOR THIS
M21           SERVICE/ITEM PROVIDED IN A HOME.                                  (Modified 2/28/03)
M22           MISSING/INCOMPLETE/INVALID NUMBER OF MILES TRAVELED.              (Modified 2/28/03)
M23           MISSING INVOICE.                                                  Modified 08/01/05.




5/16/2012                                        Page 77
                                      835 Remittance Remark Master


835 REMIT
REMARK CODE   835 REMITTANCE REMARK CODE                                          NOTES
M24           MISSING/INCOMPLETE/INVALID NUMBER OF DOSES PER VIAL.                (Modified 2/28/03)

              THE INFORMATION FURNISHED DOES NOT SUBSTANTIATE THE NEED
              FOR THIS LEVEL OF SERVICE. IF YOU BELIEVE THE SERVICE SHOULD
              HAVE BEEN FULLY COVERED AS BILLED, OR IF YOU DID NOT KNOW AND
              COULD NOT REASONABLY HAVE BEEN EXPECTED TO KNOW THAT WE
              WOULD NOT PAY FOR THIS LEVEL OF SERVICE, OR IF YOU NOTIFIED THE
              PATIENT IN WRITING IN ADVANCE THAT WE WOULD NOT PAY FOR THIS
              LEVEL OF SERVICE AND HE/SHE AGREED IN WRITING TO PAY, ASK US TO
              REVIEW YOUR CLAIM WITHIN 120 DAYS OF THE DATE OF THIS NOTICE. IF
              YOU DO NOT REQUEST A APPEAL, WE WILL, UPON APPLICATION FROM
              THE PATIENT, REIMBURSE HIM/HER FOR THE AMOUNT YOU HAVE
              COLLECTED FROM HIM/HER IN EXCESS OF ANY DEDUCTIBLE AND           (Modified 10/1/02,
              COINSURANCE AMOUNTS. WE WILL RECOVER THE REIMBURSEMENT           6/30/03, 8/1/05,
M25           FROM YOU AS AN OVERPAYMENT.                                      11/5/07)

              THE INFORMATION FURNISHED DOES NOT SUBSTANTIATE THE NEED
              FOR THIS LEVEL OF SERVICE. IF YOU HAVE COLLECTED ANY AMOUNT
              FROM THE PATIENT FOR THIS LEVEL OF SERVICE/ANY AMOUNT THAT
              EXCEEDS THE LIMITING CHARGE FOR THE LESS EXTENSIVE SERVICE,
              THE LAW REQUIRES YOU TO REFUND THAT AMOUNT TO THE PATIENT
              WITHIN 30 DAYS OF RECEIVING THIS NOTICE. THE REQUIREMENTS FOR
              REFUND ARE IN 1824(I) OF THE SOCIAL SECURITY ACT AND
              42CFR411.408. THE SECTION SPECIFIES THAT PHYSICIANS WHO
              KNOWINGLY AND WILLFULLY FAIL TO MAE APPROPRIATE REFUNDS MAY
              BE SUBJECT TO CIVIL MONETARY PENALTIES AND/OR EXCLUSION FROM        (Modified 10/1/02,
              THE PROGRAM. IF YOU HAVE ANY QEUSTIONS ABOUT THIS NOTICE,           6/30/03, 8/1/05,
M26           PLEASE CONTACT THIS OFFICE.                                         11/5/07)

              ALERT: THE PATIENT HAS BEEN RELIEVED OF LIABILITY OF PAYMENT OF
              THESE ITEMS AND SERVICES UNDER THE LIMITATION OF LIABILITY
              PROVISION OF THE LAW. THE PROVIDER IS ULTIMATELY LIABLE FOR THE
              PATIENT'S WAIVED CHARGES, INCLUDING ANY CHARGES FOR
              COINSURANCE, SINCE THE ITEMS OR SERVICES WERE NOT
              REASONABLE AND NECESSARY OR CONSTITUTED CUSTODIAL CARE,
              AND YOU KNEW OR COULD REASONABLY HAVE BEEN EXPECTED TO
              KNOW, THAT THEY WERE NOT COVERED. YOU MAY APPEAL THIS
              DETERMINATION AND THE ISSUE OF WHETHER YOU EXERCISED DUE
              CARE. THE APPEAL REQUEST MUST BE FILED WITHIN 120 DAYS OF THE (Modified 10/1/02,
              DATE YOU RECEIVE THIS NOTICE. YOU MUST MAKE THE REQUEST         8/1/05, 4/1/07,
M27           THROUGH THIS OFFICE.                                            8/1/07)
              THIS DOES NOT QUALIFY FOR PAYMENT UNDER PART B WHEN PART A
M28           COVERAGE IS EXHAUSTED OR NOT OTHERWISE AVAILABLE.
M29           MISSING OPERATIVE REPORT.                                           (Modified 2/28/03)
M30           MISSING PATHOLOGY REPORT.                                           (Modified 2/28/03)
M31           MISSING RADIOLOGY REPORT.                                           (Modified 2/28/03)
              ALERT: THIS IS A CONDITIONAL PAYMENT MADE PENDING A DECISION
              ON THIS SERVICE BY THE PATIENT'S PRIMARY PAYER. THIS PAYMENT
              MAY BE SUBJECT TO REFUND UPON YOUR RECEIPT OF ANY ADDITIONAL
              PAYMENT FOR THIS SERVICE FROM ANOTHER PAYER. YOU MUST
              CONTACT THIS OFFICE IMMEDIATELY UPON RECEIPT OF AN ADDITIONAL
M32           PAYMENT FOR THIS SERVICE.                                     Modified 04/01/07.
                                                                                  (Modified 2/28/03;
                                                                                  Deactivated eff.
              MISSING/INCOMPLETE/INVALID UPIN FOR THE                             8/1/04. Refer to
M33           ORDERING/REFERRING/PERFORMING PROVIDER.                             M68)
                                                                                  (Deactivated eff.
                                                                                  8/1/04. Refer to
M34           CLAIM LACKS THE CLIA CERTIFICATION NUMBER.                          MA120)




5/16/2012                                         Page 78
                                      835 Remittance Remark Master


835 REMIT
REMARK CODE   835 REMITTANCE REMARK CODE                                       NOTES
                                                                               Deactivated eff.
              MISSING/INCOMPLETE/INVALID PRE-OPERATIVE PHOTOS OR VISUAL        02/05/05. Refer to
M35           FIELD RESULTS.                                                   N178.
              THIS IS THE 11TH RENTAL MONTH. WE CANNOT PAY FOR THIS UNTIL
              YOU INDICATE THAT THE PATIENT HAS BEEN GIVEN THE OPTION OF
M36           CHANGING THE RENTAL TO A PURCHASE.
M37           SERVICE NOT COVERED WHEN THE PATIENT IS UNDER AGE 35.
              THE PATIENT IS LIABLE FOR THE CHARGES FOR THIS SERVICE AS YOU
              INFORMED THE PATIENT IN WRITING BEFORE THE SERVICE WAS
              FURNISHED THAT WE WOULD NOT PAY FOR IT, AND THE PATIENT
M38           AGREED TO PAY.
              ALERT: THE PATIENT IS NOT LIABLE FOR PAYMENT FOR THIS SERVICE
              AS THE ADVANCE NOTICE OF NON-COVERAGE YOU PROVIDED THE
M39           PATIENT DID NOT COMPLY WITH PROGRAM REQUIREMENTS.                (Modified 4/1/07)
              CLAIM MUST BE ASSIGNED AND MUST BE FILED BY THE PRACTITIONER'S
M40           EMPLOYER.
              WE DO NOT PAY FOR THIS AS THE PATIENT HAS NO LEGAL OBLIGATION
M41           TO PAY FOR THIS.
              THE MEDICAL NECESSITY FORM MUST BE PERSONALLY SIGNED BY THE
M42           ATTENDING PHYSICIAN.
                                                                           (Deactivated eff.
              PAYMENT FOR THIS SERVICE PREVIOUSLY ISSUED TO YOU OR ANOTHER 1/31/04. Refer to
M43           PROVIDER BY ANOTHER CARRIER/INTERMEDIARY.                    Reason Code 23)
M44           MISSING/INCOMPLETE/INVALID CONDITION CODE.                       (Modified 2/28/03)

M45           MISSING/INCOMPLETE/INVALID OCCURRENCE CODES.                     (Modified 12/02/04)

M46           MISSING/INCOMPLETE/INVALID OCCURRENCE SPAN CODE.                 (Modified 12/02/04)
              MISSING/INCOMPLETE/INVALID INTERNAL OR DOCUMENT CONTROL
M47           NUMBER.                                                          (Modified 2/28/03)
              PAYMENT FOR SERVICES FURNISHED TO HOSPITAL INPATIENTS (OTHER
              THAN PROFESSIONAL SERVICES OF PHYSICIANS) CAN ONLY BE MADE   (Deactivated eff.
              TO THE HOSPITAL. YOU MUST REQUEST PAYMENT FROM THE HOSPITAL 1/31/04. Refer to
M48           RATHER THAN THE PATIENT FOR THIS SERVICE.                    M97)
M49           MISSING/INCOMPLETE/INVALID VALUE CODE(S) OR AMOUNT(S).           (Modified 2/28/03)
M50           MISSING/INCOMPLETE/INVALID REVENUE CODE(S).                      (Modified 2/28/03)

M51           MISSING/INCOMPLETE/INVALID PROCEDURE CODE(S).                    (Modified 12/02/04)
M52           MISSING/INCOMPLETE/INVALID “FROM” DATE(S) OF SERVICE.            (Modified 2/28/03)
M53           MISSING/INCOMPLETE/INVALID DAYS OR UNITS OF SERVICE.             (Modified 2/28/03)
M54           MISSING/INCOMPLETE/INVALID TOTAL CHARGES.                        (Modified 2/28/03)
              WE DO NOT PAY FOR SELF-ADMINISTERED ANTI-EMETIC DRUGS THAT
M55           ARE NOT ADMINISTERED WITH A COVERED ORAL ANTI-CANCER DRUG.
M56           MISSING/INCOMPLETE/INVALID PAYER IDENTIFIER.                     (Modified 2/28/03)
                                                                               Deactivated as of
M57           MISSING/INCOMPLETE/INVALID PROVIDER IDENTIFIER.                  6/2/05.
              MISSING/INCOMPLETE/INVALID CLAIM INFORMATION. RESUBMIT CLAIM     Deactivated as of
M58           AFTER CORRECTIONS.                                               2/5/05.
M59           MISSING/INCOMPLETE/INVALID “TO” DATE(S) OF SERVICE.              (Modified 2/28/03)
M60           MISSING CERTIFICATE OF MEDICAL NECESSITY.                        (Modified 8/1/04)
              WE CANNOT PAY FOR THIS AS THE APPROVAL PERIOD FOR THE FDA
M61           CLINICAL TRIAL HAS EXPIRED.
M62           MISSING/INCOMPLETE/INVALID TREATMENT AUTHORIZATION CODE.         (Modified 2/28/03)
                                                                               (Deactivated eff.
                                                                               1/31/04. Refer to
M63           WE DO NOT PAY FOR MORE THAN ONE OF THESE ON THE SAME DAY.        M86)



5/16/2012                                        Page 79
                                      835 Remittance Remark Master


835 REMIT
REMARK CODE   835 REMITTANCE REMARK CODE                                      NOTES
M64           MISSING/INCOMPLETE/INVALID OTHER DIAGNOSIS.                     (Modified 2/28/03)
              ONE INTERPRETING PHYSICIAN CHARGE CAN BE SUBMITTED PER CLAIM
              WHEN A PURCHASED DIAGNOSTIC TEST IS INDICATED. PLEASE SUBMIT
M65           A SEPARATE CLAIM FOR EACH INTERPRETING PHYSICIAN.
              OUR RECORDS INDICATE THAT YOU BILLED DIAGNOSTIC TESTS
              SUBJECT TO PRICE LIMITATIONS AND THE PROCEDURE CODE
              SUBMITTED INCLUDES A PROFESSIONAL COMPONENT. ONLY THE
              TECHNICAL COMPONENT IS SUBJECT TO PRICE LIMITATIONS. PLEASE
              SUBMIT THE TECHNICAL AND PROFESSIONAL COMPONENTS OF THIS
M66           SERVICE AS SEPARATE LINE ITEMS.
M67           MISSING/INCOMPLETE/INVALID OTHER PROCEDURE CODE(S).             (Modified 12/2/04)
              MISSING/INCOMPLETE/INVALID ATTENDING, ORDERING, RENDERING,      Deactivated as of
M68           SUPERVISING OR REFERRING PHYSICIAN IDENTIFICATION.              6/2/05.
              PAID AT THE REGULAR RATE AS YOU DID NOT SUBMIT DOCUMENTATION
M69           TO JUSTIFY THE MODIFIED PROCEDURE CODE.                         (Modified 2/1/04)
              ALERT: THE NDC CODE SUBMITTED FOR THIS SERVICE WAS
              TRANSLATED TO A HCPCS CODE FOR PROCESSING, BUT PLEASE
M70           CONTINUE TO SUBMIT THE NDC ON FUTURE CLAIMS FOR THIS ITEM.      Modified 8/1/07.
M71           TOTAL PAYMENT REDUCED DUE TO OVERLAP OF TESTS BILLED.
                                                                              (Deactivated eff.
                                                                              10/16/2003. C149
M72           DID NOT ENTER FULL 8-DIGIT DATE (MM/DD/CCYY).                   Refer to MA52)
              THE HPSA/PHYSICIAN SCARCITY BONUS CAN ONLY BE PAID ON THE
              PROFESSIONAL COMPONENT OF THIS SERVICE. REBILL AS SEPARATE
M73           PROFESSIONAL AND TECHNICAL COMPONENTS.                          Modified 8/1/04.
              THIS SERVICE DOES NOT QUALIFY FOR A HPSA/PHYSICIAN SCARCITY
M74           BONUS PAYMENT.                                                  Modified 12/2/04.
              MULTIPLE AUTOMATED MULTICHANNEL TESTS PERFORMED ON THE
M75           SAME DAY COMBINED FOR PAYMENT.                                  Modified 11/5/07.
M76           MISSING/INCOMPLETE/INVALID DIAGNOSIS OR CONDITION.              (Modified 2/28/03)
M77           MISSING/INCOMPLETE/INVALID PLACE OF SERVICE.                    (Modified 2/28/03)
                                                                              Deactivated eff.
                                                                              05/18/06. Consider
                                                                              using Reason Code
M78           MISSING/INCOMPLETE/INVALID HCPCS MODIFIER.                      4.
M79           MISSING/INCOMPLETE/INVALID CHARGE.                         (Modified 2/28/03)
              NOT COVERED WHEN PERFORMED DURING THE SAME SESSION/DATE AS
M80           A PREVIOUSLY PROCESSED SERVICE FOR THE PATIENT.            (Modified 10/31/02)
M81           YOU ARE REQUIRED TO CODE TO THE HIGHEST LEVEL OF SPECIFICITY.   (Modified 2/1/04)
M82           SERVICE IS NOT COVERED WHEN PATIENT IS UNDER AGE 50.
              SERVICE IS NOT COVERED UNLESS THE PATIENT IS CLASSIFIED AS AT
M83           HIGH RISK.
              MEDICAL CODE SETS USED MUST BE THE CODES IN EFFECT AT THE
M84           TIME OF SERVICE.                                                (Modified 2/1/04)
              SUBJECTED TO REVIEW OF PHYSICIAN EVALUATION AND MANAGEMENT
M85           SERVICES.
              SERVICE DENIED BECAUSE PAYMENT ALREADY MADE FOR
M86           SAME/SIMILAR PROCEDURE WITHIN SET TIME FRAME.                   (Modified 6/30/03)
M87           CLAIM/SERVICE(S) SUBJECTED TO CFO-CAP PREPAYMENT REVIEW.

                                                                              (Deactivated
              WE CANNOT PAY FOR LABORATORY TESTS UNLESS BILLED BY THE         eff.8/1/04. Refer to
M88           LABORATORY THAT DID THE WORK.                                   Reason Code B20)
M89           NOT COVERED MORE THAN ONCE UNDER AGE 40.
M90           NOT COVERED MORE THAN ONCE IN A 12 MONTH PERIOD.




5/16/2012                                         Page 80
                                     835 Remittance Remark Master


835 REMIT
REMARK CODE   835 REMITTANCE REMARK CODE                                       NOTES
              LAB PROCEDURES WITH DIFFERENT CLIA CERTIFICATION NUMBERS
M91           MUST BE BILLED ON SEPARATE CLAIMS.
              SERVICES SUBJECTED TO REVIEW UNDER THE HOME HEALTH MEDICAL       (Deactivated eff.
M92           REVIEW INITIATIVE.                                               8/1/04.)
              INFORMATION SUPPLIED SUPPORTS A BREAK IN THERAPY. A NEW
M93           CAPPED RENTAL PERIOD BEGAN WITH DELIVERY OF THIS EQUIPMENT.
              INFORMATION SUPPLIED DOES NOT SUPPORT A BREAK IN THERAPY. A
M94           NEW CAPPED RENTAL PERIOD WILL NOT BEGIN.
              SERVICES SUBJECTED TO HOME HEALTH INITIATIVE MEDICAL
M95           REVIEW/COST REPORT AUDIT.
              THE TECHNICAL COMPONENT OF A SERVICE FURNISHED TO AN
              INPATIENT MAY ONLY BE BILLED BY THAT INPATIENT FACILITY. YOU
              MUST CONTACT THE INPATIENT FACILITY FOR TECHNICAL COMPONENT
              REIMBURSEMENT. IF NOT ALREADY BILLED, YOU SHOULD BILL US FOR
M96           THE PROFESSIONAL COMPONENT ONLY.
              NOT PAID TO PRACTITIONER WHEN PROVIDED TO PATIENT IN THIS
              PLACE OF SERVICE. PAYMENT INCLUDED IN THE REIMBURSEMENT
M97           ISSUED THE FACILITY.
              BEGIN TO REPORT THE UNIVERSAL PRODUCT NUMBER ON CLAIMS FOR
              ITEMS OF THIS TYPE. WE WILL SOON BEGIN TO DENY PAYMENT FOR       (Deactivated eff.
M98           ITEMS OF THIS TYPE IF BILLED WITHOUT THE CORRECT UPN.            1/31/2004. Use M99)
              MISSING/INCOMPLETE/INVALID UNIVERSAL PRODUCT NUMBER/SERIAL
M99           NUMBER.                                                          (Modified 2/28/03)
              WE DO NOT PAY FOR AN ORAL ANTI-EMETIC DRUG THAT IS NOT
              ADMINISTERED FOR USE IMMEDIATELY BEFORE, AT, OR WITHIN 48
M100          HOURS OF ADMINISTRATION OF A COVERED CHEMOTHERAPY DRUG.
              BEGIN TO REPORT A G1-G5 MODIFIER WITH THIS HCPCS. WE WILL SOON
              BEGIN TO DENY PAYMENT FOR THIS SERVICE IF BILLED WITHOUT A G1- (Deactivated eff.
M101          G5 MODIFIER.                                                   1/31/2004. Use M78)
              SERVICE NOT PERFORMED ON EQUIPMENT APPROVED BY THE FDA FOR
M102          THIS PURPOSE.
              INFORMATION SUPPLIED SUPPORTS A BREAK IN THERAPY. HOWEVER,
              THE MEDICAL INFORMATION WE HAVE FOR THIS PATIENT DOES NOT
              SUPPORT THE NEED FOR THIS ITEM AS BILLED. WE HAVE APPROVED
              PAYMENT FOR THIS ITEM AT A REDUCED LEVEL, AND A NEW CAPPED
M103          RENTAL PERIOD WILL BEGIN WITH THE DELIVERY OF THIS EQUIPMENT.
              INFORMATION SUPPLIED SUPPORTS A BREAK IN THERAPY. A NEW
              CAPPED RENTAL PERIOD WILL BEGIN WITH DELIVERY OF THE
              EQUIPMENT. THIS IS THE MAXIMUM APPROVED UNDER THE FEE
M104          SCHEDULE FOR THIS ITEM OR SERVICE.
              INFORMATION SUPPLIED DOES NOT SUPPORT A BREAK IN THERAPY.
              THE MEDICAL INFORMATION WE HAVE FOR THIS PATIENT DOES NOT
              SUPPORT THE NEED FOR THIS ITEM AS BILLED. WE HAVE APPROVED
              PAYMENT FOR THIS ITEM AT A REDUCED LEVEL, AND A NEW CAPPED
M105          RENTAL PERIOD WILL NOT BEGIN.
              INFORMATION SUPPLIED DOES NOT SUPPORT A BREAK IN THERAPY. A      (Deactivated eff.
              NEW CAPPED RENTAL PERIOD WILL NOT BEGIN. THIS IS THE MAXIMUM     1/31/2004. Use
M106          APPROVED UNDER THE FEE SCHEDULE FOR THIS ITEM OR SERVICE.        MA31)
              PAYMENT REDUCED AS 90-DAY ROLLING AVERAGE HEMATOCRIT FOR
M107          ESRD PATIENT EXCEEDED 36.5%.
              MISSING/INCOMPLETE/INVALID PROVIDER IDENTIFIER FOR THE           Deactivated eff.
M108          PROVIDER WHO INTERPRETED THE DIAGNOSTIC TEST.                    06/02/05.
              WE HAVE PROVIDED YOU WITH A BUNDLED PAYMENT FOR A
              TELECONSULTATION. YOU MUST SEND 25 PERCENT OF THE
M109          TELECONSULTATION PAYMENT TO THE REFERRING PRACTITIONER.
              MISSING/INCOMPLETE/INVALID PROVIDER IDENTIFIER FOR THE           Deactivated eff.
M110          PROVIDER FROM WHOM YOU PURCHASED INTERPRETATION SERVICES.        06/02/05.




5/16/2012                                        Page 81
                                     835 Remittance Remark Master


835 REMIT
REMARK CODE   835 REMITTANCE REMARK CODE                                        NOTES
              WE DO NOT PAY FOR CHIROPRACTIC MANIPULATIVE TREATMENT WHEN
M111          THE PATIENT REFUSES TO HAVE AN X-RAY TAKEN.
              THE APPROVED AMOUNT IS BASED ON THE SINGLE PAYMENT AMOUNT
              REQUIRED UNDER THE DMEPOS COMPETITIVE BIDDING PROGRAM FOR
M112          THE AREA WHERE THE PATIENT RESIDES.                               Modified 11/5/07.
              OUR RECORDS INDICATE THAT THIS PATIENT BEGAN USING THIS
              SERVICE(S) PRIOR TO THE CURRENT CONTRACT PERIOD FOR THE
M113          DMEPOS COMPETITIVE BIDDING PROGRAM.                               Modified 11/5/07.
              THIS SERVICE WAS PROCESSED IN ACCORDANCE WITH RULES AND
              GUIDELINES UNDER THE DMEPOS COMPETITIVE BIDDING PROGRAM OR
              A DEMONSTRATION PROJECT. FOR MORE INFORMATION REGARDING
M114          THESE PROJECTS, CONTACT YOUR LOCAL CONTRACTOR.                    Modified 11/5/07.
              THIS ITEM IS DENIED WHEN PROVIDED TO THIS PATIENT BY A NON-
M115          DEMONSTRATION SUPPLIER.
              PAID UNDER THE COMPETITIVE BIDDING DEMONSTRATION PROJECT.
              PROJECT IS ENDING, AND FUTURE SERVICES MAY NOT BE PAID UNDER
M116          THIS PROJECT.                                                     (Modified 2/1/04)
M117          NOT COVERED UNLESS SUBMITTED VIA ELECTRONIC CLAIM.                (Modified 6/30/03)
M118          ALERT: LETTER TO FOLLOW CONTAINING FURTHER INFORMATION.           Modified 4/1/07
              MISSING/INCOMPLETE/INVALID/DEACTIVATED/WITHDRAWN NATIONAL         (Modified 2/28/03,
M119          DRUG CODE (NDC).                                                  4/1/04)
              MISSING/INCOMPLETE/INVALID PROVIDER IDENTIFIER FOR THE
              SUBSTITUTING PHYSICIAN WHO FURNISHED THE SERVICE(S) UNDER A
M120          RECIPROCAL BILLING OR LOCUM TENENS ARRANGEMENT.                   (Modified 2/28/03)
              WE PAY FOR THIS SERVICE ONLY WHEN PERFORMED WITH A COVERED
M121          CRYOSURGICAL ABLATION.
M122          MISSING/INCOMPLETE/INVALID LEVEL OF SUBLUXATION.                  (Modified 2/28/03)
              MISSING/INCOMPLETE/INVALID NAME, STRENGTH, OR DOSAGE OF THE
M123          DRUG FURNISHED.                                                   (Modified 2/28/03)
              MISSING INDICATION OF WHETHER THE PATIENT OWNS THE EQUIPMENT
M124          THAT REQUIRES THE PART OR SUPPLY.                                 (Modified 2/28/03)
              MISSING/INCOMPLETE/INVALID INFORMATION ON THE PERIOD OF TIME
M125          FOR WHICH THE SERVICE/SUPPLY/EQUIPMENT WILL BE NEEDED.            (Modified 2/28/03)
              MISSING/INCOMPLETE/INVALID INDIVIDUAL LAB CODES INCLUDED IN THE
M126          TEST.                                                             (Modified 2/28/03)
              MISSING/INCOMPLETE/INVALID PATIENT MEDICAL RECORD FOR THIS
M127          SERVICE.                                                          (Modified 2/28/03)
              MISSING/INCOMPLETE/INVALID DATE OF THE PATIENT’S LAST PHYSICIAN
M128          VISIT.                                                            (Modified 2/28/03)
              MISSING/INCOMPLETE/INVALID INDICATOR OF X-RAY AVAILABILITY FOR    (Modified 2/28/03,
M129          REVIEW.                                                           6/30/03)
              MISSING INVOICE OR STATEMENT CERTIFYING THE ACTUAL COST OF
              THE LENS, LESS DISCOUNTS, AND/OR THE TYPE OF INTRAOCULAR LENS
M130          USED.                                                             (Modified 2/28/03)
M131          MISSING PHYSICIAN FINANCIAL RELATIONSHIP FORM.                    (Modified 2/28/03)
M132          MISSING PACEMAKER REGISTRATION FORM.                              (Modified 2/28/03)

              CLAIM DID NOT IDENTIFY WHO PERFORMED THE PURCHASED
M133          DIAGNOSTIC TEST OR THE AMOUNT YOU WERE CHARGED FOR THE TEST.
              PERFORMED BY A FACILITY/SUPPLIER IN WHICH THE PROVIDER HAS A
M134          FINANCIAL INTEREST.                                          (Modified 6/30/03)
M135          MISSING/INCOMPLETE/INVALID PLAN OF TREATMENT.                     (Modified 2/28/03)
              MISSING/INCOMPLETE/INVALID INDICATION THAT THE SERVICE WAS
M136          SUPERVISED OR EVALUATED BY A PHYSICIAN.                           (Modified 2/28/03)
M137          PART B COINSURANCE UNDER A DEMONSTRATION PROJECT.




5/16/2012                                        Page 82
                                      835 Remittance Remark Master


835 REMIT
REMARK CODE   835 REMITTANCE REMARK CODE                                         NOTES
              PATIENT IDENTIFIED AS A DEMONSTRATION PARTICIPANT BUT THE
              PATIENT WAS NOT ENROLLED IN THE DEMONSTRATION AT THE TIME
              SERVICES WERE RENDERED. COVERAGE IS LIMITED TO
M138          DEMONSTRATION PARTICIPANTS.
              DENIED SERVICES EXCEED THE COVERAGE LIMIT FOR THE
M139          DEMONSTRATION.
                                                                                 (Deactivated eff.
              SERVICE NOT COVERED UNTIL AFTER THE PATIENT’S 50TH BIRTHDAY,       1/30/2004. Refer to
M140          I.E., NO COVERAGE PRIOR TO THE DAY AFTER THE 50TH BIRTHDAY         M82)
M141          MISSING PHYSICIAN CERTIFIED PLAN OF CARE.                          (Modified 2/28/03)
              MISSING AMERICAN DIABETES ASSOCIATION CERTIFICATE OF
M142          RECOGNITION.                                                       (Modified 2/28/03)
                                                                                 MODIFIED
M143          THE PROVIDER MUST UPDATE LICENSE INFORMATION WITH THE PAYER.       12/1/2006
              PRE-/POST-OPERATIVE CARE PAYMENT IS INCLUDED IN THE
M144          ALLOWANCE FOR THE SURGERY/PROCEDURE.
              ALERT: IF YOU DO NOT AGREE WITH WHAT WE APPROVED FOR THESE
              SERVICES, YOU MAY APPEAL OUR DECISION. TO MAKE SURE THAT WE
              ARE FAIR TO YOU, WE REQUIRE ANOTHER INDIVIDUAL THAT DID NOT
              PROCESS YOUR INITIAL CLAIM TO CONDUCT THE REVIEW. HOWEVER, IN
              ORDER TO BE ELIGIBLE FOR AN APPEAL YOU MUST WRITE TO US WITHIN
              120 DAYS OF THE DATE OF THIS NOTICE, UNLESS YOU HAVE A GOOD    (Modified 10/31/02,
MA01          REASON FOR BEING LATE.                                         6/30/03, 4/1/07)
              ALERT: IF YOU DO NOT AGREE WITH THIS DETERMINATION, YOU HAVE
              THE RIGHT TO APPEAL. YOU MUST FILE A WRITTEN REQUEST FOR AN        (Modified 10/31/02,
MA02          APPEAL WITHIN 180 DAYS OF THE DATE YOU RECEIVE THIS NOTICE.        6/30/03, 4/1/07)
              IF YOU DO NOT AGREE WITH THE APPROVED AMOUNTS AND $100 OR
              MORE IS IN DISPUTE (LESS DEDUCTIBLE AND COINSURANCE), YOU MAY
              ASK FOR A HEARING WITHIN SIX MONTHS OF THE DATE OF THIS NOTICE.
               TO MEET THE $100, YOU MAY COMBINE AMOUNTS ON OTHER CLAIMS
              THAT HAVE BEEN DENIED, INCLUDING REOPENED APPEALS IF YOU        Deactivated eff.
              RECEIVED A REVISED DECISION. YOU MUST APPEAL EACH CLAIM ON      10/1/06. Refer to
MA03          TIME.                                                           MA02.
              SECONDARY PAYMENT CANNOT BE CONSIDERED WITHOUT THE
              IDENTITY OF OR PAYMENT INFORMATION FROM THE PRIMARY PAYER.
MA04          THE INFORMATION WAS EITHER NOT REPORTED OR WAS ILLEGIBLE.
                                                                                 (Deactivated eff.
                                                                                 10/16/2003. Refer
              INCORRECT ADMISSION DATE PATIENT STATUS OR TYPE OF BILL ENTRY      to MA30 or MA40 or
MA05          ON CLAIM.                                                          MA43.)
                                                                                 (Modified 2/28/03.
                                                                                 Deactivated eff.
                                                                                 8/1/04. Refer to
MA06          MISSING/INCOMPLETE/INVALID BEGINNING AND/OR ENDING DATE(S).        MA31)
              ALERT: THE CLAIM INFORMATION HAS ALSO BEEN FORWARDED TO
MA07          MEDICAID FOR REVIEW.                                               Modified 4/1/07.
              ALERT: CLAIM INFORMATION WAS NOT FORWARDED BECAUSE THE
              SUPPLEMENTAL COVERAGE IS NOT WITH A MEDIGAP PLAN, OR YOU DO
MA08          NOT PARTICIPATE IN MEDICARE.                                 Modified 4/1/07.
              CLAIM SUBMITTED AS UNASSIGNED BUT PROCESSED AS ASSIGNED. YOU
MA09          AGREED TO ACCEPT ASSIGNMENT FOR ALL CLAIMS.
              ALERT: THE PATIENT'S PAYMENT WAS IN EXCESS OF THE AMOUNT
MA10          OWED. YOU MUST REFUND THE OVERPAYMENT TO THE PATIENT.        Modified 4/1/07.




5/16/2012                                         Page 83
                                       835 Remittance Remark Master


835 REMIT
REMARK CODE   835 REMITTANCE REMARK CODE                                          NOTES
              PAYMENT IS BEING ISSUED ON A CONDITIONAL BASIS. IF NO-FAULT
              INSURANCE, LIABILITY INSURANCE, WORKERS' COMPENSATION,
              DEPARTMENT OF VETERANS AFFAIRS, OR A GROUP HEALTH PLAN FOR
              EMPLOYEES AND DEPENDENTS ALSO COVERS THIS CLAIM, A REFUND           (Deactivated eff.
              MAY BE DUE US. PLEASE CONTACT US IF THE PATIENT IS COVERED BY       1/31/2004. Refer to
MA11          ANY OF THESE SOURCES.                                               M32)
              YOU HAVE NOT ESTABLISHED THAT YOU HAVE THE RIGHT UNDER THE
              LAW TO BILL FOR SERVICES FURNISHED BY THE PERSON(S) THAT
MA12          FURNISHED THIS (THESE) SERVICE(S).
              ALERT: YOU MAY BE SUBJECT TO PENALTIES IF YOU BILL THE PATIENT
              FOR AMOUNTS NOT REPORTED WITH THE PR (PATIENT RESPONSIBILITY)
MA13          GROUP CODE.                                                    Modified 4/1/07.
              ALERT: THE PATIENT IS A MEMBER OF AN EMPLOYER-SPONSORED
              PREPAID HEALTH PLAN. SERVICES FROM OUTSIDE THAT HEALTH PLAN
              ARE NOT COVERED. HOWEVER, AS YOU WERE NOT PREVIOUSLY
              NOTIFIED OF THIS, WE ARE PAYING THIS TIME. IN THE FUTURE, WE WILL
MA14          NOT PAY YOU FOR NON-PLAN SERVICES.                                Modified 8/1/07.
              ALERT: YOUR CLAIM HAS BEEN SEPARATED TO EXPEDITE HANDLING.
              YOU WILL RECEIVE A SEPARATE NOTICE FOR THE OTHER SERVICES
MA15          REPORTED.                                                           Modified 4/1/07.
              THE PATIENT IS COVERED BY THE BLACK LUNG PROGRAM. SEND THIS
              CLAIM TO THE DEPARTMENT OF LABOR, FEDERAL BLACK LUNG
MA16          PROGRAM, P.O. BOX 828, LANHAM-SEABROOK MD 20703.

              WE ARE THE PRIMARY PAYER AND HAVE PAID AT THE PRIMARY RATE.
              YOU MUST CONTACT THE PATIENT'S OTHER INSURER TO REFUND ANY
MA17          EXCESS IT MAY HAVE PAID DUE TO ITS ERRONEOUS PRIMARY PAYMENT.
              ALERT: THE CLAIM INFORMATION IS ALSO BEING FORWARDED TO THE
              PATIENT'S SUPPLEMENTAL INSURER. SEND ANY QUESTIONS
MA18          REGARDING SUPPLEMENTAL BENEFITS TO THEM.                            Modified 4/1/07.
              ALERT: INFORMATION WAS NOT SENT TO THE MEDIGAP INSURER DUE
              TO INCORRECT/INVALID INFORMATION YOU SUBMITTED CONCERNING
              THAT INSURER. PLEASE VERIFY YOUR INFORMATION AND SUBMIT YOUR
MA19          SECONDARY CLAIM DIRECTLY TO THAT INSURER.                           Modified 4/1/07.
              SKILLED NURSING FACILITY (SNF) STAY NOT COVERED WHEN CARE IS
              PRIMARILY RELATED TO THE USE OF AN URETHRAL CATHETER FOR
MA20          CONVENIENCE OR THE CONTROL OF INCONTINENCE.                         (Modified 6/30/03)
MA21          SSA RECORDS INDICATE MISMATCH WITH NAME AND SEX.
MA22          PAYMENT OF LESS THAN $1.00 SUPPRESSED.
MA23          DEMAND BILL APPROVED AS RESULT OF MEDICAL REVIEW.
              CHRISTIAN SCIENCE SANITARIUM/SKILLED NURSING FACILITY (SNF) BILL
MA24          IN THE SAME BENEFIT PERIOD.                                      (Modified 6/30/03)
              A PATIENT MAY NOT ELECT TO CHANGE A HOSPICE PROVIDER MORE
MA25          THAN ONCE IN A BENEFIT PERIOD.
              ALERT: OUR RECORDS INDICATE THAT YOU WERE PREVIOUSLY
MA26          INFORMED OF THIS RULE.                                           Modified 4/1/07.
              MISSING/INCOMPLETE/INVALID ENTITLEMENT NUMBER OR NAME SHOWN
MA27          ON THE CLAIM.                                                    (Modified 2/28/03)
              ALERT: RECEIPT OF THIS NOTICE BY A PHYSICIAN OR SUPPLIER WHO
              DID NOT ACCEPT ASSIGNMENT IS FOR INFORMATION ONLY AND DOES
              NOT MAKE THE PHYSICIAN OR SUPPLIER A PARTY TO THE
              DETERMINATION. NO ADDITIONAL RIGHTS TO APPEAL THIS DECISION,
              ABOVE THOSE RIGHTS ALREADY PROVIDED FOR BY
              REGULATION/INSTRUCTION, ARE CONFERRED BY RECEIPT OF THIS
MA28          NOTICE.                                                             Modified 4/1/07.
              MISSING/INCOMPLETE/INVALID PROVIDER NAME, CITY, STATE, OR ZIP
MA29          CODE.                                                               (Modified 2/28/03)



5/16/2012                                          Page 84
                                     835 Remittance Remark Master


835 REMIT
REMARK CODE   835 REMITTANCE REMARK CODE                                      NOTES
MA30          MISSING/INCOMPLETE/INVALID TYPE OF BILL.                        (Modified 2/28/03)
              MISSING/INCOMPLETE/INVALID BEGINNING AND ENDING DATES OF THE
MA31          PERIOD BILLED.                                                  (Modified 2/28/03)
              MISSING/INCOMPLETE/INVALID NUMBER OF COVERED DAYS DURING THE
MA32          BILLING PERIOD.                                                 (Modified 2/28/03)
              MISSING/INCOMPLETE/INVALID NONCOVERED DAYS DURING THE BILLING
MA33          PERIOD.                                                         (Modified 2/28/03)
              MISSING/INCOMPLETE/INVALID NUMBER OF COINSURANCE DAYS
MA34          DURING THE BILLING PERIOD.                                      (Modified 2/28/03)
MA35          MISSING/INCOMPLETE/INVALID NUMBER OF LIFETIME RESERVE DAYS.     (Modified 2/28/03)
MA36          MISSING/INCOMPLETE/INVALID PATIENT NAME.                        (Modified 2/28/03)
MA37          MISSING/INCOMPLETE/INVALID PATIENT'S ADDRESS.                   (Modified 2/28/03)
MA38          MISSING/INCOMPLETE/INVALID BIRTH DATE.                          (Modified 2/28/03)
MA39          MISSING/INCOMPLETE/INVALID GENDER.                              (Modified 2/28/03)
MA40          MISSING/INCOMPLETE/INVALID ADMISSION DATE.                      (Modified 2/28/03)
MA41          MISSING/INCOMPLETE/INVALID ADMISSION TYPE.                      (Modified 2/28/03)
MA42          MISSING/INCOMPLETE/INVALID ADMISSION SOURCE.                    (Modified 2/28/03)
MA43          MISSING/INCOMPLETE/INVALID PATIENT STATUS.                      (Modified 2/28/03)
MA44          ALERT: NO APPEAL RIGHTS. ADJUDICATIVE DECISION BASED ON LAW.    Modified 4/1/07.
              ALERT: AS PREVIOUSLY ADVISED, A PORTION OR ALL OF YOUR
MA45          PAYMENT IS BEING HELD IN A SPECIAL ACCOUNT.                     Modified 4/1/07.
              THE NEW INFORMATION WAS CONSIDERED, HOWEVER, ADDITIONAL
              PAYMENT CANNOT BE ISSUED. PLEASE REVIEW THE INFORMATION
MA46          LISTED FOR THE EXPLANATION.
              OUR RECORDS SHOW YOU HAVE OPTED OUT OF MEDICARE, AGREEING
              WITH THE PATIENT NOT TO BILL MEDICARE FOR
              SERVICES/TESTS/SUPPLIES FURNISHED. AS RESULT, WE CANNOT PAY
MA47          THIS CLAIM. THE PATIENT IS RESPONSIBLE FOR PAYMENT.
              MISSING/INCOMPLETE/INVALID NAME OR ADDRESS OF RESPONSIBLE
MA48          PARTY OR PRIMARY PAYER.                                         (Modified 2/28/03)
                                                                              (Modified 2/28/03.
              MISSING/INCOMPLETE/INVALID SIX-DIGIT PROVIDER IDENTIFIER FOR    Deactivated eff.
              HOME HEALTH AGENCY OR HOSPICE FOR PHYSICIAN(S) PERFORMING       8/1/04. Refer to
MA49          CARE PLAN OVERSIGHT SERVICES.                                   MA76)
              MISSING/INCOMPLETE/INVALID INVESTIGATIONAL DEVICE EXEMPTION
MA50          NUMBER FOR FDA-APPROVED CLINICAL TRIAL SERVICES.                (Modified 2/28/03)
                                                                              Deactivated eff.
              MISSING/INCOMPLETE/INVALID CLIA CERTIFICATION NUMBER FOR        02/05/05. Refer to
MA51          LABORATORY SERVICES BILLED BY PHYSICIAN OFFICE LABORATORY.      MA120.
                                                                              Deactivated eff.
MA52          MISSING/INCOMPLETE/INVALID DATE.                                06/02/05.
              MISSING/INCOMPLETE/INVALID COMPETITIVE BIDDING DEMONSTRATION
MA53          PROJECT IDENTIFICATION.                                         (Modified 2/1/04)
              PHYSICIAN CERTIFICATION OR ELECTION CONSENT FOR HOSPICE CARE
MA54          NOT RECEIVED TIMELY.
              NOT COVERED AS PATIENT RECEIVED MEDICAL HEALTH CARE
              SERVICES, AUTOMATICALLY REVOKING HIS/HER ELECTION TO RECEIVE
MA55          RELIGIOUS NON-MEDICAL HEALTH CARE SERVICES.
              OUR RECORDS SHOW YOU HAVE OPTED OUT OF MEDICARE, AGREEING
              WITH THE PATIENT NOT TO BILL MEDICARE FOR
              SERVICES/TESTS/SUPPLIES FURNISHED. AS RESULT, WE CANNOT PAY
              THIS CLAIM. THE PATIENT IS RESPONSIBLE FOR PAYMENT, BUT UNDER
              FEDERAL LAW, YOU CANNOT CHARGE THE PATIENT MORE THAN THE
MA56          LIMITING CHARGE AMOUNT.
              PATIENT SUBMITTED WRITTEN REQUEST TO REVOKE HIS/HER ELECTION
MA57          FOR RELIGIOUS NON-MEDICAL HEALTH CARE SERVICES.



5/16/2012                                        Page 85
                                      835 Remittance Remark Master


835 REMIT
REMARK CODE   835 REMITTANCE REMARK CODE                                        NOTES
MA58          MISSING/INCOMPLETE/INVALID RELEASE OF INFORMATION INDICATOR.      (Modified 2/28/03)
              ALERT: THE PATIENT OVERPAID YOU FOR THESE SERVICES. YOU MUST
              ISSUE THE PATIENT A REFUND WITHIN 30 DAYS FOR THE DIFFERENCE
              BETWEEN HIS/HER PAYMENT AND THE TOTAL AMOUNT SHOWN AS
MA59          PATIENT RESPONSIBILITY ON THIS NOTICE.                            Modified 4/1/07.
MA60          MISSING/INCOMPLETE/INVALID PATIENT RELATIONSHIP TO INSURED.       (Modified 2/28/03)
              MISSING/INCOMPLETE/INVALID SOCIAL SECURITY NUMBER OR HEALTH
MA61          INSURANCE CLAIM NUMBER.                                           (Modified 2/28/03)
MA62          ALERT: THIS IS A TELEPHONE REVIEW DECISION.                       Modified 8/1/07.
MA63          MISSING/INCOMPLETE/INVALID PRINCIPAL DIAGNOSIS.                   (Modified 2/28/03)
              OUR RECORDS INDICATE THAT WE SHOULD BE THE THIRD PAYER FOR
              THIS CLAIM. WE CANNOT PROCESS THIS CLAIM UNTIL WE HAVE
              RECEIVED PAYMENT INFORMATION FROM THE PRIMARY AND
MA64          SECONDARY PAYERS.
MA65          MISSING/INCOMPLETE/INVALID ADMITTING DIAGNOSIS.                   (Modified 2/28/03)
MA66          MISSING/INCOMPLETE/INVALID PRINCIPAL PROCEDURE CODE.              (Modified 12/2/04)
MA67          CORRECTION TO A PRIOR CLAIM.
              ALERT: WE DID NOT CROSSOVER THIS CLAIM BECAUSE THE
              SECONDARY INSURANCE INFORMATION ON THE CLAIM WAS
              INCOMPLETE. PLEASE SUPPLY COMPLETE INFORMATION OR USE THE
              PLANID OF THE INSURER TO ASSURE CORRECT AND TIMELY ROUTING
MA68          OF THE CLAIM.
MA69          MISSING/INCOMPLETE/INVALID REMARKS.                               (Modified 2/28/03)
MA70          MISSING/INCOMPLETE/INVALID PROVIDER REPRESENTATIVE SIGNATURE. (Modified 2/28/03)
              MISSING/INCOMPLETE/INVALID PROVIDER REPRESENTATIVE SIGNATURE
MA71          DATE.                                                         (Modified 2/28/03)
              ALERT: THE PATIENT OVERPAID YOU FOR THESE ASSIGNED SERVICES.
              YOU MUST ISSUE THE PATIENT A REFUND WITHIN 30 DAYS FOR THE
              DIFFERENCE BETWEEN HIS/HER PAYMENT TO YOU AND THE TOTAL OF
              THE AMOUNT SHOWN AS PATIENT RESPONSIBILITY AND AS PAID TO THE
MA72          PATIENT ON THIS NOTICE.                                       Modified 4/1/07.
              INFORMATIONAL REMITTANCE ASSOCIATED WITH A MEDICARE
              DEMONSTRATION. NO PAYMENT ISSUED UNDER FEE-FOR-SERVICE
MA73          MEDICARE AS PATIENT HAS ELECTED MANAGED CARE.
              THIS PAYMENT REPLACES AN EARLIER PAYMENT FOR THIS CLAIM THAT
MA74          WAS EITHER LOST, DAMAGED OR RETURNED.
              MISSING/INCOMPLETE/INVALID PATIENT OR AUTHORIZED
MA75          REPRESENTATIVE SIGNATURE.                                         (Modified 2/28/03)
              MISSING/INCOMPLETE/INVALID PROVIDER IDENTIFIER FOR HOME
              HEALTH AGENCY OR HOSPICE WHEN PHYSICIAN IS PERFORMING CARE        (Modified 2/28/03,
MA76          PLAN OVERSIGHT SERVICES.                                          2/1/04)
              ALERT: THE PATIENT OVERPAID YOU. YOU MUST ISSUE THE PATIENT A
              REFUND WITHIN 30 DAYS FOR THE DIFFERENCE BETWEEN THE
              PATIENT’S PAYMENT LESS THE TOTAL OF OUR AND OTHER PAYER
              PAYMENTS AND THE AMOUNT SHOWN AS PATIENT RESPONSIBILITY ON
MA77          THIS NOTICE.                                                      Modified 4/1/07.
              THE PATIENT OVERPAID YOU. YOU MUST ISSUE THE PATIENT A REFUND (Deactivated eff.
              WITHIN 30 DAYS FOR THE DIFFERENCE BETWEEN OUR ALLOWED         1/31/2004. Refer to
MA78          AMOUNT TOTAL AND THE AMOUNT PAID BY THE PATIENT.              MA59)
MA79          BILLED IN EXCESS OF INTERIM RATE.
              INFORMATIONAL NOTICE. NO PAYMENT ISSUED FOR THIS CLAIM WITH
              THIS NOTICE. PAYMENT ISSUED TO THE HOSPITAL BY ITS INTERMEDIARY
              FOR ALL SERVICES FOR THIS ENCOUNTER UNDER A DEMONSTRATION
MA80          PROJECT.
MA81          MISSING/INCOMPLETE/INVALID PROVIDER/SUPPLIER SIGNATURE.           (Modified 2/28/03)




5/16/2012                                         Page 86
                                      835 Remittance Remark Master


835 REMIT
REMARK CODE   835 REMITTANCE REMARK CODE                                        NOTES
              MISSING/INCOMPLETE/INVALID PROVIDER/SUPPLIER BILLING
              NUMBER/IDENTIFIER OR BILLING NAME, ADDRESS, CITY, STATE, ZIP      Deactivated eff.
MA82          CODE, OR PHONE NUMBER.                                            6/2/05.
              DID NOT INDICATE WHETHER WE ARE THE PRIMARY OR SECONDARY
MA83          PAYER.                                                            Modified 8/1/05.
              PATIENT IDENTIFIED AS PARTICIPATING IN THE NATIONAL EMPHYSEMA
              TREATMENT TRIAL BUT OUR RECORDS INDICATE THAT THIS PATIENT IS
              EITHER NOT A PARTICIPANT, OR HAS NOT YET BEEN APPROVED FOR
              THIS PHASE OF THE STUDY. CONTACT JOHNS HOPKINS UNIVERSITY,
              THE STUDY COORDINATOR, TO RESOLVE IF THERE WAS A
MA84          DISCREPANCY.
              OUR RECORDS INDICATE THAT A PRIMARY PAYER EXISTS (OTHER THAN
              OURSELVES); HOWEVER, YOU DID NOT COMPLETE OR ENTER                (Deactivated eff.
              ACCURATELY THE INSURANCE PLAN/GROUP/PROGRAM NAME OR               8/1/04. Refer to
MA85          IDENTIFICATION NUMBER. ENTER THE PLANID WHEN EFFECTIVE.           MA92)
                                                                                (Modified 2/28/03.
                                                                                Deactivated eff.
              MISSING/INCOMPLETE/INVALID GROUP OR POLICY NUMBER OF THE          8/1/04. Refer to
MA86          INSURED FOR THE PRIMARY COVERAGE.                                 MA92)
                                                                                (Modified 2/28/03.
                                                                                Deactivated eff.
              MISSING/INCOMPLETE/INVALID INSURED'S NAME FOR THE PRIMARY         8/1/04. Refer to
MA87          PAYER.                                                            MA92)
              MISSING/INCOMPLETE/INVALID INSURED'S ADDRESS AND/OR
MA88          TELEPHONE NUMBER FOR THE PRIMARY PAYER.                           (Modified 2/28/03)
              MISSING/INCOMPLETE/INVALID PATIENT'S RELATIONSHIP TO THE
MA89          INSURED FOR THE PRIMARY PAYER.                                    (Modified 2/28/03)
              MISSING/INCOMPLETE/INVALID EMPLOYMENT STATUS CODE FOR THE
MA90          PRIMARY INSURED.                                                  (Modified 2/28/03)
MA91          THIS DETERMINATION IS THE RESULT OF THE APPEAL YOU FILED.
              MISSING/INCOMPLETE/INVALID PLAN INFORMATION FOR OTHER             (Modified 2/28/03,
MA92          INSURANCE.                                                        2/1/04)
MA93          NON-PIP (PERIODIC INTERIM PAYMENT) CLAIM.                         (Modified 6/30/03)
              DID NOT ENTER THE STATEMENT “ATTENDING PHYSICIAN NOT HOSPICE
              EMPLOYEE” ON THE CLAIM TO CERTIFY THAT THE RENDERING
MA94          PHYSICIAN IS NOT AN EMPLOYEE OF THE HOSPICE.                      Modified 8/1/05.
MA95          DE-ACTIVATE AND REFER TO M51.                                     (Modified 2/28/03)
              CLAIM REJECTED. CODED AS A MEDICARE MANAGED CARE
              DEMONSTRATION BUT PATIENT IS NOT ENROLLED IN A MEDICARE
MA96          MANAGED CARE PLAN.
              MISSING/INCOMPLETE/INVALID MEDICARE MANAGED CARE
MA97          DEMONSTRATION CONTRACT NUMBER.                                    (Modified 2/28/03)
              CLAIM REJECTED. DOES NOT CONTAIN THE CORRECT MEDICARE             (Deactivated eff.
              MANAGED CARE DEMONSTRATION CONTRACT NUMBER FOR THIS               10/16/2003. Refer
MA98          BENEFICIARY.                                                      to MA 97)
MA99          MISSING/INCOMPLETE/INVALID MEDIGAP INFORMATION.                   (Modified 2/28/03)
              MISSING/INCOMPLETE/INVALID DATE OF CURRENT ILLNESS, INJURY OR
MA100         PREGNANCY.                                                        (Modified 2/28/03)
              A SKILLED NURSING FACILITY (SNF) IS RESPONSIBLE FOR PAYMENT OF
              OUTSIDE PROVIDERS WHO FURNISH THESE SERVICES/SUPPLIES TO
MA101         RESIDENTS.                                                        (Modified 6/30/03)
                                                                             (Modified 2/28/03.
                                                                             Deactivated eff.
              MISSING/INCOMPLETE/INVALID NAME OR PROVIDER IDENTIFIER FOR THE 8/1/04. Refer to
MA102         RENDERING/REFERRING/ORDERING/SUPERVISING PROVIDER.             M68)
MA103         HEMOPHILIA ADD ON.




5/16/2012                                         Page 87
                                     835 Remittance Remark Master


835 REMIT
REMARK CODE   835 REMITTANCE REMARK CODE                                      NOTES
                                                                              (Modified 2/28/03.
                                                                              Deactivated eff.
              MISSING/INCOMPLETE/INVALID DATE THE PATIENT WAS LAST SEEN OR    1/31/2004. Use
MA104         THE PROVIDER IDENTIFIER OF THE ATTENDING PHYSICIAN.             M128 or M57)
              MISSING/INCOMPLETE/INVALID PROVIDER NUMBER FOR THIS PLACE OF
MA105         SERVICE.                                                        (Modified 2/28/03)
MA106         PIP (PERIODIC INTERIM PAYMENT) CLAIM.                           (Modified 6/30/03)
              PAPER CLAIM CONTAINS MORE THAN THREE SEPARATE DATA ITEMS IN
MA107         FIELD 19.
MA108         PAPER CLAIM CONTAINS MORE THAN ONE DATA ITEM IN FIELD 23.
              CLAIM PROCESSED IN ACCORDANCE WITH AMBULATORY SURGICAL
MA109         GUIDELINES.
              MISSING/INCOMPLETE/INVALID INFORMATION ON WHETHER THE
              DIAGNOSTIC TEST(S) WERE PERFORMED BY AN OUTSIDE ENTITY OR IF
MA110         NO PURCHASED TESTS ARE INCLUDED ON THE CLAIM.                   (Modified 2/28/03)
              MISSING/INCOMPLETE/INVALID PURCHASE PRICE OF THE TEST(S)
MA111         AND/OR THE PERFORMING LABORATORY'S NAME AND ADDRESS.            (Modified 2/28/03)
MA112         MISSING/INCOMPLETE/INVALID GROUP PRACTICE INFORMATION.          (Modified 2/28/03)
              INCOMPLETE/INVALID TAXPAYER IDENTIFICATION NUMBER (TIN)
              SUBMITTED BY YOU PER THE INTERNAL REVENUE SERVICE. YOUR
              CLAIMS CANNOT BE PROCESSED WITHOUT YOUR CORRECT TIN, AND
              YOU MAY NOT BILL THE PATIENT PENDING CORRECTION OF YOUR TIN.
              THERE ARE NO APPEAL RIGHTS FOR UNPROCESSABLE CLAIMS, BUT
              YOU MAY RESUBMIT THIS CLAIM AFTER YOU HAVE NOTIFIED THIS
MA113         OFFICE OF YOUR CORRECT TIN.
              MISSING/INCOMPLETE/INVALID INFORMATION ON WHERE THE SERVICES
MA114         WERE FURNISHED.                                                 (Modified 2/28/03)
              MISSING/INCOMPLETE/INVALID PHYSICAL LOCATION (NAME AND
              ADDRESS, OR PIN) WHERE THE SERVICE(S) WERE RENDERED IN A
MA115         HEALTH PROFESSIONAL SHORTAGE AREA (HPSA).                       (Modified 2/28/03)
              DID NOT COMPLETE THE STATEMENT "HOMEBOUND" ON THE CLAIM TO
              VALIDATE WHETHER LABORATORY SERVICES WERE PERFORMED AT
MA116         HOME OR IN AN INSTITUTION.                                      (Reactivated 4/1/04)
MA117         THIS CLAIM HAS BEEN ASSESSED A $1.00 USER FEE.
              COINSURANCE AND/OR DEDUCTIBLE AMOUNTS APPLY TO A CLAIM FOR
              SERVICES OR SUPPLIES FURNISHED TO A MEDICARE-ELIGIBLE VETERAN
              THROUGH A FACILITY OF THE DEPARTMENT OF VETERANS AFFAIRS. NO
MA118         MEDICARE PAYMENT ISSUED.
                                                                              Deactivated eff.
              PROVIDER LEVEL ADJUSTMENT FOR LATE CLAIM FILING APPLIES TO      5/1/08. Refer to
MA119         THIS CLAIM.                                                     Reason Code B4.
MA120         MISSING/INCOMPLETE/INVALID CLIA CERTIFICATION NUMBER.           (Modified 2/28/03)
                                                                              (Modified 2/28/03,
MA121         MISSING/INCOMPLETE/INVALID X-RAY DATE.                          6/30/03, 2/1/04)
                                                                              (Modified 2/28/03,
MA122         MISSING/INCOMPLETE/INVALID INITIAL TREATMENT DATE.              12/2/04)
              YOUR CENTER WAS NOT SELECTED TO PARTICIPATE IN THIS STUDY,
MA123         THEREFORE, WE CANNOT PAY FOR THESE SERVICES.

                                                                              (Deactivated eff.
                                                                              1/31/2004. Refer to
MA124         PROCESSED FOR IME ONLY.                                         Reason Code 74)
              PER LEGISLATION GOVERNING THIS PROGRAM, PAYMENT CONSTITUTES
MA125         PAYMENT IN FULL.
              PANCREAS TRANSPLANT NOT COVERED UNLESS KIDNEY TRANSPLANT    (New Code
MA126         PERFORMED.                                                  10/12/01)




5/16/2012                                        Page 88
                                      835 Remittance Remark Master


835 REMIT
REMARK CODE   835 REMITTANCE REMARK CODE                                      NOTES
                                                                              Deactivated eff.
MA127         RESERVED FOR FUTURE USE.                                        6/2/05.
                                                                              (Modified 2/28/03,
MA128         MISSING/INCOMPLETE/INVALID FDA APPROVAL NUMBER.                 3/30/05)
                                                                              (Modified 2/28/03.
                                                                              Deactivated eff
                                                                              1/31/2004. Refer to
              THIS PROVIDER WAS NOT CERTIFIED FOR THIS PROCEDURE ON THIS      MA120 and Reason
MA129         DATE OF SERVICE.                                                Code B7)
              YOUR CLAIM CONTAINS INCOMPLETE AND/OR INVALID INFORMATION,
              AND NO APPEAL RIGHTS ARE AFFORDED BECAUSE THE CLAIM IS
              UNPROCESSABLE. PLEASE SUBMIT A NEW CLAIM WITH THE
MA130         COMPLETE/CORRECT INFORMATION.
              PHYSICIAN ALREADY PAID FOR SERVICES IN CONJUNCTION WITH THIS
              DEMONSTRATION CLAIM. YOU MUST HAVE THE PHYSICIAN WITHDRAW
              THAT CLAIM AND REFUND THE PAYMENT BEFORE WE CAN PROCESS
MA131         YOUR CLAIM.
MA132         ADJUSTMENT TO THE PRE-DEMONSTRATION RATE.
              CLAIM OVERLAPS INPATIENT STAY. REBILL ONLY THOSE SERVICES
MA133         RENDERED OUTSIDE THE INPATIENT STAY.
              MISSING/INCOMPLETE/INVALID PROVIDER NUMBER OF THE FACILITY
MA134         WHERE THE PATIENT RESIDES.
              ALERT: YOU MAY APPEAL THIS DECISION IN WRITING WITHIN THE
              REQUIRED TIME LIMITS FOLLOWING RECEIPT OF THIS NOTICE BY
              FOLLOWING THE INSTRUCTIONS INCLUDED IN YOUR CONTRACT OR         (Modified 2/28/03,
N1            PLAN BENEFIT DOCUMENTS.                                         4/1/07)
              THIS ALLOWANCE HAS BEEN MADE IN ACCORDANCE WITH THE MOST
N2            APPROPRIATE COURSE OF TREATMENT PROVISION OF THE PLAN.
N3            MISSING CONSENT FORM.                                           (Modified 2/28/03)
N4            MISSING/INCOMPLETE/INVALID PRIOR INSURANCE CARRIER EOB.         (Modified 2/28/03)
N5            EOB RECEIVED FROM PREVIOUS PAYER. CLAIM NOT ON FILE.
              UNDER FEHB LAW (U.S.C. 8904(B)), WE CANNOT PAY MORE FOR
              COVERED CARE THAN THE AMOUNT MEDICARE WOULD HAVE ALLOWED
              IF THE PATIENT WERE ENROLLED IN MEDICARE PART A AND/OR
N6            MEDICARE PART B.                                                (Modified 2/28/03)
              PROCESSING OF THIS CLAIM/SERVICE HAS INCLUDED CONSIDERATION
N7            UNDER MAJOR MEDICAL PROVISIONS.
              CROSSOVER CLAIM DENIED BY PREVIOUS PAYER AND COMPLETE CLAIM
              DATA NOT FORWARDED. RESUBMIT THIS CLAIM TO THIS PAYER TO
N8            PROVIDE ADEQUATE DATA FOR ADJUDICATION.
              ADJUSTMENT REPRESENTS THE ESTIMATED AMOUNT A PREVIOUS
N9            PAYER MAY PAY.                                              Modified 11/18/05.
              CLAIM/SERVICE ADJUSTED BASED ON THE FINDINGS OF A REVIEW
              ORGANIZATION/PROFESSIONAL CONSULT/MANUAL
N10           ADJUDICATION/MEDICAL OR DENTAL ADVISOR.                         (Modified 10/31/02)
N11           DENIAL REVERSED BECAUSE OF MEDICAL REVIEW.
              POLICY PROVIDES COVERAGE SUPPLEMENTAL TO MEDICARE. AS
              MEMBER DOES NOT APPEAR TO BE ENROLLED IN THE APPLICABLE PART
              OF MEDICARE, THE MEMBER RESPONSIBLE FOR PAYMENT OF THE
              PORTION OF THE CHARGE THAT WOULD HAVE BEEN COVERED BY
N12           MEDICARE.                                                    Modified 8/1/07.
              PAYMENT BASED ON PROFESSIONAL/TECHNICAL COMPONENT
N13           MODIFIER(S).
                                                                              Deactivated eff.
              PAYMENT BASED ON A CONTRACTUAL AMOUNT OR AGREEMENT, FEE         10/1/07. Refer to
N14           SCHEDULE, OR MAXIMUM ALLOWABLE AMOUNT.                          reason code 45.




5/16/2012                                       Page 89
                                       835 Remittance Remark Master


835 REMIT
REMARK CODE   835 REMITTANCE REMARK CODE                                        NOTES
N15           SERVICES FOR A NEWBORN MUST BE BILLED SEPARATELY.
              FAMILY/MEMBER OUT-OF-POCKET MAXIMUM HAS BEEN MET. PAYMENT
N16           BASED ON A HIGHER PERCENTAGE.
                                                                                (Deactivated eff.
                                                                                8/1/04. Refer to
N17           PER ADMISSION DEDUCTIBLE.                                         Reason Code 1)
                                                                                (Deactivated eff.
                                                                                1/31/2004. Refer to
N18           PAYMENT BASED ON THE MEDICARE ALLOWED AMOUNT.                     N14)
N19           PROCEDURE CODE INCIDENTAL TO PRIMARY PROCEDURE.
              SERVICE NOT PAYABLE WITH OTHER SERVICE RENDERED ON THE SAME
N20           DATE.
              ATTN: YOUR LINE ITEM HAS BEEN SEPARATED INTO MULTIPLE LINES TO
N21           EXPEDITE HANDLING.                                             Modified 4/1/07.
              THIS PROCEDURE CODE WAS ADDED/CHANGED BECAUSE IT MORE          (Modified 10/31/02,
N22           ACCURATELY DESCRIBES THE SERVICES RENDERED.                    2/28/03)
              PATIENT LIABILITY MAY BE AFFECTED DUE TO COORDINATION OF
              BENEFITS WITH OTHER CARRIERS AND/OR MAXIMUM BENEFIT
N23           PROVISIONS.                                                       (Modified 8/13/01)
              MISSING/INCOMPLETE/INVALID ELECTRONIC FUNDS TRANSFER (EFT)
N24           BANKING INFORMATION.                                              (Modified 2/28/03)
              THIS COMPANY HAS BEEN CONTRACTED BY YOUR BENEFIT PLAN TO
              PROVIDE ADMINISTRATIVE CLAIMS PAYMENT SERVICES ONLY. THIS
              COMPANY DOES NOT ASSUME FINANCIAL RISK OR OBLIGATION WITH
N25           RESPECT TO CLAIMS PROCESSED ON BEHALF OF YOUR BENEFIT PLAN.
N26           MISSING ITEMIZED BILL.                                            (Modified 2/28/03)
N27           MISSING/INCOMPLETE/INVALID TREATMENT NUMBER.                      (Modified 2/28/03)
N28           CONSENT FORM REQUIREMENTS NOT FULFILLED.
              MISSING/INCOMPLETE/INVALID                                        (Modified 2/28/03,
N29           DOCUMENTATION/ORDERS/NOTES/SUMMARY/REPORT/CHART.                  8/1/05)
N30           PATIENT INELIGIBLE FOR THIS SERVICE.                              (Modified 6/30/03)
                                                                                (Modified 2/28/03,
N31           MISSING/INCOMPLETE/INVALID PRESCRIBING PROVIDER IDENTIFIER.       12/2/04)
              CLAIM MUST BE SUBMITTED BY THE PROVIDER WHO RENDERED THE
N32           SERVICE.                                                          (Modified 6/30/03)
N33           NO RECORD OF HEALTH CHECK PRIOR TO INITIATION OF TREATMENT.
N34           INCORRECT CLAIM FORM/FORMAT FOR THIS SERVICE.                     Modified 11/18/05.
N35           PROGRAM INTEGRITY/UTILIZATION REVIEW DECISION.
              CLAIM MUST MEET PRIMARY PAYER’S PROCESSING REQUIREMENTS
N36           BEFORE WE CAN CONSIDER PAYMENT.
N37           MISSING/INCOMPLETE/INVALID TOOTH NUMBER/LETTER.                   (Modified 2/28/03)
                                                                                Deactivated eff.
                                                                                2/5/05. Refer to
N38           MISSING/INCOMPLETE/INVALID PLACE OF SERVICE.                      M77.
N39           PROCEDURE CODE IS NOT COMPATIBLE WITH TOOTH NUMBER/LETTER.
                                                                                (Modified 2/28/03,
N40           MISSING X-RAY.                                                    6/30/03, 2/1/04)

                                                                                (Deactivated eff.
                                                                                10/16/2003. Refer
N41           AUTHORIZATION REQUEST DENIED.                                     to Reason Code 39)
N42           NO RECORD OF MENTAL HEALTH ASSESSMENT.
N43           BED HOLD OR LEAVE DAYS EXCEEDED.




5/16/2012                                            Page 90
                                     835 Remittance Remark Master


835 REMIT
REMARK CODE   835 REMITTANCE REMARK CODE                                       NOTES
                                                                               (Deactivated eff.
              PAYER’S SHARE OF REGULATORY SURCHARGES, ASSESSMENTS,             10/16/2003. Refer
              ALLOWANCES OR HEALTH CARE-RELATED TAXES PAID DIRECTLY TO         to Reason Code
N44           THE REGULATORY AUTHORITY.                                        137)
N45           PAYMENT BASED ON AUTHORIZED AMOUNT.
N46           MISSING/INCOMPLETE/INVALID ADMISSION HOUR.
N47           CLAIM CONFLICTS WITH ANOTHER INPATIENT STAY.
              CLAIM INFORMATION DOES NOT AGREE WITH INFORMATION RECEIVED
N48           FROM OTHER INSURANCE CARRIER.
N49           COURT ORDERED COVERAGE INFORMATION NEEDS VALIDATION.
N50           MISSING/INCOMPLETE/INVALID DISCHARGE INFORMATION.                (Modified 2/28/03)
              ELECTRONIC INTERCHANGE AGREEMENT NOT ON FILE FOR
N51           PROVIDER/SUBMITTER.
              PATIENT NOT ENROLLED IN THE BILLING PROVIDER'S MANAGED CARE
N52           PLAN ON THE DATE OF SERVICE.
N53           MISSING/INCOMPLETE/INVALID POINT OF PICK-UP ADDRESS.             (Modified 2/28/03)
              CLAIM INFORMATION IS INCONSISTENT WITH PRE-
N54           CERTIFIED/AUTHORIZED SERVICES.
              PROCEDURES FOR BILLING WITH GROUP/REFERRING/PERFORMING
N55           PROVIDERS WERE NOT FOLLOWED.
              PROCEDURE CODE BILLED IS NOT CORRECT/VALID FOR THE SERVICES
N56           BILLED OR THE DATE OF SERVICE BILLED.                            (Modified 2/28/03)
                                                                               (Modified 2/28/03,
N57           MISSING/INCOMPLETE/INVALID PRESCRIBING DATE.                     12/2/04)
N58           MISSING/INCOMPLETE/INVALID PATIENT LIABILITY AMOUNT.             (Modified 2/28/03)
              ATTN: PLEASE REFER TO YOUR PROVIDER MANUAL FOR ADDITIONAL
N59           PROGRAM AND PROVIDER INFORMATION.                                Modified 4/1/07.
                                                                               (Deactivated eff.
              A VALID NDC IS REQUIRED FOR PAYMENT OF DRUG CLAIMS EFFECTIVE     1/31/2004. Refer to
N60           OCTOBER 02.                                                      M119)
N61           REBILL SERVICES ON SEPARATE CLAIMS.
              INPATIENT ADMISSION SPANS MULTIPLE RATE PERIODS. RESUBMIT
N62           SEPARATE CLAIMS.
N63           REBILL SERVICES ON SEPARATE CLAIM LINES.
N64           THE “FROM” AND “TO” DATES MUST BE DIFFERENT.
              PROCEDURE CODE OR PROCEDURE RATE COUNT CANNOT BE
              DETERMINED, OR WAS NOT ON FILE, FOR THE DATE OF
N65           SERVICE/PROVIDER.                                                (Modified 2/28/03)
                                                                               Deactivated eff.
                                                                               2/5/05. Refer to N29
N66           MISSING/INCOMPLETE/INVALID DOCUMENTATION.                        or N225.

              PROFESSIONAL PROVIDER SERVICES NOT PAID SEPARATELY.
              INCLUDED IN FACILITY PAYMENT UNDER A DEMONSTRATION PROJECT.
              APPLY TO THAT FACILITY FOR PAYMENT, OR RESUBMIT YOUR CLAIM IF:
              THE FACILITY NOTIFIES YOU THE PATIENT WAS EXCLUDED FROM THIS
              DEMONSTRATION; OR IF YOU FURNISHED THESE SERVICES IN ANOTHER
              LOCATION ON THE DATE OF THE PATIENT’S ADMISSION OR DISCHARGE
              FROM A DEMONSTRATION HOSPITAL. IF SERVICES WERE FURNISHED IN
              A FACILITY NOT INVOLVED IN THE DEMONSTRATION ON THE SAME DATE
              THE PATIENT WAS DISCHARGED FROM OR ADMITTED TO A
              DEMONSTRATION FACILITY, YOU MUST REPORT THE PROVIDER ID
N67           NUMBER FOR THE NON-DEMONSTRATION FACILITY ON THE NEW CLAIM.




5/16/2012                                        Page 91
                                      835 Remittance Remark Master


835 REMIT
REMARK CODE   835 REMITTANCE REMARK CODE                                         NOTES
              PRIOR PAYMENT BEING CANCELLED AS WE WERE SUBSEQUENTLY
              NOTIFIED THIS PATIENT WAS COVERED BY A DEMONSTRATION PROJECT
              IN THIS SITE OF SERVICE. PROFESSIONAL SERVICES WERE INCLUDED
              IN THE PAYMENT MADE TO THE FACILITY. YOU MUST CONTACT THE
              FACILITY FOR YOUR PAYMENT. PRIOR PAYMENT MADE TO YOU BY THE
              PATIENT OR ANOTHER INSURER FOR THIS CLAIM MUST BE REFUNDED
N68           TO THE PAYER WITHIN 30 DAYS.
              PPS (PROSPECTIVE PAYMENT SYSTEM) CODE CHANGED BY CLAIMS
N69           PROCESSING SYSTEM. INSUFFICIENT VISITS OR THERAPIES.         (Modified 6/30/03)
                                                                           (Modified 2/28/02,
N70           CONSOLIDATED BILLING AND PAYMENT APPLIES.                    11/5/07)
              YOUR UNASSIGNED CLAIM FOR A DRUG OR BIOLOGICAL, CLINICAL
              DIAGNOSTIC LABORATORY SERVICES OR AMBULANCE SERVICE WAS
              PROCESSED AS AN ASSIGNED CLAIM. YOU ARE REQUIRED BY LAW TO         (Modified 2/21/02,
N71           ACCEPT ASSIGNMENT FOR THESE TYPES OF CLAIMS.                       6/30/03)
              PPS (PROSPECTIVE PAYMENT SYSTEM) CODE CHANGED BY MEDICAL
N72           REVIEWERS. NOT SUPPORTED BY CLINICAL RECORDS.                      (Modified 6/30/03)
                                                                          (Modified 7/24/01,
                                                                          2/28/03.
              A SKILLED NURSING FACILITY IS RESPONSIBLE FOR PAYMENT OF    Deactivated eff.
              OUTSIDE PROVIDERS WHO FURNISH THESE SERVICES/SUPPLIES UNDER 1/31/04. Refer to
N73           ARRANGEMENT TO ITS RESIDENTS.                               MA101 and N200)
              RESUBMIT WITH MULTIPLE CLAIMS, EACH CLAIM COVERING SERVICES
N74           PROVIDED IN ONLY ONE CALENDAR MONTH.
N75           MISSING/INCOMPLETE/INVALID TOOTH SURFACE INFORMATION.              (Modified 2/28/03)
N76           MISSING/INCOMPLETE/INVALID NUMBER OF RIDERS.                       (Modified 2/28/03)
N77           MISSING/INCOMPLETE/INVALID DESIGNATED PROVIDER NUMBER.             (Modified 2/28/03)
              THE NECESSARY COMPONENTS OF THE CHILD AND TEEN CHECKUP
N78           (EPSDT) WERE NOT COMPLETED.
              SERVICE BILLED IS NOT COMPATIBLE WITH PATIENT LOCATION
N79           INFORMATION.
N80           MISSING/INCOMPLETE/INVALID PRENATAL SCREENING INFORMATION.         (Modified 2/28/03)
N81           PROCEDURE BILLED IS NOT COMPATIBLE WITH TOOTH SURFACE CODE.
              PROVIDER MUST ACCEPT INSURANCE PAYMENT AS PAYMENT IN FULL
              WHEN A THIRD PARTY PAYER CONTRACT SPECIFIES FULL
N82           REIMBURSEMENT.
              NO APPEAL RIGHTS. ADJUDICATIVE DECISION BASED ON THE
N83           PROVISIONS OF A DEMONSTRATION PROJECT.
N84           ALERT: FURTHER INSTALLMENT PAYMENTS FORTHCOMING.                   Modified 8/1/07
N85           ALERT: THIS IS THE FINAL INSTALLMENT PAYMENT.                      Modified 8/1/07
              A FAILED TRIAL OF PELVIC MUSCLE EXERCISE TRAINING IS REQUIRED IN
              ORDER FOR BIOFEEDBACK TRAINING FOR THE TREATMENT OF URINARY
N86           INCONTINENCE TO BE COVERED.
N87           HOME USE OF BIOFEEDBACK THERAPY IS NOT COVERED.
              ALERT: THIS PAYMENT IS BEING MADE CONDITIONALLY. AN HHA
              EPISODE OF CARE NOTICE HAS BEEN FILED FOR THIS PATIENT. WHEN A
              PATIENT IS TREATED UNDER A HHA EPISODE OF CARE, CONSOLIDATED
              BILLING REQUIRES THAT CERTAIN THERAPY SERVICES AND SUPPLIES,
              SUCH AS THIS, BE INCLUDED IN THE HHA'S PAYMENT. THIS PAYMENT
              WILL NEED TO BE RECOUPED FROM YOU IF WE ESTABLISH THAT THE
              PATIENT IS CONCURRENTLY RECEIVING TREATMENT UNDER A HHA
N88           EPISODE OF CARE.                                                   Modified 4/1/07.
              ALERT: PAYMENT INFORMATION FOR THIS CLAIM HAS BEEN
              FORWARDED TO MORE THAN ONE OTHER PAYER, BUT FORMAT
              LIMITATIONS PERMIT ONLY ONE OF THE SECONDARY PAYERS TO BE
N89           IDENTIFIED IN THIS REMITTANCE ADVICE.                              Modified 4/1/07.



5/16/2012                                        Page 92
                                     835 Remittance Remark Master


835 REMIT
REMARK CODE   835 REMITTANCE REMARK CODE                                       NOTES
N90           COVERED ONLY WHEN PERFORMED BY THE ATTENDING PHYSICIAN.
N91           SERVICES NOT INCLUDED IN THE APPEAL REVIEW.
N92           THIS FACILITY IS NOT CERTIFIED FOR DIGITAL MAMMOGRAPHY.
              A SEPARATE CLAIM MUST BE SUBMITTED FOR EACH PLACE OF SERVICE.
              SERVICES FURNISHED AT MULTIPLE SITES MAY NOT BE BILLED IN THE
N93           SAME CLAIM.
              CLAIM/SERVICE DENIED BECAUSE A MORE SPECIFIC TAXONOMY CODE
N94           IS REQUIRED FOR ADJUDICATION.

              THIS PROVIDER TYPE/PROVIDER SPECIALTY MAY NOT BILL THIS          (New code 7/31/01,
N95           SERVICE.                                                         Modified 2/28/03)
              PATIENT MUST BE REFRACTORY TO CONVENTIONAL THERAPY
              (DOCUMENTED BEHAVIORAL, PHARMACOLOGIC AND/OR SURGICAL
              CORRECTIVE THERAPY) AND BE AN APPROPRIATE SURGICAL
N96           CANDIDATE SUCH THAT IMPLANTATION WITH ANESTHESIA CAN OCCUR.      (New code 8/24/01)
              PATIENTS WITH STRESS INCONTINENCE, URINARY OBSTRUCTION, AND
              SPECIFIC NEUROLOGIC DISEASES (E.G., DIABETES WITH PERIPHERAL
              NERVE INVOLVEMENT) WHICH ARE ASSOCIATED WITH SECONDARY
N97           MANIFESTATIONS OF THE ABOVE THREE INDICATIONS ARE EXCLUDED.      (New code 8/24/01)
              PATIENT MUST HAVE HAD A SUCCESSFUL TEST STIMULATION IN ORDER
              TO SUPPORT SUBSEQUENT IMPLANTATION. BEFORE A PATIENT IS
              ELIGIBLE FOR PERMANENT IMPLANTATION, HE/SHE MUST
              DEMONSTRATE A 50 PERCENT OR GREATER IMPROVEMENT THROUGH
              TEST STIMULATION. IMPROVEMENT IS MEASURED THROUGH VOIDING
N98           DIARIES.                                                         (New code 8/24/01)
              PATIENT MUST BE ABLE TO DEMONSTRATE ADEQUATE ABILITY TO
              RECORD VOIDING DIARY DATA SUCH THAT CLINICAL RESULTS OF THE
N99           IMPLANT PROCEDURE CAN BE PROPERLY EVALUATED.                     (New code 8/24/01)

              PPS (PROSPECT PAYMENT SYSTEM) CODE CORRECTED DURING              (New code 9/14/01.
N100          ADJUDICATION.                                                    Modified 6/30/03)
              ADDITIONAL INFORMATION IS NEEDED IN ORDER TO PROCESS THIS
              CLAIM. PLEASE RESUBMIT THE CLAIM WITH THE IDENTIFICATION
              NUMBER OF THE PROVIDER WHERE THIS SERVICE TOOK PLACE. THE        (New code
              MEDICARE NUMBER OF THE SITE OF SERVICE PROVIDER SHOULD BE        10/16/01.
              PRECEDED WITH THE LETTERS "HSP" AND ENTERED INTO ITEM #32 ON     Deactivated eff.
              THE CLAIM FORM. YOU MAY BILL ONLY ONE SITE OF SERVICE PROVIDER   1/31/04. Refer to
N101          NUMBER PER CLAIM.                                                MA105))
              THIS CLAIM HAS BEEN DENIED WITHOUT REVIEWING THE MEDICAL
              RECORD BECAUSE THE REQUESTED RECORDS WERE NOT RECEIVED
N102          OR WERE NOT RECEIVED TIMELY.                                     (New code 10/31/01)

              SOCIAL SECURITY RECORDS INDICATE THAT THIS PATIENT WAS A
              PRISONER WHEN THE SERVICE WAS RENDERED. THIS PAYER DOES
              NOT COVER ITEMS AND SERVICES FURNISHED TO AN INDIVIDUAL WHILE
              THEY ARE IN STATE OR LOCAL CUSTODY UNDER A PENAL AUTHORITY,
              UNLESS UNDER STATE OR LOCAL LAW, THE INDIVIDUAL IS PERSONALLY
              LIABLE FOR THE COST OF HIS OR HER HEALTH CARE WHILE              (New code
              INCARCERATED AND THE STATE OR LOCAL GOVERNMENT PURSUES           12/05/01, Modified
              SUCH DEBT IN THE SAME WAY AND WITH THE SAME VIGOR AS ANY         4/8/02, 2/28/03,
N103          OTHER DEBT.                                                      6/30/03)
              THIS CLAIM/SERVICE IS NOT PAYABLE UNDER OUR CLAIMS
              JURISDICTION AREA. YOU CAN IDENTIFY THE CORRECT MEDICARE
              CONTRACTOR TO PROCESS THIS CLAIM/SERVICE THROUGH THE CMS         (New code 1/29/02,
N104          WEBSITE AT WWW.CMS.HHS.GOV.                                      Modified 10/31/02)




5/16/2012                                        Page 93
                                       835 Remittance Remark Master


835 REMIT
REMARK CODE   835 REMITTANCE REMARK CODE                                         NOTES
              THIS IS A MISDIRECTED CLAIM/SERVICE FOR AN RRB BENEFICIARY.
              SUBMIT PAPER CLAIMS TO THE RRB CARRIER: PALMETTO GBA, P.O. BOX
              10066, AUGUSTA, GA 30999. CALL 866-749-4301 FOR RRB EDI
N105          INFORMATION FOR ELECTRONIC CLAIMS PROCESSING.                      (New code 1/29/02)
              PAYMENT FOR SERVICES FURNISHED TO SKILLED NURSING FACILITY
              (SNF) INPATIENTS (EXCEPT FOR EXCLUDED SERVICES) CAN ONLY BE
              MADE TO THE SNF. YOU MUST REQUEST PAYMENT FROM THE SNF
N106          RATHER THAN THE PATIENT FOR THIS SERVICE.                          (New code 1/31/02)
              SERVICES FURNISHED TO SKILLED NURSING FACILITY (SNF) INPATIENTS
              MUST BE BILLED ON THE INPATIENT CLAIM. THEY CANNOT BE BILLED
N107          SEPARATELY AS OUTPATIENT SERVICES.                                 (New code 1/31/02)
N108          MISSING/INCOMPLETE/INVALID UPGRADE INFORMATION.                    (Modified 2/28/03)
              THIS CLAIM WAS CHOSEN FOR COMPLEX REVIEW AND WAS DENIED
N109          AFTER REVIEWING THE MEDICAL RECORDS.                               (New Code 2/26/02)

N110          THIS FACILITY IS NOT CERTIFIED FOR FILM MAMMOGRAPHY.               (New Code 2/28/02)
              NO APPEAL RIGHT EXCEPT DUPLICATE CLAIM/SERVICE ISSUE. THIS
              SERVICE WAS INCLUDED IN A CLAIM THAT HAS BEEN PREVIOUSLY
N111          BILLED AND ADJUDICATED.                                            (New Code 2/28/02)
              THIS CLAIM IS EXCLUDED FROM YOUR ELECTRONIC REMITTANCE
N112          ADVICE.                                                            (New Code 2/28/02)

              ONLY ONE INITIAL VISIT IS COVERED PER PHYSICIAN, GROUP PRACTICE    (New Code 4/16/02.
N113          OR PROVIDER.                                                       Modified 6/30/03)


              DURING THE TRANSITION TO THE AMBULANCE FEE SCHEDULE,
              PAYMENT IS BASED ON THE LESSER OF A BLENDED AMOUNT
              CALCULATED USING A PERCENTAGE OF THE REASONABLE
              CHARGE/COST AND FEE SCHEDULE AMOUNTS, OR THE SUBMITTED
              CHARGE FOR THE SERVICE. YOU WILL BE NOTIFIED YEARLY WHAT THE
N114          PERCENTAGES FOR THE BLENDED PAYMENT CALCULATION WILL BE.           (New Code 5/30/02)
              THIS DECISION WAS BASED ON A LOCAL MEDICAL REVIEW POLICY
              (LMRP) OR LOCAL COVERAGE DETERMINATION (LCD). AN LMRP/LCD
              PROVIDES A GUIDE TO ASSIST IN DETERMINING WHETHER A
              PARTICULAR ITEM OR SERVICE IS COVERED. A COPY OF THIS POLICY IS
              AVAILABLE AT HTTP://WWW.CMS.HHS.GOV/MCD, OR IF YOU DO NOT          (New Code 6/26/02.
              HAVE WEB ACCESS, YOU MAY CONTACT THE CONTRACTOR TO                 Modified 9/16/02,
N115          REQUEST A COPY OF THE LMRP/LCD.                                    6/30/03, 4/4/04)

              THIS PAYMENT IS BEING MADE CONDITIONALLY BECAUSE THE SERVICE
              WAS PROVIDED IN THE HOME, AND IT IS POSSIBLE THAT THE PATIENT IS
              UNDER A HOME HEALTH EPISODE OF CARE. WHEN A PATIENT IS
              TREATED UNDER A HOME HEALTH EPISODE OF CARE, CONSOLIDATED
              BILLING REQUIRES THAT CERTAIN THERAPY SERVICES AND SUPPLIES,
              SUCH AS THIS, BE INCLUDED IN THE HOME HEALTH AGENCY’S (HHA’S)
              PAYMENT. THIS PAYMENT WILL NEED TO BE RECOUPED FROM YOU IF
              WE ESTABLISH THAT THE PATIENT IS CONCURRENTLY RECEIVING
N116          TREATMENT UNDER AN HHA EPISODE OF CARE.                            (New Code 6/30/02)

                                                                                 (New Code 7/30/02.
N117          THIS SERVICE IS PAID ONLY ONCE IN A PATIENT'S LIFETIME.            Modified 6/30/03)

N118          THIS SERVICE IS NOT PAID IF BILLED MORE THAN ONCE EVERY 28 DAYS.   (New Code 7/30/02)

              THIS SERVICE IS NOT PAID IF BILLED ONCE EVERY 28 DAYS, AND THE
              PATIENT HAS SPENT 5 OR MORE CONSECUTIVE DAYS IN ANY INPATIENT      (New Code 7/30/02.
N119          OR SKILLED/NURSING FACILITY (SNF) WITHIN THOSE 28 DAYS.            Modified 6/30/03)




5/16/2012                                          Page 94
                                       835 Remittance Remark Master


835 REMIT
REMARK CODE   835 REMITTANCE REMARK CODE                                             NOTES
              PAYMENT IS SUBJECT TO HOME HEALTH PROSPECTIVE PAYMENT
              SYSTEM PARTIAL EPISODE PAYMENT ADJUSTMENT. PATIENT WAS                 (New Code 8/9/02.
N120          TRANSFERRED/DISCHARGED/READMITTED DURING PAYMENT EPISODE.              Modified 6/30/03)
              MEDICARE PART B DOES NOT PAY FOR ITEMS OR SERVICES PROVIDED            (New Code 9/9/02.
              BY THIS TYPE OF PRACTITIONER FOR BENEFICIARIES IN A MEDICARE           Modified 6/30/03,
N121          PART A COVERED SKILLED NURSING FACILITY (SNF) STAY.                    8/1/04)
                                                                                     (New Code 9/12/02,
N122          ADD-ON CODE CANNOT BE BILLED BY ITSELF.                                8/1/05)
              THIS IS A SPLIT SERVICE AND REPRESENTS A PORTION OF THE UNITS
N123          FROM THE ORIGINALLY SUBMITTED SERVICE.                                 (New Code 9/24/02)
              PAYMENT HAS BEEN DENIED FOR THE/MADE ONLY FOR A LESS
              EXTENSIVE SERVICE/ITEM BECAUSE THE INFORMATION FURNISHED
              DOES NOT SUBSTANTIATE THE NEED FOR THE (MORE EXTENSIVE)
              SERVICE/ITEM. THE PATIENT IS LIABLE FOR THE CHARGES FOR THIS
              SERVICE/ITEM AS YOU INFORMED THE PATIENT IN WRITING BEFORE THE
              SERVICE/ITEM WAS FURNISHED THAT WE WOULD NOT PAY FOR IT, AND
N124          THE PATIENT AGREED TO PAY.                                     (New Code 9/26/02)

              PAYMENT HAS BEEN (DENIED FOR THE/MADE ONLY FOR A LESS
              EXTENSIVE) SERVICE/ITEM BECAUSE THE INFORMATION FURNISHED
              DOES NOT SUBSTANTIATE THE NEED FOR THE (MORE EXTENSIVE)
              SERVICE/ITEM. IF YOU HAVE COLLECTED ANY AMOUNT FROM THE
              PATIENT, YOU MUST REFUND THAT AMOUNT TO THE PATIENT WITHIN 30
              DAYS OF RECEIVING THIS NOTICE. THE REQUIREMENTS FOR A REFUND
              ARE IN 1834(A)(18) OF THE SOCIAL SECURITY ACT (AND IN 1834(J)(4) AND
              1879(H) BY CROSS-REFERENCE TO 1834(A)(18)). SECTION 1834(A)(18)(B)
              SPECIFIES THAT SUPPLIERS WHICH KNOWINGLY AND WILLFULLY FAIL
              TO MAKE APPROPRIATE REFUNDS MAY BE SUBJECT TO CIVIL MONEY
              PENALTIES AND/OR EXLUSION FROM THE MEDICARE PROGRAM. IF YOU
              HAVE ANY QUESTIONS ABOUT THIS NOTICE, PLEASE CONTACT THIS              New Code 9/26/02,
N125          OFFICE.                                                                8/1/05)
              SOCIAL SECURITY RECORDS INDICATE THAT THIS INDIVIDUAL HAS BEEN
              DEPORTED. THIS PAYER DOES NOT COVER ITEMS AND SERVICES      (New Code
N126          FURNISHED TO INDIVIDUALS WHO HAVE BEEN DEPORTED.            10/17/02)
                                                                          (New Code
              THIS IS A MISDIRECTED CLAIM/SERVICE FOR A UNITED MINE WORKERS
N127          OF AMERICA (UMWA) BENEFICIARY. PLEASE SUBMIT CLAIMS TO THEM.10/31/02, 8/1/04)
              THIS AMOUNT REPRESENTS THE PRIOR TO COVERAGE PORTION OF THE (New Code
N128          ALLOWANCE.                                                  10/31/02)
                                                                          (New Code
N129          NOT ELIGIBLE DUE TO THE PATIENT'S AGE.                      10/31/02, 8/1/07)
              ALERT: CONSULT PLAN BENEFIT DOCUMENTS FOR INFORMATION ABOUT (New Code
N130          RESTRICTIONS FOR THIS SERVICE.                              10/31/02, 4/1/07)
              TOTAL PAYMENTS UNDER MULTIPLE CONTRACTS CANNOT EXCEED THE (New Code
N131          ALLOWANCE FOR THIS SERVICE.                                 10/31/02)
              ALERT: PAYMENTS WILL CEASE FOR SERVICES RENDERED BY THIS US
              GOVERNMENT DEBARRED OR EXCLUDED PROVIDER AFTER THE 30 DAY              (New Code
N132          GRACE PERIOD AS PREVIOUSLY NOTIFIED.                                   10/31/02, 4/1/07)
              ALERT: SERVICES FOR PREDETERMINATION AND SERVICES                      (New Code
N133          REQUESTING PAYMENT ARE BEING PROCESSED SEPARATELY.                     10/31/02, 4/1/07)
              ALERT: THIS REPRESENTS YOUR SCHEDULED PAYMENT FOR THIS
              SERVICE. IF TREATMENT HAS BEEN DISCONTINUED, PLEASE CONTACT            (New Code
N134          CUSTOMER SERVICE.                                                      10/31/02, 4/1/07)
              RECORD FEES ARE THE PATIENT'S RESPONSIBILITY AND LIMITED TO            (New Code
N135          THE SPECIFIED CO-PAYMENT.                                              10/31/02)
              ALERT: TO OBTAIN INFORMATION ON THE PROCESS TO FILE AN APPEAL
              IN ARIZONA, CALL THE DEPARTMENT'S CONSUMER ASSISTANCE OFFICE           (New Code
N136          AT (602) 912-8444 OR (800) 325-2548.                                   10/31/02, 4/1/07)




5/16/2012                                           Page 95
                                      835 Remittance Remark Master


835 REMIT
REMARK CODE   835 REMITTANCE REMARK CODE                                        NOTES
              ALERT: THE PROVIDER ACTING ON THE MEMBER'S BEHALF, MAY FILE AN
              APPEAL WITH THE PAYER. THE PROVIDER ACTING ON THE MEMBER'S
              BEHALF, MAY FILE A COMPLAINT WITH THE STATE REGULATORY
              AUTHORITY WITHOUT FIRST FILING AN APPEAL, IF THE COVERAGE
              DECISION INVOLVES AN URGENT CONDITION FOR WHICH CARE HAS NOT
              BEEN RENDERED. THE ADDRESS MAY BE OBTAINED FROM THE STATE      (New Code
N137          INSURANCE REGULATORY AUTHORITY.                                10/31/02, 4/1/07)
              ALERT: IN THE EVENT YOU DISAGREE WITH THE DENTAL ADVISOR'S
              OPINION AND HAVE ADDITIONAL INFORMATION RELATIVE TO THE CASE,
              YOU MAY SUBMIT RADIOGRAPHS TO THE DENTAL ADVISOR UNIT AT THE
              SUBSCRIBER'S DENTAL INSURANCE CARRIER FOR A SECOND                (New Code
N138          INDEPENDENT DENTAL ADVISOR REVIEW.                                10/31/02, 4/1/07)

              ALERT: UNDER THE CODE OF FEDERAL REGULATIONS, CHAPTER 32,
              SECTION 199.13 A NON-PARTICIPATING PROVIDER IS NOT AN
              APPROPRIATE APPEALING PARTY. THEREFORE, IF YOU DISAGREE WITH
              THE DENTAL ADVISOR'S OPINION, YOU MAY APPEAL THE
              DETERMINATION IF APPOINTED IN WRITING, BY THE BENEFICIARY, TO
              ACT AS HIS/HER REPRESENTATIVE. SHOULD YOU BE APPOINTED AS A
              REPRESENTATIVE, SUBMIT A COPY OF THIS LETTER, A SIGNED
              STATEMENT EXPLAINING THE MATTER IN WHICH YOU DISAGREE, AND
              ANY RADIOGRAPHS AND RELEVANT INFORMATION TO THE
              SUBSCRIBER'S DENTAL INSURANCE CARRIER WITHIN 90 DAYS FROM         (New Code
N139          THE DATE OF THIS LETTER.                                          10/31/02, 4/1/07)

              ALERT: YOU HAVE NOT BEEN DESIGNATED AS AN AUTHORIZED OCONUS
              PROVIDER THEREFORE ARE NOT CONSIDERED AN APPROPRIATE
              APPEALING PARTY. IF THE BENEFICIARY HAS APPOINTED YOU, IN
              WRITING, TO ACT AS HIS/HER REPRESENTATIVE AND YOU DISAGREE
              WITH THE DENTAL ADVISOR'S OPINION, YOU MAY APPEAL BY
              SUBMITTING A COPY OF THIS LETTER, A SIGNED STATEMENT
              EXPLAINING THE MATTER IN WHICH YOU DISAGREE, AND ANY RELEVANT
              INFORMATION TO THE SUBSCRIBER'S DENTAL INSURANCE CARRIER          (New Code
N140          WITHIN 90 DAYS FROM THE DATE OF THIS LETTER.                      10/31/02, 4/1/07)
              THE PATIENT WAS NOT RESIDING IN A LONG-TERM CARE FACILITY         (New Code
N141          DURING ALL OR PART OF THE SERVICE DATES BILLED.                   10/31/02)
              THE ORIGINAL CLAIM WAS DENIED. RESUBMIT A NEW CLAIM, NOT A        (New Code
N142          REPLACEMENT CLAIM.                                                10/31/02)
              THE PATIENT WAS NOT IN A HOSPICE PROGRAM DURING ALL OR PART       (New Code
N143          OF THE SERVICE DATES BILLED.                                      10/31/02)

N144          THE RATE CHANGED DURING THE DATES OF SERVICE BILLED.              New Code 10/31/02)
              MISSING/INCOMPLETE/INVALID PROVIDER IDENTIFIER FOR THIS PLACE     Deactivated eff.
N145          OF SERVICE.                                                       6/2/05.
                                                                                (New Code
N146          MISSING SCREENING DOCUMENT.                                       10/31/02, 8/1/04)
              LONG TERM CARE CASE MIX OR PER DIEM RATE CANNOT BE
              DETERMINED BECAUSE THE PATIENT ID NUMBER IS MISSING,           (New Code
N147          INCOMPLETE, OR INVALID ON THE ASSIGNMENT REQUEST.              10/31/02)
                                                                             (New Code
N148          MISSING/INCOMPLETE/INVALID DATE OF LAST MENSTRUAL PERIOD.      10/31/02)
                                                                             (New Code
N149          REBILL ALL APPLICABLE SERVICES ON A SINGLE CLAIM.              10/31/02)
                                                                             (New Code
N150          MISSING/INCOMPLETE/INVALID MODEL NUMBER.                       10/31/02)
              TELEPHONE CONTACT SERVICES WILL NOT BE PAID UNTIL THE FACE-TO- (New Code
N151          FACE CONTACT REQUIREMENT HAS BEEN MET.                         10/31/02)
                                                                             (New Code
N152          MISSING/INCOMPLETE/INVALID REPLACEMENT CLAIM INFORMATION.      10/31/02)




5/16/2012                                        Page 96
                                     835 Remittance Remark Master


835 REMIT
REMARK CODE   835 REMITTANCE REMARK CODE                                   NOTES
                                                                           (New Code
N153          MISSING/INCOMPLETE/INVALID ROOM AND BOARD RATE.              10/31/02)
              ALERT: THIS PAYMENT WAS DELAYED FOR CORRECTION OF PROVIDER'S (New Code
N154          MAILING ADDRESS.                                             10/31/02, 4/1/07)
              ALERT: OUR RECORDS DO NOT INDICATE THAT OTHER INSURANCE IS ON
              FILE. PLEASE SUBMIT OTHER INSURANCE INFORMATION FOR OUR         (New Code
N155          RECORDS.                                                        10/31/02, 4/1/07)
              ALERT: THE PATIENT IS RESPONSIBLE FOR THE DIFFERENCE BETWEEN    (New Code
N156          THE APPROVED TREATMENT AND THE ELECTIVE TREATMENT.              10/31/02, 4/1/07)

                                                                         (New Code 2/28/03.
N157          TRANSPORTATION TO/FROM THIS DESTINATION IS NOT COVERED.    Modified 2/1/04)
              TRANSPORTATION IN A VEHICLE OTHER THAN AN AMBULANCE IS NOT
N158          COVERED.                                                   (New Code 2/28/03)
              PAYMENT DENIED/REDUCED BECAUSE MILEAGE IS NOT COVERED WHEN
N159          THE PATIENT IS NOT IN THE AMBULANCE.                       (New Code 2/28/03)

              THE PATIENT MUST CHOOSE AN OPTION BEFORE A PAYMENT CAN BE    (New Code 2/28/03.
N160          MADE FOR THIS PROCEDURE/EQUIPMENT/SUPPLY/SERVICE.            Modified 2/1/04)
              THIS DRUG/SERVICE/SUPPLY IS COVERED ONLY WHEN THE ASSOCIATED
N161          SERVICE IS COVERED.                                          (New Code 2/28/03)
              ALERT: ALTHOUGH YOUR CLAIM WAS PAID, YOU HAVE BILLED FOR A
              TEST/SPECIALTY NOT INCLUDED IN YOUR LABORATORY CERTIFICATION.
              YOUR FAILURE TO CORRECT THE LABORATORY CERTIFICATION
              INFORMATION WILL RESULT IN A DENIAL OF PAYMENT IN THE NEAR      (New Code 2/28/03,
N162          FUTURE.                                                         4/1/07)
              MEDICAL RECORD DOES NOT SUPPORT CODE BILLED PER THE CODE
N163          DEFINITION.                                                     (New Code 2/28/03)

                                                                              (New Code 2/28/03.
                                                                              Deactivated eff.
                                                                              1/31/04. Refer to
N164          TRANSPORTATION TO/FROM THIS DESTINATION IS NOT COVERED.         N157)

                                                                              (New Code 2/28/03.
                                                                              Deactivated eff.
              TRANSPORTATION IN A VEHICLE OTHER THAN AN AMBULANCE IS NOT      1/31/04. Refer to
N165          COVERED.                                                        N158)

                                                                         (New Code 2/28/03.
                                                                         Deactivated eff.
              PAYMENT DENIED/REDUCED BECAUSE MILEAGE IS NOT COVERED WHEN 1/31/04. Refer to
N166          THE PATIENT IS NOT IN THE AMBULANCE.                       N159)

N167          CHARGES EXCEED THE POST-TRANSPLANT COVERAGE LIMIT.              (New Code 2/28/03)

                                                                              (New Code 2/28/03.
                                                                              Deactivated eff.
              THE PATIENT MUST CHOOSE AN OPTION BEFORE A PAYMENT CAN BE       1/31/04. Refer to
N168          MADE FOR THIS PROCEDURE/EQUIPMENT/SUPPLY/SERVICE.               N160)

                                                                           (New Code 2/28/03.
                                                                           Deactivated eff.
              THIS DRUG/SERVICE/SUPPLY IS COVERED ONLY WHEN THE ASSOCIATED 1/31/04. Refer to
N169          SERVICE IS COVERED.                                          N161)
              A NEW/REVISED/RENEWED CERTIFICATE OF MEDICAL NECESSITY IS
N170          NEEDED.                                                      (New Code 2/28/03)




5/16/2012                                        Page 97
                                     835 Remittance Remark Master


835 REMIT
REMARK CODE   835 REMITTANCE REMARK CODE                                      NOTES
              PAYMENT FOR REPAIR OR REPLACEMENT IS NOT COVERED OR HAS
N171          EXCEEDED THE PURCHASE PRICE.                                    (New Code 2/28/03)
              THE PATIENT IS NOT LIABLE FOR THE DENIED/ADJUSTED CHARGE(S)
N172          FOR RECEIVING ANY UPDATED SERVICE/ITEM.                         (New Code 2/28/03)
              NO QUALIFYING HOSPITAL STAY DATES WERE PROVIDED FOR THIS
N173          EPISODE OF CARE.                                                (New Code 2/28/03)
              THIS IS NOT A COVERED SERVICE/PROCEDURE/ EQUIPMENT/BED,
              HOWEVER PATIENT LIABILITY IS LIMITED TO AMOUNTS SHOWN IN THE
N174          ADJUSTMENTS UNDER GROUP 'PR'.                                   (New Code 2/28/03)
                                                                              (New Code 2/28/03,
N175          MISSING REVIEW ORGANIZATION APPROVAL.                           2/29/08)
              SERVICES PROVIDED ABOARD A SHIP ARE COVERED ONLY WHEN THE
              SHIP IS OF UNITED STATES REGISTRY AND IS IN UNITED STATES
              WATERS. IN ADDITION, A DOCTOR LICENSED TO PRACTICE IN THE
N176          UNITED STATES MUST PROVIDE THE SERVICE.                         (New Code 2/28/03)
                                                                              (New Code 2/28/03.
              ALERT: WE DID NOT SEND THIS CLAIM TO PATIENT’S OTHER INSURER.   Modified 6/30/03,
N177          THEY HAVE INDICATED NO ADDITIONAL PAYMENT CAN BE MADE.          4/1/07)
                                                                              (New Code 2/28/03,
N178          MISSING PRE-OPERATIVE PHOTOS OR VISUAL FIELD RESULTS.           8/1/04)
              ADDITIONAL INFORMATION HAS BEEN REQUESTED FROM THE MEMBER.
              THE CHARGES WILL BE RECONSIDERED UPON RECEIPT OF THAT
N179          INFORMATION.                                                    (New Code 2/28/03)
              THIS ITEM OR SERVICE DOES NOT MEET THE CRITERIA FOR THE
N180          CATEGORY UNDER WHICH IT WAS BILLED.                             (New Code 2/28/03)
              ADDITIONAL INFORMATION HAS BEEN REQUESTED FROM ANOTHER          (New Code 2/28/03,
N181          PROVIDER INVOLVED IN THIS SERVICE.                              12/1/06)
              THIS CLAIM/SERVICE MUST BE BILLED ACCORDING TO THE SCHEDULE
N182          FOR THIS PLAN.                                                  (New Code 2/28/03)
              ALERT: THIS IS A PREDETERMINATION ADVISORY MESSAGE, WHEN THIS
              SERVICE IS SUBMITTED FOR PAYMENT ADDITIONAL DOCUMENTATION AS
              SPECIFIED IN PLAN DOCUMENTS WILL BE REQUIRED TO PROCESS       (New Code 2/28/03,
N183          BENEFITS.                                                     4/1/07)

N184          REBILL TECHNICAL AND PROFESSIONAL COMPONENTS SEPARATELY.        (New Code 2/28/03)
                                                                              (New Code 2/28/03,
N185          ALERT: DO NOT RESUBMIT THIS CLAIM/SERVICE.                      4/1/07)
              NON-AVAILABILITY STATEMENT (NAS) REQUIRED FOR THIS SERVICE.
              CONTACT THE NEAREST MILITARY TREATMENT FACILITY (MTF) FOR
N186          ASSISTANCE.                                                     (New Code 2/28/03)
              ALERT: YOU MAY REQUEST A REVIEW IN WRITING WITHIN THE
              REQUIRED TIME LIMITS FOLLOWING RECEIPT OF THIS NOTICE BY
              FOLLOWING THE INSTRUCTIONS INCLUDED IN YOUR CONTRACT OR         (New Code 2/28/03,
N187          PLAN BENEFIT DOCUMENTS.                                         4/1/07)
              THE APPROVED LEVEL OF CARE DOES NOT MATCH THE PROCEDURE
N188          CODE SUBMITTED.                                                 (New Code 2/28/03)
              ALERT: THIS SERVICE HAS BEEN PAID AS A ONE-TIME EXCEPTION TO    (New Code 2/28/03,
N189          THE PLAN'S BENEFIT RESTRICTIONS.                                4/1/07)
                                                                              (New Code 2/28/03,
N190          MISSING CONTRACT INDICATOR.                                     8/1/04)
              THE PROVIDER MUST UPDATE INSURANCE INFORMATION DIRECTLY
N191          WITH PAYER.                                                     (New Code 2/28/03)

N192          PATIENT IS A MEDICAID/QUALIFIED MEDICARE BENEFICIARY.           (New Code 2/28/03)
              SPECIFIC FEDERAL/STATE/LOCAL PROGRAM MAY COVER THIS SERVICE
N193          THROUGH ANOTHER PAYER.                                          (New Code 2/28/03)




5/16/2012                                        Page 98
                                      835 Remittance Remark Master


835 REMIT
REMARK CODE   835 REMITTANCE REMARK CODE                                        NOTES
              TECHNICAL COMPONENT NOT PAID IF PROVIDER DOES NOT OWN THE
N194          EQUIPMENT USED.                                                   (New Code 2/28/03)

N195          THE TECHNICAL COMPONENT MUST BE BILLED SEPARATELY.                (New Code 2/28/03)
              ALERT: PATIENT ELIGIBLE TO APPLY FOR OTHER COVERAGE WHICH MAY     (New Code 2/28/03,
N196          BE PRIMARY.                                                       4/1/07)
              THE SUBSCRIBER MUST UPDATE INSURANCE INFORMATION DIRECTLY
N197          WITH PAYER.                                                       (New Code 2/28/03)
              RENDERING PROVIDER MUST BE AFFILIATED WITH THE PAY-TO
N198          PROVIDER.                                                         (New Code 2/28/03)
              ADDITIONAL PAYMENT/RECOUPMENT APPROVED BASED ON PAYER-            (New Code 2/28/03,
N199          INITIATED REVIEW/AUDIT.                                           8/1/06)

N200          THE PROFESSIONAL COMPONENT MUST BE BILLED SEPARATELY.             (New Code 2/28/03)
              A MENTAL HEALTH FACILITY IS RESPONSIBLE FOR PAYMENT OF
              OUTSIDE PROVIDERS WHO FURNISH THESE SERVICES/SUPPLIES TO
N201          RESIDENTS.                                                        (New Code 2/28/03)
              ALERT: ADDITIONAL INFORMATION/EXPLANATION WILL BE SENT            (New Code 6/30/03,
N202          SEPARATELY.                                                       4/1/07)

N203          MISSING/INCOMPLETE/INVALID ANESTHESIA TIME/UNITS                  (New Code 6/30/03)
              SERVICES UNDER REVIEW FOR POSSIBLE PRE-EXISTING CONDITION.
N204          SEND MEDICAL RECORDS FOR PRIOR 12 MONTHS.                         (New Code 6/30/03)

N205          INFORMATION PROVIDED WAS ILLEGIBLE.                               (New Code 6/30/03)

N206          THE SUPPORTING DOCUMENTATION DOES NOT MATCH THE CLAIM.            (New Code 6/30/03)

N207          MISSING/INCOMPLETE/INVALID BIRTH WEIGHT.                          (New Code 6/30/03)

N208          MISSING/INCOMPLETE/INVALID DRG CODE.                              (New Code 6/30/03)

N209          MISSING/INVALID/INCOMPLETE TAXPAYER IDENTIFICATION NUMBER (TIN) (New Code 6/30/03)
                                                                              (New Code 6/30/03,
N210          ALERT: YOU MAY APPEAL THIS DECISION.                            4/1/07)
                                                                              (New Code 6/30/03,
N211          ALERT: YOU MAY NOT APPEAL THIS DECISION.                        4/1/07)

N212          CHARGES PROCESSED UNDER A POINT OF SERVICE BENEFIT                (New Code 2/1/04)
              MISSING/INCOMPLETE/INVALID FACILITY/DISCRETE UNIT DRG/DRG
N213          EXEMPT STATUS INFORMATION.                                        (New Code 4/1/04)
              MISSING/INCOMPLETE/INVALID HISTORY OF THE RELATED INITIAL
N214          SURGICAL PROCEDURE(S).                                            (New Code 4/1/04)
              ALERT: A PAYER PROVIDING SUPPLEMENTAL OR SECONDARY
              COVERAGE SHALL NOT REQUIRE A CLAIMS DETERMINATION FOR THIS
              SERVICE FROM A PRIMARY PAYER AS A CONDITION OF MAKING ITS OWN (New Code 4/1/04,
N215          CLAIMS DETERMINATION.                                         4/1/07)

N216          PATIENT IS NOT ENROLLED IN THIS PORTION OF OUR BENEFIT PACKAGE. (New Code 4/1/04)
N217          WE PAY ONLY ONE SITE OF SERVICE PER PROVIDER PER CLAIM            (New code 8/1/04)
              YOU MUST FURNISH AND SERVICE THIS ITEM FOR AS LONG AS THE
              PATIENT CONTINUES TO NEED IT. WE CAN PAY FOR MAINTENANCE
              AND/OR SERVICING FOR THE TIME PERIOD SPECIFIED IN THE CONTRACT
N218          OR COVERAGE MANUAL.                                            (New code 8/1/04)
N219          PAYMENT BASED ON PERVIOUS PAYER'S ALLOWED AMOUNT.                 (New code 8/1/04)




5/16/2012                                        Page 99
                                      835 Remittance Remark Master


835 REMIT
REMARK CODE   835 REMITTANCE REMARK CODE                                       NOTES
              ALERT: SEE THE PAYER'S WEB SITE OR CONTACT THE PAYER'S
              CUSTOMER SERVICE DEPARTMENT TO OBTAIN FORMS AND                  (New code 8/1/04,
N220          INSTRUCTIONS FOR FILING A PROVIDER DISPUTE.                      4/1/07)
N221          MISSING ADMITTING HISTORY AND PHYSICAL REPORT                    (New code 8/1/04)
N222          INCOMPLETE/INVALID ADMITTING HISTORY AND PHYSICAL REPORT.        (New code 8/1/04)
              MISSING DOCUMENTATION OF BENEFIT TO THE PATIENT DURING INITIAL
N223          TREATMENT PERIOD.                                                (New code 8/1/04)
              INCOMPLETE/INVALID DOCUMENTATION OF BENEFIT TO THE PATIENT
N224          DURING INITIAL TREATMENT PERIOD.                                 (New code 8/1/04)
              INCOMPLETE/INVALID                                               (New code 8/1/04,
N225          DOCUMENTATION/ORDERS/NOTES/SUMMARY/REPORT/CHART.                 8/1/05)
              INCOMPLETE/INVALID AMERICAN DIABETES ASSOCIATION CERTIFICATE
N226          OF RECOGNITION.                                                  (New code 8/1/04)
N227          INCOMPLETE/INVALID CERTIFICATE OF MEDICAL NECESSITY.             (New code 8/1/04)
N228          INCOMPLETE/INVALID CONSENT FORM.                                 (New code 8/1/04)
N229          INCOMPLETE/INVALID CONTRACT INDICATOR.                        (New code 8/1/04)
              INCOMPLETE/INVALID INDICATION OF WHETHER THE PATIENT OWNS THE
N230          EQUIPMENT THAT REQUIRES THE PART OR SUPPLY.                   (New code 8/1/04)
              INCOMPLETE/INVALID INVOICE OR STATEMENT CERTIFYING THE ACTUAL
              COST OF THE LENS, LESS DISCOUNTS, AND/OR THE TYPE OF
N231          INTRAOCULAR LENS USED.                                        (New code 8/1/04)
N232          INCOMPLETE/INVALID ITEMIZED BILL.                                (New code 8/1/04)
N233          INCOMPLETE/INVALID OPERATIVE REPORT.                             (New code 8/1/04)
N234          INCOMPLETE/INVALID OXYGEN CERTIFICATION/RE-CERTIFICATION         (New code 8/1/04)
N235          INCOMPLETE/INVALID PACEMAKER REGISTRATION FORM.                  (New code 8/1/04)
N236          INCOMPLETE/INALID PATHOLOGY REPORT.                              (New code 8/1/04)
N237          INCOMPLETE/INVALID PATIENT MEDICAL RECORD FOR THIS SERVICE.      (New code 8/1/04)
N238          INCOMPLETE/INVALID PHYSICIAN CERTIFIED PLAN OF CARE.             (New code 8/1/04)
N239          INCOMPLETE/INVALID PHYSICIAN FINANCIAL RELATIONSHIP FORM.        (New code 8/1/04)
N240          INCOMPLETE/INVALID RADIOLOGY REPORT.                             (New code 8/1/04)
N241          INCOMPLETE/INVALID REVIEW ORGANIZATION APPROVAL.                 (New code 8/1/04)
N242          INCOMPLETE/INVALID X-RAY                                         (New code 8/1/04)
N243          INCOMPLETE/INVALID/NOT APPROVED SCREENING DOCUMENT.              (New code 8/1/04)
N244          INCOMPLETE/INVALID PRE-OPERATIVE PHOTOS/VISUAL FIELD RESULTS.    (New code 8/1/04)
N245          INCOMPLETE/INVALID PLAN INFORMATION FOR OTHER INSURANCE.         (New code 8/1/04)
              STATE REGULATED PATIENT PAYMENT LIMITATIONS APPLY TO THIS
N246          SERVICE.                                                         (New code 12/2/04)

N247          MISSING/INCOMPLETE/INVALID ASSISTANT SURGEON TAXONOMY.           (New code 12/2/04)

N248          MISSING/INCOMPLETE/INVALID ASSISTANT SURGEON NAME.               (New code 12/2/04)

N249          MISSING/INCOMPLETE/INVALID ASSISTANT PRIMARY IDENTIFIER.         (New code 12/2/04)
              MISSING/INCOMPLETE/INVALID ASSISTANT SURGEON SECONDARY
N250          IDENTIFIER.                                                      (New code 12/2/04)

N251          MISSING/INCOMPLETE/INVALID ATTENDING PROVIDER IDENTIFIER.        (New code 12/2/04)

N252          MISSING/INCOMPLETE/INVALID ATTENDING PROVIDER NAME.              (New code 12/2/04)
              MISSING/INCOMPLETE/INVALID ATTENDING PROVIDER PRIMARY
N253          IDENTIFIER.                                                      (New code 12/2/04)
              MISSING/INCOMPLETE/INVALID ATTENDING PROVIDER SECONDARY
N254          IDENTIFIER.                                                      (New code 12/2/04)




5/16/2012                                         Page 100
                                     835 Remittance Remark Master


835 REMIT
REMARK CODE   835 REMITTANCE REMARK CODE                                       NOTES

N255          MISSING/INCOMPLETE/INVALID BILLING PROVIDER TAXONOMY.            (New code 12/2/04)

N256          MISSING/INCOMPLETE/INVALID BILLING PROVIDER/SUPPLIER NAME.       (New code 12/2/04)
              MISSING/INCOMPLETE/INVALID BILLING PROVIDER/SUPPLIER PRIMARY
N257          IDENTIFIER.                                                      (New code 12/2/04)

N258          MISSING/INCOMPLETE/INVALID BILLING PROVIDER/SUPPLIER ADDRESS.    (New code 12/2/04)
              MISSING/INCOMPLETE/INVALID BILLING PROVIDER/SUPPLIER
N259          SECONDARY IDENTIFIER.                                            (New code 12/2/04)
              MISSING/INCOMPLETE/INVALID BILLING PROVIDER/SUPPLIER CONTACT
N260          INFORMATION.                                                     (New code 12/2/04)

N261          MISSING/INCOMPLETE/INVALID OPERATING PROVIDER NAME.              (New code 12/2/04)
              MISSING/INCOMPLETE/INVALID OPERATING PROVIDER PRIMARY
N262          IDENTIFIER.                                                      (New code 12/2/04)
              MISSING/INCOMPLETE/INVALID OPERATING PROVIDER SECONDARY
N263          IDENTIFIER.                                                      (New code 12/2/04)

N264          MISSING/INCOMPLETE/INVALID ORDERING PROVIDER NAME.               (New code 12/2/04)
              MISSING/INCOMPLETE/INVALID ORDERING PROVIDER PRIMARY
N265          IDENTIFIER.                                                      (New code 12/2/04)

N266          MISSING/INCOMPLETE/INVALID ORDERING PROVIDER ADDRESS.            (New code 12/2/04)
              MISSING/INCOMPLETE/INVALID ORDERING PROVIDER SECONDARY
N267          IDENTIFIER.                                                      (New code 12/2/04)
              MISSING/INCOMPLETE/INVALID ORDERING PROVIDER CONTACT
N268          INFORMATION.                                                     (New code 12/2/04)

N269          MISSING/INCOMPLETE/INVALID OTHER PROVIDER NAME.                  (New code 12/2/04)

N270          MISSING/INCOMPLETE/INVALID OTHER PROVIDER PRIMARY IDENTIFIER.    (New code 12/2/04)
              MISSING/INCOMPLETE/INVALID OTHER PROVIDER SECONDARY
N271          IDENTIFIER.                                                      (New code 12/2/04)
              MISSING/INCOMPLETE/INVALID OTHER PAYER ATTENDING PROVIDER
N272          IDENTIFIER.                                                      (New code 12/2/04)
              MISSING/INCOMPLETE/INVALID OTHER PAYER OPERATING PROVIDER
N273          IDENTIFIER.                                                      (New code 12/2/04)
              MISSING/INCOMPLETE/INVALID OTHER PAYER OTHER PROVIDER
N274          IDENTIFIER.                                                      (New code 12/2/04)
              MISSING/INCOMPLETE/INVALID OTHER PAYER PURCHASED SERVICE
N275          PROVIDER IDENTIFIER.                                             (New code 12/2/04)
              MISSING/INCOMPLETE/INVALID OTHER PAYER REFERRING PROVIDER
N276          IDENTIFIER.                                                      (New code 12/2/04)
              MISSING/INCOMPLETE/INVALID OTHER PAYER RENDERING PROVIDER
N277          IDENTIFIER.                                                      (New code 12/2/04)
              MISSING/INCOMPLETE/INVALID OTHER PAYER SERVICE FACILITY
N278          PROVIDER IDENTIFIER.                                             (New code 12/2/04)

N279          MISSING/INCOMPLETE/INVALID PAY-TO PROVIDER NAME                  (New code 12/2/04)

N280          MISSING/INCOMPLETE/INVALID PAY-TO PROVIDER PRIMARY IDENTIFIER.   (New code 12/2/04)

N281          MISSING/INCOMPLETE/INVALID PAY-TO PROVIDER ADDRESS.              (New code 12/2/04)
              MISSING/INCOMPLETE/INVALID PAY-TO PROVIDER SECONDARY
N282          IDENTIFIER.                                                      (New code 12/2/04)




5/16/2012                                       Page 101
                                     835 Remittance Remark Master


835 REMIT
REMARK CODE   835 REMITTANCE REMARK CODE                                        NOTES
              MISSING/INCOMPLETE/INVALID PURCHASED SERVICE PROVIDER
N283          IDENTIFIER.                                                       (New code 12/2/04)

N284          MISSING/INCOMPLETE/INVALID REFERRING PROVIDER TAXONOMY.           (New code 12/2/04)

N285          MISSING/INCOMPLETE/INVALID REFERRING PROVIDER NAME.               (New code 12/2/04)
              MISSING/INCOMPLETE/INVALID REFERRING PROVIDER PRIMARY
N286          IDENTIFIER.                                                       (New code 12/2/04)
              MISSING/INCOMPLETE/INVALID REFERRING PROVIDER SECONDARY
N287          IDENTIFIER.                                                       (New code 12/2/04)

N288          MISSING/INCOMPLETE/INVALID RENDERING PROVIDER TAXONOMY.           (New code 12/2/04)

N289          MISSING/INCOMPLETE/INVALID RENDERING PROVIDER NAME.               (New code 12/2/04)
              MISSING/INCOMPLETE/INVALID RENDERING PROVIDER PRIMARY
N290          IDENTIFIER.                                                       (New code 12/2/04)
              MISSING/INCOMPLETE/INVALID RENDING PROVIDER SECONDARY
N291          IDENTIFIER.                                                       (New code 12/2/04)

N292          MISSING/INCOMPLETE/INVALID SERVICE FACILITY NAME.                 (New code 12/2/04)

N293          MISSING/INCOMPLETE/INVALID SERVICE FACILITY PRIMARY IDENTIFIER.   (New code 12/2/04)

N294          MISSING/INCOMPLETE/INVALID SERVICE FACILITY PRIMARY ADDRESS.      (New code 12/2/04)
              MISSING/INCOMPLETE/INVALID SERVICE FACILITY SECONDARY
N295          IDENTIFIER.                                                       (New code 12/2/04)

N296          MISSING/INCOMPLETE/INVALID SUPERVISING PROVIDER NAME.             (New code 12/2/04)
              MISSING/INCOMPLETE/INVALID SUPERVISING PROVIDER PRIMARY
N297          IDENTIFIER.                                                       (New code 12/2/04)
              MISSING/INCOMPLETE/INVALID SUPERVISING PROVIDER SECONDARY
N298          IDENTIFIER.                                                       (New code 12/2/04)

N299          MISSING/INCOMPLETE/INVALID OCCURRENCE DATE(S).                    (New code 12/2/04)

N300          MISSING/INCOMPLETE/INVALID OCCURRENCE SPAN DATE(S).               (New code 12/2/04)

N301          MISSING/INCOMPLETE/INVALID PROCEDURE DATE(S).                     (New code 12/2/04)

N302          MISSING/INCOMPLETE/INVALID OTHER PROCEDURE DATE(S).               (New code 12/2/04)

N303          MISSING/INCOMPLETE/INVALID PRINCIPAL PROCEDURE DATE.              (New code 12/2/04)

N304          MISSING/INCOMPLETE/INVALID DISPENSED DATE.                        (New code 12/2/04)

N305          MISSING/INCOMPLETE/INVALID ACCIDENT DATE.                         (New code 12/2/04)

N306          MISSING/INCOMPLETE/INVALID ACUTE MANIFESTATION DATE.              (New code 12/2/04)

N307          MISSING/INCOMPLETE/INVALID ADJUDICATION OR PAYMENT DATE.          (New code 12/2/04)

N308          MISSING/INCOMPLETE/INVALID APPLIANCE PLACEMENT DATE.              (New code 12/2/04)

N309          MISSING/INCOMPLETE/INVALID ASSESSMENT DATE.                       (New code 12/2/04)

N310          MISSING/INCOMPLETE/INVALID ASSUMED OR RELINQUISHED CARE DATE. (New code 12/2/04)




5/16/2012                                       Page 102
                                      835 Remittance Remark Master


835 REMIT
REMARK CODE   835 REMITTANCE REMARK CODE                                        NOTES

N311          MISSING/INCOMPLETE/INVALID AUTHORIZED TO RETURN TO WORK DATE. (New code 12/2/04)

N312          MISSING/INCOMPLETE/INVALID BEGIN THERAPY DATE.                    (New code 12/2/04)

N313          MISSING/INCOMPLETE/INVALID CERTIFICATION REVISION DATE.           (New code 12/2/04)

N314          MISSING/INCOMPLETE/INVALID DIAGNOSIS DATE.                        (New code 12/2/04)

N315          MISSING/INCOMPLETE/INVALID DISABILITY FROM DATE.                  (New code 12/2/04)

N316          MISSING/INCOMPLETE/INVALID DISABILITY TO DATE.                    (New code 12/2/04)

N317          MISSING/INCOMPLETE/INVALID DISCHARGE HOUR.                        (New code 12/2/04)

N318          MISSING/INCOMPLETE/INVALID DISCHARGE OR END OF CARE DATE.         (New code 12/2/04)

N319          MISSING/INCOMPLETE/INVALID HEARING OR VISION PRESCRIPTION DATE. (New code 12/2/04)

N320          MISSING/INCOMPLETE/INVALID HOME HEALTH CERTIFICATION PERIOD.      (New code 12/2/04)

N321          MISSING/INCOMPLETE/INVALID LAST ADMISSION PERIOD.                 (New code 12/2/04)

N322          MISSING/INCOMPLETE/INVALID LAST CERTIFICATION DATE.               (New code 12/2/04)

N323          MISSING/INCOMPLETE/INVALID LAST CONTACT DATE.                     (New code 12/2/04)

N324          MISSING/INCOMPLETE/INVALID LAST SEEN/VISIT DATE.                  (New code 12/2/04)

N325          MISSING/INCOMPLETE/INVALID LAST WORKED DATE.                      (New code 12/2/04)

N326          MISSING/INCOMPLETE/INVALID LAST X-RAY DATE.                       (New code 12/2/04)

N327          MISSING/INCOMPLETE/INVALID OTHER INSURED BIRTH DATE.              (New code 12/2/04)

N328          MISSING/INCOMPLETE/INVALID OXYGEN SATURATION TEST DATE.           (New code 12/2/04)

N329          MISSING/INCOMPLETE/INVALID PATIENT BIRTH DATE.                    (New code 12/2/04)

N330          MISSING/INCOMPLETE/INVALID PATIENT DEATH DATE.                    (New code 12/2/04)

N331          MISSING/INCOMPLETE/INVALID PHYSICIAN ORDER DATE.                  (New code 12/2/04)

N332          MISSING/INCOMPLETE/INVALID PRIOR HOSPITAL DISCHARGE DATE.         (New code 12/2/04)

N333          MISSING/INCOMPLETE/INVALID PRIOR PLACEMENT DATE.                  (New code 12/2/04)

N334          MISSING/INCOMPLETE/INVALID RE-EVALUATION DATE.                    (New code 12/2/04)

N335          MISSING/INCOMPLETE/INVALID REFERRAL DATE.                         (New code 12/2/04)

N336          MISSING/INCOMPLETE/INVALID REPLACEMENT DATE.                      (New code 12/2/04)

N337          MISSING/INCOMPLETE/INVALID SECONDARY DIAGNOSIS DATE.              (New code 12/2/04)

N338          MISSING/INCOMPLETE/INVALID SHIPPED DATE.                          (New code 12/2/04)




5/16/2012                                        Page 103
                                     835 Remittance Remark Master


835 REMIT
REMARK CODE   835 REMITTANCE REMARK CODE                                       NOTES

N339          MISSING/INCOMPLETE/INVALID SIMILAR ILLNESS OR SYMPTOM DATE.      (New code 12/2/04)

N340          MISSING/INCOMPLETE/INVALID SUBSCRIBER BIRTH DATE.                (New code 12/2/04)

N341          MISSING/INCOMPLETE/INVALID SURGERY DATE.                         (New code 12/2/04)

N342          MISSING/INCOMPLETE/INVALID TEST PERFORMED DATE.                  (New code 12/2/04)
              MISSING/INCOMPLETE/INVALID TRANSCUTANEOUS ELECTRICAL NERVE
N343          STIMULATOR (TENS) TRIAL START DATE.                              (New code 12/2/04)
              MISSING/INCOMPLETE/INVALID TRANSCUTANEOUS ELECTRICAL NERVE
N344          STIMULATOR (TENS) TRIAL END DATE.                                (New code 12/2/04)

N345          DATE RANGE NOT VALID WITH UNITS SUBMITTED.                       (New code 3/30/05)

N346          MISSING/INCOMPLETE/INVALID ORAL CAVITY DESIGNATION CODE.         (New code 3/30/05)
              YOUR CLAIM FOR A REFERRED OR PURCHASED SERVICE CANNOT BE
              PAID BECAUSE PAYMENT HAS ALREADY BEEN MADE FOR THIS SAME
              SERVICE TO ANOTHER PROVIDER BY A PAYMENT CONTRACTOR
N347          REPRESENTING THE PAYER.                                          (New code 3/30/05)
              YOU CHOSE THAT THIS SERVICE/SUPPLY/DRUG WOULD BE
              RENDERED/SUPPLIED AND BILLED BY A DIFFERENT
N348          PRACTITIONER/SUPPLIER.                                           (New code 8/1/05)
              THE ADMINISTRATION METHOD AND DRUG MUST BE REPORTED TO
N349          ADJUDICATE THIS SERVICE.                                         (New code 8/1/05)
              MISSING/INCOMPLETE/INVALID DESCRIPTION OF SERVICE FOR A NOT
N350          OTHERWISE CLASSIFIED (NOC) CODE OR AN UNLISTED PROCEDURE.        (New code 8/1/05)
              SERVICE DATE OUTSIDE OF THE APPROVED TREATMENT PLAN SERVICE
N351          DATES.                                                           (New code 8/1/05)

              ALERT: THERE ARE NO SCHEDULED PAYMENTS FOR THIS SERVICE.         (New code 8/1/05,
N352          SUBMIT A CLAIM FOR EACH PATIENT VISIT.                           Modified 4/1/07.
              ALERT: BENEFITS HAVE BEEN ESTIMATED, WHEN THE ACTUAL SERVICES
              HAVE BEEN RENDERED, ADDITIONAL PAYMENT WILL BE CONSIDERED     (New code 8/1/05,
N353          BASED ON THE SUBMITTED CLAIM.                                 Modified 4/1/07.
N354          INCOMPLETE/INVALID INVOICE.                                      (New code 8/1/05
              ALERT: THE LAW PERMITS EXCEPTIONS TO THE REFUND REQUIREMENT
              IN TWO CASES - IF YOU DID NOT KNOW, AND COULD NOT HAVE
              REASONABLY BEEN EXPECTED TO KNOW, THAT WE WOULD NOT PAY
              FOR THIS SERVICE; OR - IF YOU NOTIFIED THE PATIENT IN WRITING
              BEFORE PROVIDING THE SERVICE THAT YOU BELIEVED THAT WE WERE
              LIKELY TO DENY THE SERVICE, AND THE PATIENT SIGNED A STATEMENT   (New code 8/1/05,
N355          AGREEING TO PAY FOR THE SERVICE.                                 Modified 4/1/07.
              IF YOU COME WITHIN EITHER EXCEPTION, OR IF YOU BELIEVE THE
              CARRIER WAS WRONG IN ITS DETERMINATION THAT WE DO NOT PAY
              FOR THIS SERVICE, YOU SHOULD REQUEST APPEAL OF THIS
              DETERMINATION WITHIN 30 DAYS OF THE DATE OF THIS NOTICE. YOUR
              REQUEST FOR REVIEW SHOULD INCLUDE ANY ADDITIONAL
              INFORMATION NECESSARY TO SUPPORT YOUR POSITION.
              IF YOU REQUEST AN APPEAL WITHIN 30 DAYS OF RECEIVING THIS
              NOTICE, YOU MAY DELAY REFUNDING THE AMOUNT TO THE PATIENT
              UNTIL YOU RECEIVE THE RESULTS OF THE REVIEW. IF THE REVIEW
              DECISION IS FAVORABLE TO YOU, YOU DO NOT NEED TO MAKE ANY
              REFUND. IF, HOWEVER, THE REVIEW IS UNFAVORABLE, THE LAW
              SPECIFIES THAT YOU MUST MAKE THE REFUND WITHIN 15 DAYS OF
              RECEIVING THE UNFAVORABLE REVIEW DECISION.




5/16/2012                                       Page 104
                                      835 Remittance Remark Master


835 REMIT
REMARK CODE   835 REMITTANCE REMARK CODE                                        NOTES
              THE LAW ALSO PERMITS YOU TO REQUEST AN APPEAL AT ANY TIME
              WITHIN 120 DAYS OF THE DATE YOU RECEIVE THIS NOTICE. HOWEVER,
              AN APPEAL REQUEST THAT IS RECEIVED MORE THAN 30 DAYS AFTER
              THE DATE OF THIS NOTICE, DOES NOT PERMIT YOU TO DELAY MAKING
              THE REFUND. REGARDLESS OF WHEN A REVIEW IS REQUESTED THE
              PATIENT WILL BE NOTIFIED THAT YOU HAVE REQUESTED ONE, AND WILL
              RECEIVE A COPY OF THE DETERMINATION.
              THE PATIENT HAS RECEIVED A SEPARATE NOTICE OF THIS DENIAL
              DECISION. THE NOTICE ADVISES THAT HE/SHE MAY BE ENTITLED TO A
              REFUND OF ANY AMOUNTS PAID, IF YOU SHOULD HAVE KNOWN THAT
              WE WOULD NOT PAY AND DID NOT TELL HIM/HER. IT ALSO INSTRUCTS
              THE PATIENT TO CONTACT OUR OFFICE IF HE/SHE DOES NOT HEAR
              ANYTHING ABOUT A REFUND WITHIN 30 DAYS.
              THIS SERVICE IS NOT COVERED WHEN PERFORMED WITH, OR
N356          SUBSEQUENT TO, A NONCOVERED SERVICE.                              (New code 8/1/05
              TIME FRAME REQUIREMENTS BETWEEN THIS
              SERVICE/PROCEDURE/SUPPLY AND A RELATED
N357          SERVICE/PROCEDURE/SUPPLY HAVE NOT BEEN MET.                       (New code 11/18/05)
              ALERT: THIS DECISION MAY BE REVIEWED IF ADDITIONAL                (New code
              DOCUMENTATION AS DESCRIBED IN THE CONTRACT OR PLAN BENEFIT        11/18/05, Modified
N358          DOCUMENTS IS SUBMITTED.                                           4/1/07)

N359          MISSING/INCOMPLETE/INVALID HEIGHT.                                (New code 11/18/05)
              ALERT: COORDINATION OF BENEFITS HAS NOT BEEN CALCULATED
              WHEN ESTIMATING BENEFITS FOR THIS PRE-DETERMINATION. SUBMIT       (New code
              PAYMENT INFORMATION FROM THE PRIMARY PAYER WITH THE               11/18/05, Modified
N360          SECONDARY CLAIM.                                                  4/1/07)
                                                                                Deactivated eff.
              PAYMENT ADJUSTED BASED ON MULTIPLE DIAGNOSTIC IMAGING             10/1/07. Refer to
N361          PROCEDURE RULES.                                                  Reason code 59.
              THE NUMBER OF DAYS OR UNITS OF SERVICE EXCEEDS OUR
N362          ACCEPTABLE MAXIMUM.                                               (New code 11/18/05)
                                                                                (New code
              ALERT: IN THE NEAR FUTURE WE ARE IMPLEMENTING NEW                 11/18/05, Modified
N363          POLICIES/PROCEDURES THAT WOULD AFFECT THIS DETERMINATION.         4/1/07)
                                                                                (New code
              ALERT: ACCORDING TO OUR AGREEMENT, YOU MUST WAIVE THE             11/18/05, Modified
N364          DEDUCTIBLE AND/OR COINSURANCE AMOUNTS.                            4/1/07)
              THIS PROCEDURE CODE IS NOT PAYABLE. IT IS FOR
N365          REPORTING/INFORMATION PURPOSE ONLY.                               (New code 4/1/06)
              REQUESTED INFORMATION NOT PROVIDED. THE CLAIM WILL BE
              REOPENED IF THE INFORMATION PREVIOUSLY REQUESTED IS
N366          SUBMITTED WITHIN ONE YEAR AFTER THE DATE OF THIS DENIAL NOTICE. (New code 4/1/06)

              ALERT: THE CLAIM INFORMATION HAS BEEN FORWARDED TO A              (New code 4/1/06,
N367          CONSUMER ACCOUNT FUND PROCESSOR FOR REVIEW.                       Modified 11/5/07)
              YOU MUST APPEAL THE DETERMINATION OF THE PREVIOUSLY
N368          ADJUDICATED CLAIM.                                                (New code 4/1/06)
              ALERT: ALTHOUGH THIS CLAIM HAS BEEN PROCESSED, IT IS DEFICIENT
N369          ACCORDING TO STATE LEGISLATION/REGULATION.                        (New code 4/1/06)
              BILLING EXCEEDS THE RENTAL MONTHS COVERED/APPROVED BY THE
N370          PAYER.                                                            (New code 8/1/06)
              ALERT: TITLE OF THIS EQUIPMENT MUST BE TRANSFERRED TO THE
N371          PATIENT.                                                          (New code 8/1/06)
              ONLY REASONABLE AND NECESSARY MAINTENANCE/SERVICE CHARGES
N372          ARE COVERED.                                                      (New code 8/1/06)




5/16/2012                                          Page 105
                                      835 Remittance Remark Master


835 REMIT
REMARK CODE   835 REMITTANCE REMARK CODE                                       NOTES
              IT HAS BEEN DETERMINED THAT ANOTHER PAYER PAID THE SERVICES
              AS PRIMARY WHEN THEY WERE NOT THE PRIMARY PAYER. THEREFORE,
              WE ARE REFUNDING TO THE PAYER THAT PAID AS PRIMARY ON YOUR
N373          BEHALF.                                                          (New code 12/1/06)
              PRIMARY MEDICARE PART A INSURANCE HAS BEEN EXHAUSTED AND A
N374          PART B REMITTANCE ADVICE IS REQUIRED.                            (New code 12/1/06)
              MISSING/INCOMPLETE/INVALID QUESTIONNAIRE/INFORMATION
N375          REQUIRED TO DETERMINE DEPENDENT ELIGIBILITY.                     (New code 12/1/06)
              SUBSCRIBER/PATIENT IS ASSIGNED TO ACTIVE MILITARY DUTY,
N376          THEREFORE PRIMARY COVERAGE MAY BE TRICARE.                       (New code 12/1/06)

                                                                               (New code 12/1/06,
N377          PAYMENT BASED ON A PROCESSED REPLACEMENT CLAIM.                  Modified 11/5/07)

N378          MISSING/INCOMPLETE/INVALID PRESCRIPTION QUANTITY.                (New code 12/1/06)

N379          CLAIM LEVEL INFORMATION DOES NOT MATCH LINE LEVEL INFORMATION. (New code 12/1/06)
              THE ORIGINAL CLAIM HAS BEEN PROCESSED, SUBMIT A CORRECTED
N380          CLAIM.                                                         (New code 4/1/07)
              CONSULT OUR CONTRACTUAL AGREEMENT FOR
              RESTRICTION/BILLING/PAYMENT INFORMATION RELATED TO THESE
N381          CHARGES.                                                         (New code 4/1/07)
N382          MISSING/INCOMPLETE/INVALID PATIENT IDENTIFIER.                   (New code 4/1/07)
N383          SERVICES DEEMED COSMETIC ARE NOT COVERED.                        (New code 4/1/07)
              RECORDS INDICATE THAT THE REFERENCED BODY PART/TOOTH HAS
N384          BEEN REMOVED IN A PREVIOUS PROCEDURE.                            (New code 4/1/07)

              NOTIFICATION OF ADMISSION WAS NOT TIMELY ACCORDING TO            (New code 4/1/07,
N385          PUBLISHED PLAN PROCEDURES.                                       Modified 11/5/07)
              THIS DECISION WAS BASED ON A NATIONAL COVERAGE DETERMINATION
              (NCD). AN NCD PROVIDES A COVERAGE DETERMINATION AS TO
              WHETHER A PARTICULAR ITEM OR SERVICE IS COVERED. A COPY OF
              THIS POLICY IS AVAILABLE AT
              HTTP://WWW.CMS.HHS.GOV.MCD.SEARCH.ASP. IF YOU DO NOT HAVE
              WEB ACCESS, YOU MAY CONTACT THE CONTRACTOR TO REQUEST A
N386          COPY OF THE NCD.                                             (New code 4/1/07)
              YOU SHOULD SUBMIT THIS CLAIM TO THE PATIENT'S OTHER INSURER
              FOR POTENTIAL PAYMENT OF SUPPLEMENTAL BENEFITS. WE DID NOT
N387          FORWARD THE CLAIM INFORMATION.                                   (New code 4/1/07)
N388          MISSING/INCOMPLETE/INVALID PRESCRIPTION NUMBER.                  (New code 8/1/07)
N389          DUPLICATE PRESCRIPTION NUMBER SUBMITTED.                         (New code 8/1/07)
N390          THIS SERVICE CANNOT BE BILLED SEPARATELY.                        (New code 8/1/07)
N391          MISSING EMERGENCY DEPARTMENT RECORDS.                            (New code 8/1/07)
N392          INCOMPLETE/INVALID EMERGENCY DEPARTMENT RECORDS.                 (New code 8/1/07)
N393          MISSING PROGRESS NOTES OR REPORT.                                (New code 8/1/07)
N394          INCOMPLETE/INVALID PROGRESS NOTES OR REPORT.                     (New code 8/1/07)
N395          MISSING LABORATORY REPORT.                                       (New code 8/1/07)
N396          INCOMPLETE/INVALID LABORATORY REPORT.                            (New code 8/1/07)
              BENEFITS ARE NOT AVAILABLE FOR INCOMPLETE
N397          SERVICE(S)/UNDELIVERED ITEM(S).                                  (New code 8/1/07)
N398          MISSING ELECTIVE CONSENT FORM.                                   (New code 8/1/07)
N399          INCOMPLETE/INVALID ELECTIVE CONSENT FORM.                    (New code 8/1/07)
              ALERT: ELECTRONICALLY ENABLED PROVIDERS SHOULD SUBMIT CLAIMS
N400          ELECTRONICALLY.                                              (New code 8/1/07)
N401          MISSING PERIODONTAL CHARTING.                                    (New code 8/1/07)




5/16/2012                                        Page 106
                                      835 Remittance Remark Master


835 REMIT
REMARK CODE   835 REMITTANCE REMARK CODE                                     NOTES
N402          INCOMPLETE/INVALID PERIODONTAL CHARTING.                       (New code 8/1/07)
N403          MISSING FACILITY CERTIFICATION.                                (New code 8/1/07)
N404          INCOMPLETE/INVALID FACILITY CERTIFICATION.                     (New code 8/1/07)
              THIS SERVICE IS ONLY COVERED WHEN THE DONOR'S INSURER(S) DO
N405          NOT PROVIDE COVERAGE FOR THE SERVICE.                          (New code 8/1/07)
              THIS SERVICE IS ONLY COVERED WHEN THE RECIPIENT'S INSURER(S)
N406          DO NOT PROVIDE COVERAGE FOR THE SERVICE.                       (New code 8/1/07)
              YOU ARE NOT AN APPROVED SUBMITTER FOR THIS TRANSMISSION
N407          FORMAT.                                                        (New code 8/1/07)
              THIS PAYER DOES NOT COVER DEDUCTIBLES ASSESSED BY A
N408          PREVIOUS PAYER.                                                (New code 8/1/07)
              THIS SERVICE IS RELATED TO AN ACCIDENTAL INJURY AND IS NOT
              COVERED UNLESS PROVIDED WITHIN A SPECIFIC TIME FRAME FROM
N409          THE DATE OF THE ACCIDENT.                                      (New code 8/1/07)
N410          THIS IS NOT COVERED UNLESS THE PRESCRIPTION CHANGES.           (New code 8/1/07)

                                                                             Will be deactivated
                                                                             on 2/1/09. Must be
                                                                             used with reason
N411          THIS SERVICE IS ALLOWED ONE TIME IN A 6-MONTH PERIOD.          code 119

                                                                             Will be deactivated
                                                                             on 2/1/09. Must be
                                                                             used with reason
N412          THIS SERVICE IS ALLOWED 2 TIMES IN A 12-MONTH PERIOD.          code 119

                                                                             Will be deactivated
                                                                             on 2/1/09. Must be
                                                                             used with reason
N413          THIS SERVICE IS ALLOWED 2 TIMES IN A BENEFIT YEAR.             code 119

                                                                             Will be deactivated
                                                                             on 2/1/09. Must be
                                                                             used with reason
N414          THIS SERVICE IS ALLOWED 4 TIMES IN A 12-MONTH PERIOD.          code 119

                                                                             Will be deactivated
                                                                             on 2/1/09. Must be
                                                                             used with reason
N415          THIS SERVICE IS ALLOWED 1 TIME IN AN 18-MONTH PERIOD.          code 119

                                                                             Will be deactivated
                                                                             on 2/1/09. Must be
                                                                             used with reason
N416          THIS SERVICE IS ALLOWED 1 TIME IN A 3-YEAR PERIOD.             code 119

                                                                             Will be deactivated
                                                                             on 2/1/09. Must be
                                                                             used with reason
N417          THIS SERVICE IS ALLOWED 1 TIME IN A 5-YEAR PERIOD.             code 119
              MISROUTED CLAIM. SEE THE PAYER'S CLAIM SUBMISSION
N418          INSTRUCTIONS.                                                  (New code 8/1/07)
              CLAIM PAYMENT WAS THE RESULT OF A PAYER'S RETROACTIVE
N419          ADJUSTMENT DUE TO A RETROACTIVE RATE CHANGE.                   (New code 8/1/07)




5/16/2012                                        Page 107
                                     835 Remittance Remark Master


835 REMIT
REMARK CODE   835 REMITTANCE REMARK CODE                                    NOTES
              CLAIM PAYMENT WAS THE RESULT OF A PAYER'S RETROACTIVE
              ADJUSTMENT DUE TO A COORDINATION OF BENEFITS OR THIRD PARTY
N420          LIABILITY RECOVERY.                                           (New code 8/1/07)

              CLAIM PAYMENT WAS THE RESULT OF A PAYER'S RETROACTIVE         (New code 8/1/07,
N421          ADJUSTMENT DUE TO A REVIEW ORGANIZATION DECISION.             Modified 2/29/08)
              CLAIM PAYMENT WAS THE RESULT OF A PAYER'S RETROACTIVE
N422          ADJUSTMENT DUE TO A PAYER'S CONTRACT INCENTIVE PROGRAM.       (New code 8/1/07)
              CLAIM PAYMENT WAS THE RESULT OF A PAYER'S RETROACTIVE
N423          ADJUSTMENT DUE TO A NON STANDARD PROGRAM.                     (New code 8/1/07)
              PATIENT DOES NOT RESIDE IN THE GEOGRAPHIC AREA REQUIRED FOR
N424          THIS TYPE OF PAYMENT.                                         (New code 8/1/07)
N425          STATUTORILY EXCLUDED SERVICE(S).                              (New code 8/1/07)
N426          NO COVERAGE WHEN SELF-ADMINISTERED.                        (New code 8/1/07)
              PAYMENT FOR EYEGLASSES OR CONTACT LENSES CAN BE MADE ONLY
N427          AFTER CATARACT SURGERY.                                    (New code 8/1/07)
              SERVICE/PROCEDURE NOT COVERED WHEN PERFORMED IN THIS PLACE
N428          OF SERVICE.                                                (New code 8/1/07)
N429          THIS IS NOT COVERED SINCE IT IS CONSIDERED ROUTINE.           (New code 8/1/07)

N430          PROCEDURE CODE IS INCONSISTENT WITH THE UNITS BILLED.         (New code 11/5/07)

N431          SERVICE IS NOT COVERED WITH THIS PROCEDURE.                   (New code 11/5/07)

N432          ADJUSTMENT BASED ON A RECOVERY AUDIT.                         (New code 11/5/07)
              RESUBMIT THIS CLAIM USING ONLY YOUR NATIONAL PROVIDER
N433          IDENTIFIER (NPI).                                             (New code 2/29/08)




5/16/2012                                        Page 108
                                     835 Remittance Remark Master




Arkansas Medicaid Revised 00/00/00




         5/16/2012                            Page 109
            835 Remittance Remark Master




5/16/2012            Page 110
            835 Remittance Remark Master




5/16/2012            Page 111
            835 Remittance Remark Master




5/16/2012            Page 112
            835 Remittance Remark Master




5/16/2012            Page 113
            835 Remittance Remark Master




5/16/2012            Page 114
            835 Remittance Remark Master




5/16/2012            Page 115
            835 Remittance Remark Master




5/16/2012            Page 116
            835 Remittance Remark Master




5/16/2012            Page 117
            835 Remittance Remark Master




5/16/2012            Page 118
            835 Remittance Remark Master




5/16/2012            Page 119
            835 Remittance Remark Master




5/16/2012            Page 120
            835 Remittance Remark Master




5/16/2012            Page 121
            835 Remittance Remark Master




5/16/2012            Page 122
            835 Remittance Remark Master




5/16/2012            Page 123
            835 Remittance Remark Master




5/16/2012            Page 124
            835 Remittance Remark Master




5/16/2012            Page 125
            835 Remittance Remark Master




5/16/2012            Page 126
            835 Remittance Remark Master




5/16/2012            Page 127
            835 Remittance Remark Master




5/16/2012            Page 128
            835 Remittance Remark Master




5/16/2012            Page 129
            835 Remittance Remark Master




5/16/2012            Page 130
            835 Remittance Remark Master




5/16/2012            Page 131
            835 Remittance Remark Master




5/16/2012            Page 132
            835 Remittance Remark Master




5/16/2012            Page 133
            835 Remittance Remark Master




5/16/2012            Page 134
            835 Remittance Remark Master




5/16/2012            Page 135
            835 Remittance Remark Master




5/16/2012            Page 136
            835 Remittance Remark Master




5/16/2012            Page 137
            835 Remittance Remark Master




5/16/2012            Page 138
            835 Remittance Remark Master




5/16/2012            Page 139
            835 Remittance Remark Master




5/16/2012            Page 140
                                                                             EOB TO 277 & 835



                                                                                                                                                 Arkansas Medicaid Revised 03/16/12
                                                                        EOB 277 & 835
                                                                                        835                                             277
                                     835 ADJ   835 ADJUSTMENT REASON CODE               REMIT    835 REMITTANCE REMARK CODE             CLAIM
EOB   HP DESCRIPTION                 REASON    DESCRIPTION                              REMARK   DESCRIPTION                            STATUS
001   DETAIL FROM DATE OF SERVICE 16           CLAIM/SERVICE LACKS INFORMATION          M52      MISSING/INCOMPLETE/INVALID “FROM”      188
      MISSING/ INVALID                         WHICH IS NEEDED FOR ADJUDICATION.                 DATE(S) OF SERVICE.
002   THE ADMITTING DATE OF          16        CLAIM/SERVICE LACKS INFORMATION          MA40     MISSING/INCOMPLETE/INVALID ADMISSION   189
      SERVICE IS MISSING OR INVALID.           WHICH IS NEEDED FOR ADJUDICATION.                 DATE.

003   THE TO SERVICE DATE IS           16      CLAIM/SERVICE LACKS INFORMATION          M59      MISSING/INCOMPLETE/INVALID “TO”        188
      INVALID.                                 WHICH IS NEEDED FOR ADJUDICATION.                 DATE(S) OF SERVICE.
004   DATES OF SERVICE SPAN STATE      A1      CLAIM DENIED CHARGES.                    MA31     MISSING/INCOMPLETE/INVALID BEGINNING   187
      FISCAL YEAR. PLEASE SUBMIT 2                                                               AND ENDING DATES OF THE PERIOD
      SEPARATE BILLS.                                                                            BILLED.
005   DATE OF DELIVERY/SURGERY         16      CLAIM/SERVICE LACKS INFORMATION          MA31     MISSING/INCOMPLETE/INVALID BEGINNING   187
      DOES NOT CORRESPOND WITH                 WHICH IS NEEDED FOR ADJUDICATION.                 AND ENDING DATES OF THE PERIOD
      HOSPITAL STAY                                                                              BILLED.
006   THE DISCHARGE DATE OF            16      CLAIM/SERVICE LACKS INFORMATION          N50      MISSING/INCOMPLETE/INVALID             190
      SERVICE IS MISSING OR INVALID.           WHICH IS NEEDED FOR ADJUDICATION.                 DISCHARGE INFORMATION.

007   TOTAL DAYS NOT EQUAL TO                                                           MA32     MISSING/INCOMPLETE/INVALID NUMBER      188
      THE DIFFERENCE BETWEEN THE                                                                 OF COVERED DAYS DURING THE BILLING
      "FROM" AND "TO" DATES.                                                                     PERIOD.
008   THIS REQUEST FOR PAYMENT         29      THE TIME LIMIT FOR FILING HAS EXPIRED.                                                   9
      WAS RECEIVED BEYOND 185
      DAYS MEDICAL BILLING
      LIMITATION.
009   THIS CLAIM WAS RECEIVED          29      THE TIME LIMIT FOR FILING HAS EXPIRED.                                                   9
      BEYOND THE 12 MONTH CLAIM
      SUBMISSION LIMITATION.
010   LEAVE OF ABSENCE DAYS NOT        96      NON-COVERED CHARGE(S).                   N43      BED HOLD OR LEAVE DAYS EXCEEDED.       498
      COVERED
011   MEDICARE PAID DATE INVALID.      129     PRIOR PROCESSING INFORMATION                                                             21
                                               APPEARS INCORRECT.
012   INPATIENT CLAIM MISSING A        16      CLAIM/SERVICE LACKS INFORMATION          M44      MISSING/INCOMPLETE/INVALID CONDITION 460
      REQUIRED CONDITION CODE.                 WHICH IS NEEDED FOR ADJUDICATION.                 CODE.
      REQUIRED CONDITION CODES
      ARE AB, AN, OR AX.
013   SERVICE INCLUDED IN FEE FOR      97      THE BENEFIT FOR THIS SERVICE IS                                                          247
      HOSPITAL VISIT                           INCLUDED IN THE PAYMENT/ALLOWANCE
                                               FOR ANOTHER SERVICE/PROCEDURE
                                               THAT HAS ALREADY BEEN ADJUDICATED.

014   CLAIM STILL IN PROCESS.                                                           N185     DO NOT RESUBMIT THIS CLAIM/SERVICE.    20
      PLEASE DO NOT REBILL.




                                                                                                                                                            Effective 10/22/10
                                                                         EOB TO 277 & 835



                                                                                 835                                             277
                                   835 ADJ   835 ADJUSTMENT REASON CODE          REMIT      835 REMITTANCE REMARK CODE           CLAIM
EOB   HP DESCRIPTION               REASON    DESCRIPTION                         REMARK     DESCRIPTION                          STATUS
015   STATE RECORDS INDICATE       16        CLAIM/SERVICE LACKS INFORMATION     N188       THE APPROVED LEVEL OF CARE DOES
      LEVEL OF CARE (LOC) AS --.             WHICH IS NEEDED FOR ADJUDICATION.              NOT MATCH THE PROCEDURE CODE
      TAKE NO ACTION IF CHANGE                                                              SUBMITTED.
      HAS BEEN MADE.
016   LOA CODE IS MISSING OR       16        CLAIM/SERVICE LACKS INFORMATION     N225       INCOMPLETE/INVALID                   21
      INVALID.                               WHICH IS NEEDED FOR ADJUDICATION.              DOCUMENTATION/ORDERS/NOTES/SUMMA
                                                                                            RY/REPORT/CHART.
017   INSUFFICIENT OR INVALID DATA 16        CLAIM/SERVICE LACKS INFORMATION     M44        MISSING/INCOMPLETE/INVALID CONDITION 460
      FOR THE CONDITION CODE                 WHICH IS NEEDED FOR ADJUDICATION.              CODE.
      AB/80. INDICATES MISSING OR
      INVALID TYPE OF RECIPIENT
      SEX, AGE RANGE OF RECIPIENT,
      OR DIAG. CODES.

018   DUPLICATE NUTRITIONAL        18        DUPLICATE CLAIM/SERVICE.                                                            54
      FORMULA PROCEDURES NOT
      REIMBURSEABLE ON THE SAME
      OR OVERLAPPING DATES OF
      SERVICE.
019   DOCUMENTATION INADEQUATE.    16        CLAIM/SERVICE LACKS INFORMATION     N29        MISSING/INCOMPLETE/INVALID       21
                                             WHICH IS NEEDED FOR ADJUDICATION.              DOCUMENTATION/ORDERS/NOTES/SUMMA
                                                                                            RY/REPORT/CHART.
020   NO LINE ITEMS PRESENT ON     16        CLAIM/SERVICE LACKS INFORMATION     N26        MISSING ITEMIZED BILL.           247
      THE CLAIM.                             WHICH IS NEEDED FOR ADJUDICATION.
021   TPL AMOUNT PRESENT ON THE    16        CLAIM/SERVICE LACKS INFORMATION     MA92       MISSING/INCOMPLETE/INVALID PLAN      171
      CLAIM; NO INSURANCE                    WHICH IS NEEDED FOR ADJUDICATION.              INFORMATION FOR OTHER INSURANCE.
      COMPANY INFORMATION
      PRESENT.
022   COVERED DAYS FORMAT                                                        MA32       MISSING/INCOMPLETE/INVALID NUMBER    456
      INVALID.                                                                              OF COVERED DAYS DURING THE BILLING
                                                                                            PERIOD.
023   LEAVE OF ABSENCE DAYS                                                      N43        BED HOLD OR LEAVE DAYS EXCEEDED.     456
      CUTBACK TO ALLOWED NUMBER
      OF DAYS PER STATE
      GUIDELINES.
024   TOTAL BILLED DOES NOT EQUAL                                                M54        MISSING/INCOMPLETE/INVALID TOTAL     400
      SUM OF DETAILS                                                                        CHARGES.
025   PATIENT STATUS CODE IS      16         CLAIM/SERVICE LACKS INFORMATION     MA43       MISSING/INCOMPLETE/INVALID PATIENT   234
      MISSING OR INVALID.                    WHICH IS NEEDED FOR ADJUDICATION.              STATUS.
026   ENTER TOS 8 IN FIELD C WHEN 16         CLAIM/SERVICE LACKS INFORMATION     MA67       CORRECTION TO A PRIOR CLAIM.         250
      BILLING FOR ASSISTANT                  WHICH IS NEEDED FOR ADJUDICATION.
      SURGEON.
027   REPORT ATTACHED DOES NOT    16         CLAIM/SERVICE LACKS INFORMATION     N225       INCOMPLETE/INVALID               294
      DESCRIBE PROCEDURE BILLED.             WHICH IS NEEDED FOR ADJUDICATION.              DOCUMENTATION/ORDERS/NOTES/SUMMA
                                                                                            RY/REPORT/CHART.




                                                                                                                                          Effective 10/22/10
                                                                         EOB TO 277 & 835



                                                                                  835                                              277
                                   835 ADJ   835 ADJUSTMENT REASON CODE           REMIT     835 REMITTANCE REMARK CODE             CLAIM
EOB   HP DESCRIPTION               REASON    DESCRIPTION                          REMARK    DESCRIPTION                            STATUS
028   PRIOR AUTHORIZATION IS       197       PRECERTIFICATION/AUTHORIZATION/NOTIF                                                  252
      REQUIRED FOR ASSISTANT                 ICATION ABSENT.
      SURGEON.
029   THIS AMOUNT WILL BE          23        THE IMPACT OF PRIOR PAYER(S)
      DEDUCTED FROM FUTURE                   ADJUDICATION INCLUDING PAYMENTS
      CLAIMS PROCESSING                      AND/OR ADJUSTMENTS.
030   RECOUPMENT OF OUR PRIOR      23        THE IMPACT OF PRIOR PAYER(S)                                                          101
      PAYMENT HAS BEEN MADE.                 ADJUDICATION INCLUDING PAYMENTS
      RESUBMIT THE CLAIM WITH A              AND/OR ADJUSTMENTS.
      COPY OF THE MEDICARE
      EXPLANATION OF BENEFITS.
031   PA WAS REQUESTED FOR        15         THE AUTHORIZATION NUMBER IS MISSING,                                                  84
      INCORRECT PROCEDURE CODE -             INVALID, OR DOES NOT APPLY TO THE
       PLEASE    CONTACT                     BILLED SERVICES OR PROVIDER.
      UTILIZATION REVIEW, ADEMS
032   INVALID DATA FOR THE        16         CLAIM/SERVICE LACKS INFORMATION        M44     MISSING/INCOMPLETE/INVALID CONDITION 460
      CONDITION CODE AN. THE                 WHICH IS NEEDED FOR ADJUDICATION.              CODE.
      ADMISSION DATA IS NOT EQUAL
      TO THE BIRTH DATE.
033   THIS PAYMENT, SUPPLEMENTED 22          THIS CARE MAY BE COVERED BY                                                           65
      BY A PREVIOUS PAYMENT MADE             ANOTHER PAYER PER COORDINATION OF
      BY MEDICARE, CONSTITUTES               BENEFITS.
      THE TOTAL PAYMENT.

034   SERVICE NOT PAYABLE TO                                                        N30     PATIENT INELIGIBLE FOR THIS SERVICE.   109
      POST STERILIZED RECIPIENTS
035   VERIFY UNITS OF SERVICE ON   154       PAYER DEEMS THE INFORMATION            M53     MISSING/INCOMPLETE/INVALID DAYS OR     476
      CLAIM FORM                             SUBMITTED DOES NOT SUPPORT THIS                UNITS OF SERVICE.
                                             DAY'S SUPPLY.
036   UNITS OF SERVICE ARE         16        CLAIM/SERVICE LACKS INFORMATION        M53     MISSING/INCOMPLETE/INVALID DAYS OR     476
      INCORRECT ON CLAIM FORM                WHICH IS NEEDED FOR ADJUDICATION.              UNITS OF SERVICE.
037   STAND BY FOR ANESTHESIA      125       SUBMISSION/BILLING ERROR(S).           MA66    MISSING/INCOMPLETE/INVALID PRINCIPAL   84
      SHOULD BE BILLED AS                                                                   PROCEDURE CODE.
      DETENTION TIME, NOT AS
      ANESTHESIA
038   WAIVER SERVICES                                                               MA31    MISSING/INCOMPLETE/INVALID BEGINNING 188
      PROCEDURES BEGIN/END                                                                  AND ENDING DATES OF THE PERIOD
      DATES NOT SAME MONTH                                                                  BILLED.
039   INAPPROPRIATE CLAIM FORM                                                      N34     INCORRECT CLAIM FORM/FORMAT FOR      481
      FOR PROCEDURE CODE                                                                    THIS SERVICE.
040   TYPE OF SERVICE IS MISSING   16        CLAIM/SERVICE LACKS INFORMATION        MA67    CORRECTION TO A PRIOR CLAIM.         250
      OR INVALID.                            WHICH IS NEEDED FOR ADJUDICATION.
                                             ADDITIONAL INFORMATION IS SUPPLIED
                                             USING REMITTANCE ADVICE REMARKS
                                             CODES WHENEVER APPROPRIATE.




                                                                                                                                            Effective 10/22/10
                                                                           EOB TO 277 & 835



                                                                                      835                                              277
                                    835 ADJ   835 ADJUSTMENT REASON CODE              REMIT    835 REMITTANCE REMARK CODE              CLAIM
EOB   HP DESCRIPTION                REASON    DESCRIPTION                             REMARK   DESCRIPTION                             STATUS
041   TYPE OF SERVICE OR            16        CLAIM/SERVICE LACKS INFORMATION         N56      PROCEDURE CODE BILLED IS NOT            250
      PROCEDURE IS INVALID.                   WHICH IS NEEDED FOR ADJUDICATION.                CORRECT/VALID FOR THE SERVICES
                                              ADDITIONAL INFORMATION IS SUPPLIED               BILLED OR THE DATE OF SERVICE BILLED.
                                              USING REMITTANCE ADVICE REMARKS
                                              CODES WHENEVER APPROPRIATE.
042   PLEASE DO NOT REBILL. CLAIM  133        THE DISPOSITION OF THIS CLAIM/SERVICE                                                    46
      IS BEING REVIEWED BY MEDICAL            IS PENDING FURTHER REVIEW.
        CONSULTANT.
043   PA REQUIRED FOR UNITS        197        PRECERTIFICATION/AUTHORIZATION/NOTIF                                                     252
      EXCEEDING 64 PER MONTH                  ICATION ABSENT.
044   OTHER INSURANCE AMOUNT IS    23         THE IMPACT OF PRIOR PAYER(S)                                                             171
      GREATER THAN THE TOTAL                  ADJUDICATION INCLUDING PAYMENTS
      BILLED.                                 AND/OR ADJUSTMENTS.
045   MEDICARE DENIED THIS CLAIM.                                                     N45      PAYMENT BASED ON AUTHORIZED             481
      IF THE SERVICE IS COVERED BY                                                             AMOUNT.
      ARKANSAS MEDICAID, YOU MAY
      SUBMIT A MEDICAID CLAIM TO
      EDS
046   EMERGENCY DEPARTMENT          40        CHARGES DO NOT MEET QUALIFICATIONS                                                       84
      SUPPLIES, DRUGS AND                     FOR EMERGENT/URGENT CARE.
      INJECTIONS ARE NOT ALLOWED
      WITHOUT AN EMERGENCY
      DEPARTMENT ROOM CHARGE
      ON THE SAME DATE.

047   PATIENTS UNMET LIABILITY      142       MONTHLY MEDICAID PATIENT LIABILITY                                                       106
      EXCEEDS CLAIM ALLOWED                   AMOUNT.
      AMOUNT
048   CLAIM PAYMENT REDUCED DUE     142       MONTHLY MEDICAID PATIENT LIABILITY                                                       68
      TO RECIPIENTS' UNMET                    AMOUNT.
      LIABILITY AMOUNT
049   EPSDT INTER/PERIODIC SCREEN   B5        COVERAGE/PROGRAM GUIDELINES WERE                                                         107
      NON-PAYABLE 7 DAYS                      NOT MET OR WERE EXCEEDED.
      BEFORE/AFTER FULL MEDICAL
      SCREEN
050   FULL MEDICAL SCREEN NON-      B5        COVERAGE/PROGRAM GUIDELINES WERE                                                         107
      PAYABLE 7 DAYS                          NOT MET OR WERE EXCEEDED.
      BEFORE/AFTER EPSDT
      INTER/PERIODIC SCREEN
051   EXCEEDS LIMIT OF 60 SERVICE   B5        COVERAGE/PROGRAM GUIDELINES WERE                                                         483
      COORDINATION PER STATE                  NOT MET OR WERE EXCEEDED.
      FISCAL YEAR
052   EXCEEDS LIMIT OF 16 SERVICE   B5        COVERAGE/PROGRAM GUIDELINES WERE                                                         483
      PLAN UPDATING UNITS PER                 NOT MET OR WERE EXCEEDED.
      STATE FISCAL YEAR




                                                                                                                                                Effective 10/22/10
                                                                            EOB TO 277 & 835



                                                                                       835                                             277
                                     835 ADJ   835 ADJUSTMENT REASON CODE              REMIT    835 REMITTANCE REMARK CODE             CLAIM
EOB   HP DESCRIPTION                 REASON    DESCRIPTION                             REMARK   DESCRIPTION                            STATUS
053   POST-OP VISITS FOR SAME                                                          M144     PRE-/POST-OPERATIVE CARE PAYMENT IS    107
      PRIMARY DETAIL DX AS THIS                                                                 INCLUDED IN THE ALLOWANCE FOR THE
      SURGICAL PROCEDURE HAVE                                                                   SURGERY/PROCEDURE.
      BEEN PAID TO SAME/DIFFERENT
      PROVIDER; SUBMIT
      ADJUSTMENT IF APPLICABLE

054   PROCEDURE NOT COVERED          96        NON-COVERED CHARGE(S).                  MA66     MISSING/INCOMPLETE/INVALID PRINCIPAL   475
      FOR RECIPIENTS AGE 21 OR                                                                  PROCEDURE CODE.
      OLDER
055   FACILITY PROVIDER ID MISSING   171       PAYMENT IS DENIED WHEN                                                                  132
      OR INVALID                               PERFORMED/BILLED BY THIS TYPE OF
                                               PROVIDER IN THIS TYPE OF FACILITY.
056   PERS LIMITED TO 31 UNITS PER   119       BENEFIT MAXIMUM FOR THE TIME PERIOD                                                     483
      MONTH.                                   OR OCCURRENCE HAS BEEN REACHED.

057   ADULT FOSTER CARE LIMITED      119       BENEFIT MAXIMUM FOR THE TIME PERIOD                                                     483
      TO 31 UNITS PER MONTH.                   OR OCCURRENCE HAS BEEN REACHED.

058   CLAIM IN ADJUDICATION.                                                           N185     DO NOT RESUBMIT THIS CLAIM/SERVICE.    3
      PLEASE DO NOT REBILL.
059   CLAIM BEING REVIEWED BY    133           THE DISPOSITION OF THIS CLAIM/SERVICE                                                   46
      PHARMACY CONSULTANT.                     IS PENDING FURTHER REVIEW.
      PLEASE DO NOT REBILL.
060   SPANNING DOS. DOS MUST BE                                                        N61      REBILL SERVICES ON SEPARATE CLAIMS.    187
      SPECIFIC TO DAY SERVICE
      RENDERED. PLEASE RESUBMIT.

061   PAID IN FULL BY MEDICAID.                                                        N45      PAYMENT BASED ON AUTHORIZED            67
                                                                                                AMOUNT.
062   ADULT SERVICES - LIMITED TO  119         BENEFIT MAXIMUM FOR THE TIME PERIOD                                                     483
      155 UNITS PER CALENDAR                   OR OCCURRENCE HAS BEEN REACHED.
      MONTH
063   MEDICAL SUPPLIES OR DIAPERS/                                                     N74      RESUBMIT WITH MULTIPLE CLAIMS, EACH    187
      UNDERPADS CANNOT SPAN                                                                     CLAIM COVERING SERVICES PROVIDED IN
      CALENDAR MONTHS                                                                           ONLY ONE CALENDAR MONTH.

064   EXCEEDS BENEFIT LIMIT OF       119       BENEFIT MAXIMUM FOR THE TIME PERIOD                                                     483
      TWO ULTRASOUND                           OR OCCURRENCE HAS BEEN REACHED.
      PROCEDURES PER     NINE-
      MONTH PERIOD.
065   RESPITE CARE CUT BACK TO 14    119       BENEFIT MAXIMUM FOR THE TIME PERIOD                                                     456
      CONSECUTIVE DAYS                         OR OCCURRENCE HAS BEEN REACHED.




                                                                                                                                                Effective 10/22/10
                                                                             EOB TO 277 & 835



                                                                                       835                                           277
                                    835 ADJ   835 ADJUSTMENT REASON CODE               REMIT    835 REMITTANCE REMARK CODE           CLAIM
EOB   HP DESCRIPTION                REASON    DESCRIPTION                              REMARK   DESCRIPTION                          STATUS
066   ARKIDS FIRST-B PARTICIPANT    119       BENEFIT MAXIMUM FOR THE TIME PERIOD                                                    483
      CUMULATIVE ALLOWED                      OR OCCURRENCE HAS BEEN REACHED.
      EXCEEDS $500 PER STATE
      FISCAL YEAR FOR DME.
067   ARKIDS FIRST-B PARTICIPANT    119       BENEFIT MAXIMUM FOR THE TIME PERIOD                                                    483
      EXCEEDED $125 LIMIT FOR                 OR OCCURRENCE HAS BEEN REACHED.
      MEDICAL SUPPLIES.
068   EXCEEDS BENEFIT LIMIT OF FIVE 119       BENEFIT MAXIMUM FOR THE TIME PERIOD                                                    483
      FETAL NON-STRESS TESTS PER              OR OCCURRENCE HAS BEEN REACHED.
       NINE-MONTH PERIOD.

069   EXCEEDS PROGRAM               B5        COVERAGE/PROGRAM GUIDELINES WERE                                                       483
      LIMITATIONS.                            NOT MET OR WERE EXCEEDED.
070   NOT IN ACCORD WITH MEDICAL    96        NON-COVERED CHARGE(S).                   M16      ALERT: PLEASE SEE OUR WEB SITE,      9
      POLICY GUIDELINES.                                                                        MAILING, OR BULLETINS FOR MORE
                                                                                                DETAILS CONCERNING THIS
                                                                                                POLICY/PROCEDURE/DECISION.
071   EXCEEDS LIMIT OF FOUR UNITS   119       BENEFIT MAXIMUM FOR THE TIME PERIOD                                                    483
      PER WEEK FOR INDIVIDUAL                 OR OCCURRENCE HAS BEEN REACHED.
      OUTPT - THERAPY SESSION

072   ONLY ONE PSYCHOTHERAPY        119       BENEFIT MAXIMUM FOR THE TIME PERIOD                                                    483
      VISIT ALLOWED PER DATE OF               OR OCCURRENCE HAS BEEN REACHED.
      SERVICE PER RECIPIENT
073   LACKS JUSTIFICATION FOR       29        THE TIME LIMIT FOR FILING HAS EXPIRED.                                                 9
      WAITING TIME.
074   VENIPUNCTURE NON-PAYABLE      97        THE BENEFIT FOR THIS SERVICE IS          M86      SERVICE DENIED BECAUSE PAYMENT       107
      SAME DATE OF SERVICE AS LAB             INCLUDED IN THE PAYMENT/ALLOWANCE                 ALREADY MADE FOR SAME/SIMILAR
      TEST                                    FOR ANOTHER SERVICE/PROCEDURE                     PROCEDURE WITHIN SET TIME FRAME.
                                              THAT HAS ALREADY BEEN ADJUDICATED.

075   EXCEEDED 720 UNITS PER 12     119       BENEFIT MAXIMUM FOR THE TIME PERIOD      N182     THIS CLAIM/SERVICE MUST BE BILLED    483
      MONTH PERIOD FOR RESPITE                OR OCCURRENCE HAS BEEN REACHED.                   ACCORDING TO THE SCHEDULE FOR THIS
      CARE                                                                                      PLAN.
076   EXCEEDED 12 PROFESSIONAL      119       BENEFIT MAXIMUM FOR THE TIME PERIOD      N45      PAYMENT BASED ON AUTHORIZED          483
      OUTPATIENT HOSPITAL VISITS              OR OCCURRENCE HAS BEEN REACHED.                   AMOUNT.
      FOR STATE FISCAL YEAR
077   THERAPY SERVICES INDICATOR    16        CLAIM/SERVICE LACKS INFORMATION          MA114    MISSING/INCOMPLETE/INVALID           21
      AND/OR SCHOOL DISTRICT LEA              WHICH IS NEEDED FOR ADJUDICATION.                 INFORMATION ON WHERE THE SERVICES
      CODE MISSING/INVALID                                                                      WERE FURNISHED.

078   BREASTCARE CLIENT -           125       SUBMISSION/BILLING ERROR(S).             N182     THIS CLAIM/SERVICE MUST BE BILLED    9
      BREASTCARE SERVICES MUST                                                                  ACCORDING TO THE SCHEDULE FOR THIS
      BE BILLED ON BREASTCARE                                                                   PLAN.
      CLAIM.




                                                                                                                                              Effective 10/22/10
                                                                             EOB TO 277 & 835



                                                                                     835                                               277
                                    835 ADJ   835 ADJUSTMENT REASON CODE             REMIT      835 REMITTANCE REMARK CODE             CLAIM
EOB   HP DESCRIPTION                REASON    DESCRIPTION                            REMARK     DESCRIPTION                            STATUS
079   BILLING PROVIDER -            125       SUBMISSION/BILLING ERROR(S).           N182       THIS CLAIM/SERVICE MUST BE BILLED      9
      BREASTCARE SERVICES MUST                                                                  ACCORDING TO THE SCHEDULE FOR THIS
      BE BILLED ON BREASTCARE                                                                   PLAN.
      CLAIM.
080   PAID TO PHYSICIAN PROVIDING                                                    N32        CLAIM MUST BE SUBMITTED BY THE     65
      SERVICE.                                                                                  PROVIDER WHO RENDERED THE SERVICE.

081   DUPLICATE CHARGE. NO          18        DUPLICATE CLAIM/SERVICE.               M86        SERVICE DENIED BECAUSE PAYMENT         54
      JUSTIFICATION TO SHOW                                                                     ALREADY MADE FOR SAME/SIMILAR
      MEDICAL NECESSITY                                                                         PROCEDURE WITHIN SET TIME FRAME.
082   PERFORMING PROVIDER -         125       SUBMISSION/BILLING ERROR(S).           N182       THIS CLAIM/SERVICE MUST BE BILLED      9
      BREASTCARE SERVICES MUST                                                                  ACCORDING TO THE SCHEDULE FOR THIS
      BE BILLED ON BREASTCARE                                                                   PLAN.
      CLAIM.
083   EVALUATION LIMITED TO FOUR    119       BENEFIT MAXIMUM FOR THE TIME PERIOD    M86        SERVICE DENIED BECAUSE PAYMENT         483
      PER STATE FISCAL YEAR.                  OR OCCURRENCE HAS BEEN REACHED.                   ALREADY MADE FOR SAME/SIMILAR
                                                                                                PROCEDURE WITHIN SET TIME FRAME.
084   TRANSPORTATION SERVICES     107         THE RELATED OR QUALIFYING                                                                42
      ALLOWED ONLY WHEN BILLED IN             CLAIM/SERVICE WAS NOT IDENTIFIED ON
      CONJUNCTION WITH A0370 OR               THIS CLAIM.
      A0427.
085   LEAVE OF ABSENCE DENIED PER 96          NON-COVERED CHARGE(S).                 N43        BED HOLD OR LEAVE DAYS EXCEEDED.       457
      MEDICAL GUIDELINES.
086   PA REQUIRED FOR ARKIDS      197         PRECERTIFICATION/AUTHORIZATION/NOTIF M62          MISSING/INCOMPLETE/INVALID             483
      FIRST-B PARTICIPANTS                    ICATION ABSENT.                                   TREATMENT AUTHORIZATION CODE.
      EXCEEDING $500 LIMIT PER
      STATE FISCAL YEAR FOR
      MENTAL HEALTH SERVICES.
087   OPERATIVE REPORT THAT WAS                                                      M29        MISSING OPERATIVE REPORT.              298
      ATTACHED DID NOT DESCRIBE
      THE PROCEDURE THAT WAS
      BILLED ON YOUR CLAIM.

088   ARKIDS FIRST-B PARTICIPANTS   119       BENEFIT MAXIMUM FOR THE TIME PERIOD                                                      483
      EXCEEDED $2500 LIMIT PER                OR OCCURRENCE HAS BEEN REACHED.
      STATE FISCAL YEAR FOR
      MENTAL HEALTH SERVICES.

089   DIAGNOSIS/EVALUATION          119       BENEFIT MAXIMUM FOR THE TIME PERIOD                                                      483
      EXCEEDS TWO PER STATE                   OR OCCURRENCE HAS BEEN REACHED.
      FISCAL YEAR
090   DAY OF DISCHARGE NOT          96        NON-COVERED CHARGE(S).                 N50        MISSING/INCOMPLETE/INVALID             190
      COVERED.                                                                                  DISCHARGE INFORMATION.
091   THERAPY SERVICES INDICATOR    16        CLAIM/SERVICE LACKS INFORMATION        N129       NOT ELIGIBLE DUE TO THE PATIENT'S AGE. 21
      INVALID FOR RECIPIENT'S AGE             WHICH IS NEEDED FOR ADJUDICATION.




                                                                                                                                                Effective 10/22/10
                                                                            EOB TO 277 & 835



                                                                                       835                                             277
                                    835 ADJ   835 ADJUSTMENT REASON CODE               REMIT    835 REMITTANCE REMARK CODE             CLAIM
EOB   HP DESCRIPTION                REASON    DESCRIPTION                              REMARK   DESCRIPTION                            STATUS
092   THERAPY SERVICES INDICATOR    16        CLAIM/SERVICE LACKS INFORMATION          N95      THIS PROVIDER TYPE/PROVIDER            21
      INVALID FOR PROVIDER TYPE               WHICH IS NEEDED FOR ADJUDICATION.                 SPECIALTY MAY NOT BILL THIS SERVICE.

093   EXCEEDS LIMIT OF FOUR         119       BENEFIT MAXIMUM FOR THE TIME PERIOD      N45      PAYMENT BASED ON AUTHORIZED            483
      TREATMENTS PER STATE                    OR OCCURRENCE HAS BEEN REACHED.                   AMOUNT.
      FISCAL YEAR
094   SERVICES EXCEED LIMIT OF      119       BENEFIT MAXIMUM FOR THE TIME PERIOD      N45      PAYMENT BASED ON AUTHORIZED            483
      $75.00 PER DATE OF SERVICE              OR OCCURRENCE HAS BEEN REACHED.                   AMOUNT.

095   THIS SERVICE WAS REVIEWED                                                        N10      CLAIM/SERVICE ADJUSTED BASED ON THE 107
      BY OUR MEDICAL CONSULTANT                                                                 FINDINGS OF A REVIEW
      AND WAS DENIED.                                                                           ORGANIZATION/PROFESSIONAL
                                                                                                CONSULT/MANUAL
                                                                                                ADJUDICATION/MEDICAL OR DENTAL
                                                                                                ADVISOR.
096   THIS CLAIM TYPE CAN ONLY BE                                                      M117     NOT COVERED UNLESS SUBMITTED VIA   481
      BILLED USING AEVCS                                                                        ELECTRONIC CLAIM.
097   RECIPIENT HAS MEDICARE HMO. 109         CLAIM NOT COVERED BY THIS                MA04     SECONDARY PAYMENT CANNOT BE        116
      BENEFITS LIMITED TO                     PAYER/CONTRACTOR. YOU MUST SEND                   CONSIDERED WITHOUT THE IDENTITY OF
      COPAYMENT AMOUNTS ONLY.                 THE CLAIM TO THE CORRECT                          OR PAYMENT INFORMATION FROM THE
      PLEASE FILE MEDICARE HMO                PAYER/CONTRACTOR.                                 PRIMARY PAYER. THE INFORMATION WAS
      FIRST.                                                                                    EITHER NOT REPORTED OR WAS
                                                                                                ILLEGIBLE.
098   SERVICE NOT PROVIDED UNDER 96           NON-COVERED CHARGE(S).                   N425     STATUTORILY EXCLUDED SERVICE(S).       107
      THE MEDICAID PROGRAM.

099   CLAIM DENIED. VALID DATE OF   57        PAYMENT DENIED/REDUCED BECAUSE        N301        MISSING/INCOMPLETE/INVALID             187
      SERVICE REQUIRED ON EACH                THE PAYER DEEMS THE INFORMATION                   PROCEDURE DATE(S).
      DETAIL.                                 SUBMITTED DOES NOT SUPPORT THIS
                                              LEVEL OF SERVICE, THIS MANY SERVICES,
                                              THIS LENGTH OF SERVICE, THIS DOSAGE,
                                              OR THIS DAY'S SUPPLY.
100   SERVICES ARE NOT PAYABLE IN   A1        CLAIM DENIED CHARGES.                    N351     SERVICE DATE OUTSIDE OF THE        9
      ADVANCE.                                                                                  APPROVED TREATMENT PLAN SERVICE
                                                                                                DATES.
101   JUSTIFICATION REQUIRED FOR    16        CLAIM/SERVICE LACKS INFORMATION          MA130    YOUR CLAIM CONTAINS INCOMPLETE     294
      SERVICES RENDERED.                      WHICH IS NEEDED FOR ADJUDICATION.                 AND/OR INVALID INFORMATION, AND NO
                                                                                                APPEAL RIGHTS ARE AFFORDED BECAUSE
                                                                                                THE CLAIM IS UNPROCESSABLE. PLEASE
                                                                                                SUBMIT A NEW CLAIM WITH THE
                                                                                                COMPLETE/CORRECT INFORMATION.

102   THIS REQUEST FOR PAYMENT      29        THE TIME LIMIT FOR FILING HAS EXPIRED.                                                   9
      WAS RECEIVED BEYOND THE
      185 DAYS LIMITATION FOR
      MEDICAID BILLING.




                                                                                                                                                Effective 10/22/10
                                                                            EOB TO 277 & 835



                                                                                       835                                            277
                                    835 ADJ   835 ADJUSTMENT REASON CODE               REMIT    835 REMITTANCE REMARK CODE            CLAIM
EOB   HP DESCRIPTION                REASON    DESCRIPTION                              REMARK   DESCRIPTION                           STATUS
103   THIS CLAIM WAS RECEIVED       29        THE TIME LIMIT FOR FILING HAS EXPIRED.                                                  9
      BEYOND THE 12 MONTH
      SUBMISSION LIMITATION.
104   DIAGNOSIS/EVALUATION         119        BENEFIT MAXIMUM FOR THE TIME PERIOD                                                     483
      EXCEEDS EIGHT PER STATE                 OR OCCURRENCE HAS BEEN REACHED.
      FISCAL YEAR
105   DIAGNOSIS/EVALUATION         119        BENEFIT MAXIMUM FOR THE TIME PERIOD                                                     483
      EXCEEDS SIX PER STATE FISCAL            OR OCCURRENCE HAS BEEN REACHED.
      YEAR
106   DIAGNOSIS/ EVALUATION        119        BENEFIT MAXIMUM FOR THE TIME PERIOD                                                     483
      EXCEEDS FOUR PER STATE                  OR OCCURRENCE HAS BEEN REACHED.
      FISCAL YEAR
107   CHMS PROVIDERS CAN NOT BILL                                                      N61      REBILL SERVICES ON SEPARATE CLAIMS.   252
      SPANNING DATES OF SERVICE
      FOR RECIPIENTS REQUIRING
      AFMC PRIOR AUTHORIZATION
      FOR PART OF THE SERVICES
      BILLED. PLEASE SUBMIT AS
      SEPARATE DETAILS.

108   DETAIL BEGIN/END DATES MUST                                                      MA31     MISSING/ INCOMPLETE/INVALID           187
      BE IN SAME MONTH AND EQUAL                                                                BEGINNING AND ENDING DATES OF
      NUMBER OF UNITS BILLED EACH                                                               SERVICE
      DAY FOR SPAN DATES OF
      SERVICE
109   TIME NOT EQUAL TO UNITS,                                                         M53      MISSING/INCOMPLETE/INVALID DAYS OR    251
      CORRECT AND REFILE                                                                        UNITS OF SERVICE.
110   MEDICARE PAYMENT EXCEEDS      45        CHARGES EXCEEDS FEE                      N45      PAYMENT BASED ON AUTHORIZED           9
      MEDICAID MAX ALLOWED FOR                SCHEDULE/MAXIMUM ALLOWABLE OR                     AMOUNT.
      PROCEDURE.RECIPIENT NOT                 CONTRACTED/LEGISLTATED FEE
      RESPONSIBLE.                            ARRANGMENT. (USE GROUPE CODES PR
                                              OR CO DEPENDING ON LIABILITY).
111   PAYMENT AMOUNT ADDED TO       97        THE BENEFIT FOR THIS SERVICE IS                                                         65
      CLAIMS PAYMENT.                         INCLUDED IN THE PAYMENT/ALLOWANCE
                                              FOR ANOTHER SERVICE/PROCEDURE
                                              THAT HAS ALREADY BEEN ADJUDICATED.

112   RECOUPMENT - THIS AMOUNT IS 23          THE IMPACT OF PRIOR PAYER(S)                                                            101
      WITHHELD FROM YOUR CHECK.               ADJUDICATION INCLUDING PAYMENTS
                                              AND/OR ADJUSTMENTS.
113   REFUND CHECK AMOUNT
      CREDITED TO YOUR IRS YEAR
      TOTAL.
114   RETURNED CHECK AMOUNT
      CREDITED TO YOUR IRS YEAR
      TOTAL




                                                                                                                                               Effective 10/22/10
                                                                             EOB TO 277 & 835



                                                                                        835                                           277
                                     835 ADJ   835 ADJUSTMENT REASON CODE               REMIT    835 REMITTANCE REMARK CODE           CLAIM
EOB    HP DESCRIPTION                REASON    DESCRIPTION                              REMARK   DESCRIPTION                          STATUS
115    PAYMENT APPLIED TO            97        THE BENEFIT FOR THIS SERVICE IS                                                        65
       RECEIVABLE.                             INCLUDED IN THE PAYMENT/ALLOWANCE
                                               FOR ANOTHER SERVICE/PROCEDURE
                                               THAT HAS ALREADY BEEN ADJUDICATED.

116    CLAIM IN PROCESS DUE TO       133       THE DISPOSITION OF THIS CLAIM/SERVICE                                                  20
       REVIEW OF CLAIM HISTORY.                IS PENDING FURTHER REVIEW.
       PLEASE DO NOT RESUBMIT.
 117   INVALID NCCI BILLING          96        NON-COVERED CHARGE(S).                   N59      ATTN: PLEASE REFER TO YOUR PROVIDER 54
       COMBINATIONS - CMS ALLOWS                                                                 MANUAL FOR ADDITIONAL PROGRAM AND
       APPEAL.                                                                                   PROVIDER INFORMATION.

118    DENIED BY MEDICARE.                                                                                                            9

119    NOT COVERED UNDER THE       96          NON-COVERED CHARGE(S).                   N78      THE NECESSARY COMPONENTS OF THE     107
       PROGRAM EXCEPT UNDER                                                                      CHILD AND TEEN CHECKUP (EPSDT) WERE
       EPSDT.                                                                                    NOT COMPLETED.
120    PROVIDER TYPE CAN ONLY BE A                                                      N32      CLAIM MUST BE SUBMITTED BY THE      84
       PERFORMING PROVIDER.                                                                      PROVIDER WHO RENDERED THE SERVICE.

121    THIS NEW BALANCE IS A                                                                                                          101
       RECOUPMENT STILL
       OUTSTANDING.
122    INVALID/MULTIPLE PROVIDER     B7        THIS PROVIDER WAS NOT                    N55      PROCEDURES FOR BILLING WITH          145
       DISCIPLINE FOR PROVIDER                 CERTIFIED/ELIGIBLE TO BE PAID FOR THIS            GROUP/REFERRING/PERFORMING
       SPECIALTY                               PROCEDURE/SERVICE ON THIS DATE OF                 PROVIDERS WERE NOT FOLLOWED.
                                               SERVICE.
123    INVALID DATA FOR THE          17        REQUESTED INFORMATION WAS NOT            M44      MISSING/INCOMPLETE/INVALID CONDITION 460
       CONDITION CODE AX/82.                   PROVIDED OR WAS                                   CODE.
       INDICATES INVALID TYPE OF               INSUFFICINET/INCOMPLETE.
       RECIPIENT SEX, AGE RANGE OF
       RECIPIENT, DIAGNOSIS CODE,
       OR BIRTH DATE NOT EQUAL TO
       THE ADMISSION DATE.

124    ARKIDS FIRST-B PARTICIPANT  197         PRECERTIFICATION/AUTHORIZATION/NOTIF                                                   483
       CUMULATIVE ALLOWED AMOUNT               ICATION ABSENT.
       EXCEEDS$500 PER SFY '98 FOR
       OUTPATIENT MENTAL AND
       BEHAVIORAL HEALTH SERVICES.
       PRIOR AUTHORIZATION
       REQUIRED.
125    THE TOOTH NUMBER IS MISSING 16          CLAIM/SERVICE LACKS INFORMATION          N37      MISSING/INCOMPLETE/INVALID TOOTH     244
       OR INVALID.                             WHICH IS NEEDED FOR ADJUDICATION.                 NUMBER/LETTER.
126    THE TOOTH SURFACE CODE IS   16          CLAIM/SERVICE LACKS INFORMATION          N75      MISSING/INCOMPLETE/INVALID TOOTH     240
       MISSING OR INVALID                      WHICH IS NEEDED FOR ADJUDICATION.                 SURFACE INFORMATION.




                                                                                                                                               Effective 10/22/10
                                                                             EOB TO 277 & 835



                                                                                    835                                                277
                                     835 ADJ   835 ADJUSTMENT REASON CODE           REMIT       835 REMITTANCE REMARK CODE             CLAIM
EOB   HP DESCRIPTION                 REASON    DESCRIPTION                          REMARK      DESCRIPTION                            STATUS
127   PRIOR AUTHORIZATION            197       PRECERTIFICATION/AUTHORIZATION/NOTIF N54         CLAIM INFORMATION IS INCONSISTENT      483
      REQUIRED FOR OUTPATIENT                  ICATION ABSENT.                                  WITH PRE-CERTIFIED/AUTHORIZED
      MENTAL HEALTH VISITS OVER                                                                 SERVICES.
      FOUR
128   PROC REQUIRES A VALID TOOTH 16           CLAIM/SERVICE LACKS INFORMATION          N37     MISSING/INCOMPLETE/INVALID TOOTH       244
      NO. PROC D1351/01351                     WHICH IS NEEDED FOR ADJUDICATION.                NUMBER/LETTER.
      REQUIRES A TOOTH NO. OF
      2,3,14,15,18,19,30 OR 31. ALL
      OTHER PROC REQUIRE A TOOTH
      NO. BETWEEN 1-9,10-32,51-82,A-
      T,AS-TS.

129   EXCEEDS LIMIT OF 1             119       BENEFIT MAXIMUM FOR THE TIME PERIOD                                                     483
      WHEELCHAIR PER 2 YEAR                    OR OCCURRENCE HAS BEEN REACHED.
      PERIOD
130   PUBLIC TRANSPORTATION          119       BENEFIT MAXIMUM FOR THE TIME PERIOD      N45     PAYMENT BASED ON AUTHORIZED            483
      LIMITED TO 30 UNITS PER DATE             OR OCCURRENCE HAS BEEN REACHED.                  AMOUNT.
      OF SERVICE
131   NON-COVERED                    96        NON-COVERED CHARGE(S).                   N157    TRANSPORTATION TO/FROM THIS            84
      TRANSPORTATION SERVICE                                                                    DESTINATION IS NOT COVERED.
      BASED ON RECIPIENT'S COUNTY
      OF RESIDENCE
132   SUBMISSION DATE DOES NOT       29        THE TIME LIMIT FOR FILING HAS EXPIRED.   N102    THIS CLAIM HAS BEEN DENIED WITHOUT     9
      MEET TIMELY FILING                                                                        REVIEWING THE MEDICAL RECORD
      REQUIREMENTS.                                                                             BECAUSE THE REQUESTED RECORDS
                                                                                                WERE NOT RECEIVED OR WERE NOT
                                                                                                RECEIVED TIMELY.
133   INDICATE ON YOUR INVOICE IF    16        CLAIM/SERVICE LACKS INFORMATION          N225    INCOMPLETE/INVALID               21
      THIS LENS IS INVESTIGATIONAL             WHICH IS NEEDED FOR ADJUDICATION.                DOCUMENTATION/ORDERS/NOTES/SUMMA
      OR FDA APPROVED                                                                           RY/REPORT/CHART.

134   MORE MEDICAL INFORMATION       16        CLAIM/SERVICE LACKS INFORMATION          N29     MISSING/INCOMPLETE/INVALID             123
      NECESSARY                                WHICH IS NEEDED FOR ADJUDICATION.                DOCUMENTATION/ORDERS/NOTES/SUMMA
                                                                                                RY/REPORT/CHART.
135   PROCEDURE CODE LIMITED TO      96        NON-COVERED CHARGE(S).                   N30     RECIPIENT INELIGIBLE FOR THIS SERVICE. 84
      RECIPIENTS IN AID CATEGORY
      69 ONLY
136   PLACE OF SERVICE MISSING OR    16        CLAIM/SERVICE LACKS INFORMATION          M77     MISSING/INCOMPLETE/INVALID PLACE OF    249
      INVALID                                  WHICH IS NEEDED FOR ADJUDICATION.                SERVICE.
137   PAID CLAIM FOR SAME DOS IN     45        CHARGES EXCEEDS FEE                      N45     PAYMENT BASED ON AUTHORIZED            107
      RELATED HISTORY PAYMENT                  SCHEDULE/MAXIMUM ALLOWABLE OR                    AMOUNT.
      CUT BACK TO MAX ALLOWABLE.               CONTRACTED/LEGISLTATED FEE
                                               ARRANGMENT. (USE GROUPE CODES PR
                                               OR CO DEPENDING ON LIABILITY).
138   DIAGNOSIS CODE INVALID FOR     11        THE DIAGNOSIS IS INCONSISTENT WITH       M50     MISSING/INCOMPLETE/INVALID REVENUE     488
      REVENUE CODE                             THE PROCEDURE.                                   CODE(S).




                                                                                                                                                Effective 10/22/10
                                                                           EOB TO 277 & 835



                                                                                     835                                            277
                                    835 ADJ   835 ADJUSTMENT REASON CODE             REMIT    835 REMITTANCE REMARK CODE            CLAIM
EOB   HP DESCRIPTION                REASON    DESCRIPTION                            REMARK   DESCRIPTION                           STATUS
139   SURGICAL/OBSTETRICAL          B18       THIS PROCEDURE CODE AND MODIFIER       N65      PROCEDURE CODE OR PROCEDURE RATE      454
      PROCEDURE NOT ON FILE.                  WERE INVALID ON THE DATE OF SERVICE.            COUNT CANNOT BE DETERMINED, OR
                                                                                              WAS NOT ON FILE, FOR THE DATE OF
                                                                                              SERVICE/PROVIDER.
140   MODIFIER MISSING OR INVALID   4         THE PROCEDURE CODE IS INCONSISTENT     M78      MISSING/INCOMPLETE/INVALID HCPCS      453
      FOR PROCEDURE CODE/TOS                  WITH THE MODIFIER USED OR A                     MODIFIER.
                                              REQUIRED MODIFIER IS MISSING.

141   PROSTHETIC DEVICE(S)          119       BENEFIT MAXIMUM FOR THE TIME PERIOD    M90      NOT COVERED MORE THAN ONCE IN A 12    483
      EXCEEDS $20,000 PER STATE               OR OCCURRENCE HAS BEEN REACHED.                 MONTH PERIOD.
      FISCAL YEAR
142   PROSTHETICS DEVICE LIMITED    119       BENEFIT MAXIMUM FOR THE TIME PERIOD                                                   483
      TO ONE PER FIVE YEARS                   OR OCCURRENCE HAS BEEN REACHED.

143   ORTHOTIC APPLIANCE EXCEEDS 119          BENEFIT MAXIMUM FOR THE TIME PERIOD    M90      NOT COVERED MORE THAN ONCE IN A 12    483
      $3,000 PER STATE FISCAL YEAR            OR OCCURRENCE HAS BEEN REACHED.                 MONTH PERIOD.

144   ORTHOTIC APPLIANCE LIMITED    119       BENEFIT MAXIMUM FOR THE TIME PERIOD    M90      NOT COVERED MORE THAN ONCE IN A 12    483
      TO ONE PER 12 MONTH PERIOD              OR OCCURRENCE HAS BEEN REACHED.                 MONTH PERIOD.

145   DIAGNOSIS INVALID FOR         11        THE DIAGNOSIS IS INCONSISTENT WITH      M64     MISSING/INCOMPLETE/INVALID OTHER      488
      PROCEDURE CODE                          THE PROCEDURE.                                  DIAGNOSIS.
146   PROVIDER IS NOT CERTIFIED     B7        THIS PROVIDER WAS NOT                   MA120   MISSING/INCOMPLETE/INVALID CLIA       109
      FOR PROCEDURE                           CERTIFIED/ELIGIBLE TO BE PAID FOR THIS          CERTIFICATION NUMBER.
                                              PROCEDURE/SERVICE ON THIS DATE OF
                                              SERVICE.
147   PROCEDURE/NDC/REVENUE         47        THIS (THESE) DIAGNOSIS(ES) IS (ARE) NOT M20     MISSING/INCOMPLETE/INVALID HCPCS.     454
      CODE MISSING OR INVALID.                COVERED, MISSING, OR ARE INVALID.

148   PROCEDURE INAPPROPRIATE       5         THE PROCEDURE CODE/BILL TYPE IS        M77      MISSING/INCOMPLETE/INVALID PLACE OF   249
      FOR PLACE OF SERVICE.                   INCONSISTENT WITH THE PLACE OF                  SERVICE.
                                              SERVICE.
149   PROCEDURE INAPPROPRIATE       6         THE PROCEDURE/REVENUE CODE IS                                                         475
      FOR THE RECIPIENT'S AGE.                INCONSISTENT WITH THE PATIENT'S AGE.

150   THIS PROCEDURE IS INVALID     7         THE PROCEDURE/REVENUE CODE IS          MA39     MISSING/INCOMPLETE/INVALID GENDER.    474
      FOR THE RECIPIENT'S SEX.                INCONSISTENT WITH THE PATIENT'S
                                              GENDER.
151   PROCEDURE/NDC INVALID FOR     B18       THIS PROCEDURE CODE AND MODIFIER                                                      454
      DATE OF SERVICE.                        WERE INVALID ON THE DATE OF SERVICE.

152   NDC/PROCEDURE/REVENUE                                                          M51      MISSING/INCOMPLETE/INVALID            454
      CODES ARE NOT ON FILE                                                                   PROCEDURE CODE(S).
153   NON-COVERED SERVICE FOR       11        THE DIAGNOSIS IS INCONSISTENT WITH                                                    488
      THE DIAGNOSIS.                          THE PROCEDURE.




                                                                                                                                             Effective 10/22/10
                                                                             EOB TO 277 & 835



                                                                                        835                                               277
                                     835 ADJ   835 ADJUSTMENT REASON CODE               REMIT    835 REMITTANCE REMARK CODE               CLAIM
EOB   HP DESCRIPTION                 REASON    DESCRIPTION                              REMARK   DESCRIPTION                              STATUS
154   AMBULANCE ATTACHMENT           16        CLAIM/SERVICE LACKS INFORMATION          N29      MISSING/INCOMPLETE/INVALID               337
      REQUIRED ON AMBULANCE                    WHICH IS NEEDED FOR ADJUDICATION.                 DOCUMENTATION/ORDERS/NOTES/SUMMA
      BILLINGS                                                                                   RY/REPORT/CHART.
155   UNITS FIELD INDICATES          16        CLAIM/SERVICE LACKS INFORMATION          N29      MISSING/INCOMPLETE/INVALID               21
      MILEAGE BUT THE OUTSIDE CITY             WHICH IS NEEDED FOR ADJUDICATION.                 DOCUMENTATION/ORDERS/NOTES/SUMMA
      LIMITS INDICATOR IS NOT                                                                    RY/REPORT/CHART.
      PRESENT.
156   THE OUTSIDE CITY LIMITS        16        CLAIM/SERVICE LACKS INFORMATION          N29      MISSING/INCOMPLETE/INVALID       21
      INDICATOR IS PRESENT BUT THE             WHICH IS NEEDED FOR ADJUDICATION.                 DOCUMENTATION/ORDERS/NOTES/SUMMA
      UNITS FIELD IS BLANK.                                                                      RY/REPORT/CHART.
157   DIAGNOSIS INVALID FOR          11        THE DIAGNOSIS IS INCONSISTENT WITH                                                 488
      PROCEDURE CODE                           THE PROCEDURE.
158   PROVIDER NOT CERTIFIED TO      B7        THIS PROVIDER WAS NOT                                                                      88
      BILL THIS PROCEDURE ON THIS              CERTIFIED/ELIGIBLE TO BE PAID FOR THIS
      DATE OF SERVICE.                         PROCEDURE/SERVICE ON THIS DATE OF
                                               SERVICE.
159   ONLY ONE POST STERILIZATION    119       BENEFIT MAXIMUM FOR THE TIME PERIOD                                                        483
      VISIT PER STATE FISCAL YEAR              OR OCCURRENCE HAS BEEN REACHED.

160   PROCEDURE REQUIRES A VALID     17        REQUESTED INFORMAITON WAS NOT            N75      MISSING/INCOMPLETE/INVALID TOOTH         240
      TOOTH SURFACE CODE.                      PROVIDED OR WAS                                   SURFACE INFORMATION.
                                               INSUFFICIENT/INCOMPLETE.
161   TYPE OF PROVIDER               B7        THIS PROVIDER WAS NOT                    MA120    MISSING/INCOMPLETE/INVALID CLIA          454
      INAPPROPRIATE FOR THIS                   CERTIFIED/ELIGIBLE TO BE PAID FOR THIS            CERTIFICATION NUMBER.
      PROCEDURE.                               PROCEDURE/SERVICE ON THIS DATE OF
                                               SERVICE.
162   UNITS BILLED EXCEED MAX        119       BENEFIT MAXIMUM FOR THE TIME PERIOD                                                        258
      ALLOWED PER DAY. UNITS CUT               OR OCCURRENCE HAS BEEN REACHED.
      BACK TO MAX ALLOWED FOR
      PROCEDURE.
163   LAB NOT CERTIFIED FOR          170       PAYMENT IS DENIED WHEN                                                                     454
      PROCEDURE.                               PERFORMED/BILLED BY THIS TYPE OF
                                               PROVIDER.
164   TOS INVALID TO PROCEDURE                                                          N56      PROCEDURE CODE BILLED IS NOT             250
      CODE                                                                                       CORRECT/VALID FOR THE SERVICES
                                                                                                 BILLED OR THE DATE OF SERVICE BILLED.

165   INPATIENT SERVICES ARE NOT     96        NON-COVERED CHARGE(S).                   N30      RECIPIENT INELIGIBLE FOR THIS SERVICE.   88
      COVERED FOR PW-PE
      (PREGNANT WOMEN
      PRESUMPTIVE ELIGIBILITY)
      CATEGORY OF ELIGIBILITY
166   INVALID MEDICARE TYPE OF       16        CLAIM/SERVICE LACKS INFORMATION          M51      MISSING/INCOMPLETE/INVALID               454
      SERVICE OR INVALID MEDICARE              WHICH IS NEEDED FOR ADJUDICATION.                 PROCEDURE CODE(S).
      PROCEDURE CODE.




                                                                                                                                                   Effective 10/22/10
                                                                           EOB TO 277 & 835



                                                                                      835                                           277
                                   835 ADJ   835 ADJUSTMENT REASON CODE               REMIT    835 REMITTANCE REMARK CODE           CLAIM
EOB   HP DESCRIPTION               REASON    DESCRIPTION                              REMARK   DESCRIPTION                          STATUS
167   CONSENT FORM NOT SIGNED BY                                                      N28      CONSENT FORM REQUIREMENTS NOT        466
      PATIENT.                                                                                 FULFILLED.
168   PROCEDURE CODE/MODIFIER    4           THE PROCEDURE CODE IS INCONSISTENT                                                     453
      COMBINATION INVALID                    WITH THE MODIFIER USED OR A
                                             REQUIRED MODIFIER IS MISSING.

169   NON-EMERGENCY PROCEDURE                                                         MA30     MISSING/INCOMPLETE/INVALID TYPE OF   454
      BILLED TO AN EMERGENCY-                                                                  BILL.
      INDICATED CLAIM.

170   EMERGENCY PROCEDURE          17        REQUESTED INFORMAITON WAS NOT                                                          454
      BILLED WITHOUT EMERGENCY               PROVIDED OR WAS
      INDICATOR.                             INSUFFICIENT/INCOMPLETE.
171   PROCEDURES BEGIN/END                                                            MA31     MISSING/INCOMPLETE/INVALID BEGINNING 187
      DATES NOT SAME MONTH                                                                     AND ENDING DATES OF THE PERIOD
                                                                                               BILLED.
172   OB DISCOUNT POLICY IN       95         PLAN PROCEDURES NOT FOLLOWED.                                                          107
      EFFECT AS OF JULY 15, 1997.
      CLAIM DISCOUNTED BY 15%.
173   SEE MEDICAID BILLING MANUAL                                                     N59      ALERT: PLEASE REFER TO YOUR
      CONCERNING FAMILY PLANNING                                                               PROVIDER MANUAL FOR ADDITIONAL
      BILLING PROCEDURES.                                                                      PROGRAM AND PROVIDER INFORMATION.

174   HOME HEALTH PROCEDURE'S                                                         MA31     MISSING/INCOMPLETE/INVALID BEGINNING 187
      BEGIN/END DATES NOT SAME                                                                 AND ENDING DATES OF THE PERIOD
      MONTH.                                                                                   BILLED.
175   PERSONAL CARE PROCEDURE'S                                                       MA31     MISSING/INCOMPLETE/INVALID BEGINNING 187
      BEGIN/END DATES NOT SAME                                                                 AND ENDING DATES OF THE PERIOD
      MONTH.                                                                                   BILLED.
176   ARKIDS FIRST-B PARTICIPANT                                                      MA92     MISSING PLAN INFORMATION FOR OTHER 171
      IDENTIFIED WITH                                                                          INSURANCE.
      COMPREHENSIVE MEDICAL
      COVERAGE. BILL OTHER
      INSURANCE.
177   ADMISSION DATE OUTSIDE PA    197       PRECERTIFICATION/AUTHORIZATION/NOTIF                                                   189
      BEGIN AND END DATES                    ICATION ABSENT.
178   OCCUPATIONAL THERAPY EVAL    119       BENEFIT MAXIMUM FOR THE TIME PERIOD                                                    483
      LIMITED TO FOUR PER STATE              OR OCCURRENCE HAS BEEN REACHED.
      FISCAL YEAR
179   SERVICES ASSOCIATED WITH     B7        THIS PROVIDER WAS NOT                                                                  454
      PROVIDER SPECIALTY LIMITED             CERTIFIED/ELIGIBLE TO BE PAID FOR THIS
      TO ARKIDS 1ST PARTICIPANT              PROCEDURE/SERVICE ON THIS DATE OF
      ONLY.                                  SERVICE.




                                                                                                                                             Effective 10/22/10
                                                                              EOB TO 277 & 835



                                                                                      835                                             277
                                       835 ADJ   835 ADJUSTMENT REASON CODE           REMIT      835 REMITTANCE REMARK CODE           CLAIM
EOB   HP DESCRIPTION                   REASON    DESCRIPTION                          REMARK     DESCRIPTION                          STATUS
180   PERSONAL CARE SERVICES           96        NON-COVERED CHARGE(S).               N20        SERVICE NOT PAYABLE WITH OTHER       107
      PROVIDED THROUGH WAIVER                                                                    SERVICE RENDERED ON THE SAME DATE.
      PROGRAM NOT ALLOWED SAME
      DATES OF SERVICE AS
      PERSONAL CARE SERVICES
      PROVIDED THROUGH MEDICAID

181   RSPMI SERVICE OR RELATED         B20       PROCEDURE/SERVICE WAS PARTIALLY OR                                                   107
      SERVICE HAS BEEN SUBMITTED                 FULLY FURNISHED BY ANOTHER
      AND PAID TO ANOTHER RSPMI                  PROVIDER.
      PROVIDER FOR THIS DATE OF
      SERVICE.
182   PRIVATE ROOM REVENUE CODE                                                       M44        MISSING/INCOMPLETE/INVALID CONDITION 460
      ON UB-92 REQUIRES ENTERING                                                                 CODE.
      APPROPRIATE CONDITION CODE
      (38 OR 39) IN FORM LOCATOR 24-
      30.
183   RSPMI DAILY BENEFIT LIMIT        B20       PROCEDURE/SERVICE WAS PARTIALLY OR M86          SERVICE DENIED BECAUSE PAYMENT     107
      REACHED.                                   FULLY FURNISHED BY ANOTHER                      ALREADY MADE FOR SIMILAR PROCEDURE
                                                 PROVIDER.                                       WITHIN SET TIME FRAME.
184   ACCOMODATION UNITS (LOC 46 150             PAYER DEEMS THE INFORMATION                                                        258
      OR 52) DO NOT EQUAL COVERED                SUBMITTED DOES NOT SUPPORT THIS
      DAYS (LOC 7 OR 23).                        LEVEL OF SERVICE.
185   DURABLE MEDICAL SUPPLIES -                                                    N26          MISSING ITEMIZED BILL.               279
      ITEMIZED LIST REQUIRED
186   RSPMI SFY BENEFIT LIMIT     B20            PROCEDURE/SERVICE WAS PARTIALLY OR M86          SERVICE DENIED BECAUSE PAYMENT       107
      REACHED.                                   FULLY FURNISHED BY ANOTHER                      ALREADY MADE FOR SIMILAR PROCEDURE
                                                 PROVIDER.                                       WITHIN SET TIME FRAME.
187   PARTICIPANT NOT ELIGIBLE FOR                                                  N30          PATIENT INELIGIBLE FOR THIS SERVICE. 109
      BILLED SERVICES UNDER
      ARKIDS FIRST-B PROGRAM.
188   SECONDARY HEADER             17            REQUESTED INFORMAITON WAS NOT        M64        MISSING/INCOMPLETE/INVALID OTHER     255
      DIAGNOSIS CODE INVALID.                    PROVIDED OR WAS                                 DIAGNOSIS.
      LENGTH OF STAY CALCULATED                  INSUFFICIENT/INCOMPLETE.
      AS SINGLE DIAGNOSIS CODE.
      CORRECT AND RESUBMIT AN
      ADJUSTMENT REQUEST.

189   SECONDARY DIAGNOSIS CODE         17        REQUESTED INFORMAITON WAS NOT        M64        MISSING/INCOMPLETE/INVALID OTHER     255
      INVALID. PLEASE RESUBMIT                   PROVIDED OR WAS                                 DIAGNOSIS.
      WITH CORRECT DIAGNOSIS                     INSUFFICIENT/INCOMPLETE.
      CODE AND ADJUSTMENT
      REQUEST FORM.
190   CLAIM DIAGNOSIS CODE IS          146       DIAGNOSIS WAS INVALID FOR THE        M64        MISSING/INCOMPLETE/INVALID OTHER     254
      MISSING OR INVALID.                        DATE(S) OF SERVICE REPORTED.                    DIAGNOSIS.
191   SECONDARY HEADER                 11        THE DIAGNOSIS IS INCONSISTENT WITH   M64        MISSING/INCOMPLETE/INVALID OTHER     255
      DIAGNOSIS CODE INVALID.                    THE PROCEDURE.                                  DIAGNOSIS.




                                                                                                                                               Effective 10/22/10
                                                                           EOB TO 277 & 835



                                                                                     835                                             277
                                     835 ADJ   835 ADJUSTMENT REASON CODE            REMIT    835 REMITTANCE REMARK CODE             CLAIM
EOB   HP DESCRIPTION                 REASON    DESCRIPTION                           REMARK   DESCRIPTION                            STATUS
192   PRIMARY/SECONDARY              9         THE DIAGNOSIS IS INCONSISTENT WITH    MA63     MISSING/INCOMPLETE/INVALID PRINCIPAL   426
      DIAGNOSIS CODE INVALID FOR               THE PATIENT'S AGE.                             DIAGNOSIS.
      THE RECIPIENT'SAGE
193   INVALID SECONDARY DIAGNOSIS 9            THE DIAGNOSIS IS INCONSISTENT WITH    M64      MISSING/INCOMPLETE/INVALID OTHER       255
      CODE FOR THIS PATIENT'S AGE.             THE PATIENT'S AGE.                             DIAGNOSIS.

194   PRIMARY DIAGNOSIS CODE         10        THE DIAGNOSIS IS INCONSISTENT WITH    MA63     MISSING/INCOMPLETE/INVALID PRINCIPAL   86
      INVALID FOR PATIENT'S SEX.               THE PATIENT'S GENDER.                          DIAGNOSIS.
195   SECONDARY DIAGNOSIS CODE       10        THE DIAGNOSIS IS INCONSISTENT WITH    M64      MISSING/INCOMPLETE/INVALID OTHER       86
      INVALID FOR PATIENT'S SEX.               THE PATIENT'S GENDER.                          DIAGNOSIS.

196   SERVICE IS INCONSISTENT WITH   11        THE DIAGNOSIS IS INCONSISTENT WITH    M64      MISSING/INCOMPLETE/INVALID OTHER       488
      THE DIAGNOSIS CODE ON THE                THE PROCEDURE.                                 DIAGNOSIS.
      CLAIM
197   PHYSICAL THERAPY EVAL          119       BENEFIT MAXIMUM FOR THE TIME PERIOD                                                   483
      LIMITED TO FOUR PER STATE                OR OCCURRENCE HAS BEEN REACHED.
      FISCAL YEAR
198   $5,000 SFY LIMITATION FOR      119       BENEFIT MAXIMUM FOR THE TIME PERIOD                                                   483
      FAMILY SUPPORT SERVICES                  OR OCCURRENCE HAS BEEN REACHED.
      HAS BEEN EXCEEDED.
199   PARTICIPANT'S AGE IS                                                                                                           109
      INAPPROPRIATE FOR ARKIDS
      FIRST-B PROGRAM.
200   RECOUPED PAID CLAIM.           B13       PREVIOUSLY PAID. PAYMENT FOR THIS                                                     101
      RESTORATIONS COMBINED AND                CLAIM/SERVICE MAY HAVE BEEN
      PAID AT MAX ALLOWED.                     PROVIDED IN A PREVIOUS PAYMENT.
201   DETAIL DIAGNOSIS CODE NOT      146       DIAGNOSIS WAS INVALID FOR THE                                                         255
      ON FILE.                                 DATE(S) OF SERVICE REPORTED.
202   ADMITTING DIAGNOSIS CODE       146       DIAGNOSIS WAS INVALID FOR THE                                                         232
      MISSING, INVALID, OR NOT ON              DATE(S) OF SERVICE REPORTED.
      FILE.
203   EXCEEDED ONE PREVENTATIVE      119       BENEFIT MAXIMUM FOR THE TIME PERIOD                                                   483
      DENTAL SCREEN APPROPRIATE                OR OCCURRENCE HAS BEEN REACHED.
      PER 150 DAYS.

204   PROVIDER SPECIALTY INVALID     96        NON-COVERED CHARGE(S).                N95      THIS PROVIDER TYPE/PROVIDER            145
      FOR RECIPIENT'S AGE.                                                                    SPECIALTY MAY NOT BILL THIS SERVICE.
205   ONLY ONE EYE EXAM PER 12       119       BENEFIT MAXIMUM FOR THE TIME PERIOD                                                   483
      MONTHS FOR PARTICIPANT                   OR OCCURRENCE HAS BEEN REACHED.
      UNDER 19.
206   DETAIL DIAGNOSIS CODE IS       10        THE DIAGNOSIS IS INCONSISTENT WITH                                                    86
      INVALID FOR PATIENT'S SEX.               THE PATIENT'S GENDER.
207   DETAIL DIAGNOSIS CODE          9         THE DIAGNOSIS IS INCONSISTENT WITH                                                    255
      INVALID FOR PATIENT'S AGE.               THE PATIENT'S AGE.
208   RECIPIENT AID CATEGORY 69      96        NON-COVERED CHARGE(S).                N30      PATIENT INELIGIBLE FOR THIS SERVICE.   109
      LIMITED TO FAMILY PLANNING
       SERVICES




                                                                                                                                              Effective 10/22/10
                                                                            EOB TO 277 & 835



                                                                                       835                                             277
                                    835 ADJ   835 ADJUSTMENT REASON CODE               REMIT    835 REMITTANCE REMARK CODE             CLAIM
EOB   HP DESCRIPTION                REASON    DESCRIPTION                              REMARK   DESCRIPTION                            STATUS
209   MAXIMUM PAYMENT OF 72 UNITS 96          NON-COVERED CHARGE(S).                   N362     THE NUMBER OF DAYS OR UNITS OF         483
      PERSONAL CARE NOT                                                                         SERVICE EXCEEDS OUR ACCEPTABLE
      PREVIOUSLY BILLED FOR DDS                                                                 MAXIMUM.
      WAIVER RECIPIENT.
210   DETAIL DIAGNOSIS CODE NOT     146       DIAGNOSIS WAS INVALID FOR THE                                                            255
      ALLOWED.                                DATE(S) OF SERVICE REPORTED.
211   CLAIM "TO" DATE OF SERVICE    29        THE TIME LIMIT FOR FILING HAS EXPIRED.                                                   9
      OVER TWO YEARS OLD
212   ONLY ONE PAIR OF GLASSES      119       BENEFIT MAXIMUM FOR THE TIME PERIOD                                                      483
      PER 12 MONTHS FOR                       OR OCCURRENCE HAS BEEN REACHED.
      PARTICIPANT UNDER 19.
213   MEALS DISALLOWED SAME DOS                                                        N30      PATIENT INELIGIBLE FOR THIS SERVICE.   107
      AS ADC, ADHC OR IN-HOME
      RESPITE CARE.
214   FACILITY RESPITE CARE LIMITED 119       BENEFIT MAXIMUM FOR THE TIME PERIOD                                                      483
      TO 600 UNITS PER SFY                    OR OCCURRENCE HAS BEEN REACHED.

215   PRIVATE DUTY NURSING                                                             N26      MISSING ITEMIZED BILL.                 279
      MEDICAL SUPPLIES ITEMIZED
      LIST REQUIRED
216   DATES OF SERVICE SPAN                                                            N61      REBILL SERVICES ON SEPARATE CLAIMS.    187
      PROVIDER FISCAL YEAR.
217   MEDICARE - DAYS NOT           96        NON-COVERED CHARGE(S).                   N18      PAYMENT BASED ON THE MEDICARE          457
      COVERED BY MEDICAID.                                                                      ALLOWED AMOUNT.
218   BENEFITS FOR QUALIFIED        96        NON-COVERED CHARGE(S).                   N30      PATIENT INELIGIBLE FOR THIS SERVICE.   88
      MEDICARE BENEFICIARIES DO
      NOT INCLUDE OUTPATIENT
      PRESCRIPTION DRUGS, OR
      ROUTINE DENTAL SERVICES.
      BEN ARE LIM TO COST SHARING
      EXPENSES FOR SVCS CVRD BY
      MDCARE
219   BENEFITS FOR QUALIFIED        96        NON-COVERED CHARGE(S).                   N30      PATIENT INELIGIBLE FOR THIS SERVICE.   171
      MEDICARE BENEFICIARIES ARE
      LIMITED TO MEDICARE
      DEDUCTIBLE AND
      COINSURANCE PAYMENTS.
      PLEASE FILE MEDICARE
      COVERED SERVICES WITH
      MEDICARE FIRST.
220   PROCEDURE MAY BE              119       BENEFIT MAXIMUM FOR THE TIME PERIOD                                                      483
      PERFORMED ONLY 6 TIMES PER              OR OCCURRENCE HAS BEEN REACHED.
      FFY
221   PROVIDER DECEASED WHEN        B7        THIS PROVIDER WAS NOT                                                                    91
      SERVICES WERE PERFORMED.                CERTIFIED/ELIGIBLE TO BE PAID FOR THIS
                                              PROCEDURE/SERVICE ON THIS DATE OF
                                              SERVICE.




                                                                                                                                                Effective 10/22/10
                                                                              EOB TO 277 & 835



                                                                                        835                                             277
                                     835 ADJ   835 ADJUSTMENT REASON CODE               REMIT    835 REMITTANCE REMARK CODE             CLAIM
EOB   HP DESCRIPTION                 REASON    DESCRIPTION                              REMARK   DESCRIPTION                            STATUS
222   PROVIDER NOT ELIGIBLE-         B7        THIS PROVIDER WAS NOT                                                                    91
      PROVIDER CANCELLED ON DATE               CERTIFIED/ELIGIBLE TO BE PAID FOR THIS
      OF SERVICE.                              PROCEDURE/SERVICE ON THIS DATE OF
                                               SERVICE.
223   THE PROVIDER IS NOT ELIGIBLE   B7        THIS PROVIDER WAS NOT                                                                    91
      ON DATE OF SERVICE. PLEASE               CERTIFIED/ELIGIBLE TO BE PAID FOR THIS
      CONTACT STATE PROVIDER                   PROCEDURE/SERVICE ON THIS DATE OF
      ENROLLMENT UNIT IF ANY                   SERVICE.
      QUESTIONS.

224   AGE INVALID FOR INPATIENT                                                         N30      PATIENT INELIGIBLE FOR THIS SERVICE.   84
      PSYCHE SERVICE.
225   INVALID NCCI BILLING           96        NON-COVERED CHARGE(S).                   N59      ATTN: PLEASE REFER TO YOUR PROVIDER 107
      COMBINATIONS - CMS DOES                                                                    MANUAL FOR ADDITIONAL PROGRAM AND
      NOT ALLOW                                                                                  PROVIDER INFORMATION.

226   PRIOR AUTHORIZATION VALID                                                         N54      CLAIM INFORMATION IS INCONSISTENT      252
      FOR CMS NON-MEDICAID                                                                       WITH PRE-CERTIFIED/AUTHORIZED
      SERVICES ONLY                                                                              SERVICES.
227   EPSDT CONDITION (REASON)     125         SUBMISSION/BILLING ERROR(S).             MA58     MISSING/INCOMPLETE/INVALID RELEASE     21
      CODE REQUIRED                                                                              OF INFORMATION INDICATOR.
228   THE PROVIDER IS NOT ELIGIBLE B7          THIS PROVIDER WAS NOT                                                                    91
      FOR DATE(S) OF SERVICE.                  CERTIFIED/ELIGIBLE TO BE PAID FOR THIS
      PLEASE CONTACT THE STATE                 PROCEDURE/SERVICE ON THIS DATE OF
      PROVIDER ENROLLMENT UNIT IF              SERVICE.
      THERE ARE ANY QUESTIONS.

229   NO OTHER ACCOMMODATION                                                            M80      NOT COVERED WHEN PERFORMED             455
      REVENUE CODE ALLOWED ON                                                                    DURING THE SAME SESSION/DATE AS A
      THE SAME CLAIM WITH                                                                        PREVIOUSLY PROCESSED SERVICE FOR
      REVENUE CODE 128.                                                                          THE PATIENT.
230   ATTENDING PHYSICIAN NAME,  B7            THIS PROVIDER WAS NOT                                                                    142
      NON-PARTTICIPATING OR                    CERTIFIED/ELIGIBLE TO BE PAID FOR THIS
      LICENSE NUMBER NOT                       PROCEDURE/SERVICE ON THIS DATE OF
      INDICATED                                SERVICE.
231   EXCEEDS BENEFIT LIMIT OF   119           BENEFIT MAXIMUM FOR THE TIME PERIOD                                                      483
      TWO FETAL NON-STRESS TESTS               OR OCCURRENCE HAS BEEN REACHED.
      PER NINE-MONTH PERIOD.

232   SERVICES NOT COVERED BY        96        NON-COVERED CHARGE(S).                   M20      MISSING/INCOMPLETE/INVALID HCPCS.      84
      MEDICAID.
233   DENIED BY UTILIZATION REVIEW   50        THESE ARE NON-COVERED SERVICES                                                           287
      FOR MEDICAL NECESSITY.                   BECAUSE THIS IS NOT DEEMED A
                                               'MEDICAL NECESSITY' BY THE PAYER.




                                                                                                                                                 Effective 10/22/10
                                                                              EOB TO 277 & 835



                                                                                        835                                             277
                                     835 ADJ   835 ADJUSTMENT REASON CODE               REMIT    835 REMITTANCE REMARK CODE             CLAIM
EOB   HP DESCRIPTION                 REASON    DESCRIPTION                              REMARK   DESCRIPTION                            STATUS
234   PERFORMING PROVIDER IS NOT     B7        THIS PROVIDER WAS NOT                                                                    91
      ENROLLED UNDER THE BILLING               CERTIFIED/ELIGIBLE TO BE PAID FOR THIS
      GROUP NUMBER FOR DATES OF                PROCEDURE/SERVICE ON THIS DATE OF
      SERVICE BILLED. CONTACT                  SERVICE.
      PROVIDER     ENROLLMENT
      WITH QUESTIONS AT 1-800-482-
      1141
235   PROCEDURE CODE NON-          B18         THIS PROCEDURE CODE AND MODIFIER         M20      MISSING/INCOMPLETE/INVALID HCPCS.      84
      PAYABLE FOR DATE OF                      WERE INVALID ON THE DATE OF SERVICE.
      SERVICE. CHECK    MANUAL
      FOR CORRECT CODE
236   PERFORMING PROVIDER IS NOT B7            THIS PROVIDER WAS NOT                                                                    91
      ENROLLED UNDER THE BILLING               CERTIFIED/ELIGIBLE TO BE PAID FOR THIS
      GROUP PROVIDER NUMBER ON                 PROCEDURE/SERVICE ON THIS DATE OF
      THE CLAIM. CONTACT PROVIDER              SERVICE.
      ENROLLMENT WITH
      QUESTIONS AT 1-800-482-1141.

237   PERFORMING PROVIDER          16          CLAIM/SERVICE LACKS INFORMATION          N77      MISSING/INCOMPLETE/INVALID             153
      NUMBER IS INVALID, MISSING,              WHICH IS NEEDED FOR ADJUDICATION.                 DESIGNATED PROVIDER NUMBER.
      OR PERFORMING PROVIDER IS
      CANCELLED.
238   ATTENDING PHYSICIAN'S                                                             N55      PROCEDURES FOR BILLING WITH            153
      INDIVIDUAL PROVIDER NUMBER                                                                 GROUP/REFERRING/PERFORMING
      WAS USED RATHER THAN                                                                       PROVIDERS WERE NOT FOLLOWED.
      CLINIC NUMBER.
239   PROVIDER ELIGIBILITY                                                                                                              56
      DETERMINATION IS BEING MADE.
      PLEASE DO NOT REBILL.

240   REFERRING PHYSICIAN NAME,      B7        THIS PROVIDER WAS NOT                                                                    153
      NON-PARTICIPATING, OR                    CERTIFIED/ELIGIBLE TO BE PAID FOR THIS
      MEDICAID NUMBER INVALID.                 PROCEDURE/SERVICE ON THIS DATE OF
                                               SERVICE.
241   RECIPIENT AID CATEGORY 69  96            NON-COVERED CHARGE(S).                   N30      PATIENT INELIGIBLE FOR THIS SERVICE.   84
      LIMITED TO FAMILY PLANNING
      NDC.
242   CLAIM TYPE MUST BE CROSS-  125           SUBMISSION/BILLING ERROR(S).             N34      INCORRECT CLAIM FORM/FORMAT FOR    481
      OVER ONLY.                                                                                 THIS SERVICE.
243   FORMULAS NOT PAYABLE WITH                                                         M86      SERVICE DENIED BECAUSE PAYMENT     107
      DIFFERENT TYPES OF SERVICE                                                                 ALREADY MADE FOR SIMILAR PROCEDURE
      IN THE SAME CALENDAR MONTH                                                                 WITHIN SET TIME FRAME.

244   CLAIMS MUST BE BILLED                                                             M117     NOT COVERED UNLESS SUBMITTED VIA       481
      ELECTRONICALLY.                                                                            ELECTRONIC CLAIM.




                                                                                                                                                 Effective 10/22/10
                                                                            EOB TO 277 & 835



                                                                                     835                                            277
                                     835 ADJ   835 ADJUSTMENT REASON CODE            REMIT     835 REMITTANCE REMARK CODE           CLAIM
EOB   HP DESCRIPTION                 REASON    DESCRIPTION                           REMARK    DESCRIPTION                          STATUS
245   NOT PAYABLE ON THIS CLAIM                                                      N34       INCORRECT CLAIM FORM/FORMAT FOR      481
      TYPE. PLEASE BILL ON                                                                     THIS SERVICE.
      APPROPRIATE CLAIM FORM AND
      RESUBMIT.
246   FLU VACCINE LIMITED TO ONE 119           BENEFIT MAXIMUM FOR THE TIME PERIOD                                                  483
      PER STATE FISCAL YEAR.                   OR OCCURRENCE HAS BEEN REACHED.

247   PNEUMONIA VACCINE LIMITED      119       BENEFIT MAXIMUM FOR THE TIME PERIOD                                                  483
      TO ONE EVERY TEN YEARS.                  OR OCCURRENCE HAS BEEN REACHED.

248   PAYMENT OF YOUR CLAIM WAS                                                      N55       PROCEDURES FOR BILLING WITH          153
      DELAYED BECAUSE ANY                                                                      GROUP/REFERRING/PERFORMING
      PHYSICIAN PRACTICING IN A                                                                PROVIDERS WERE NOT FOLLOWED.
      GROUP WHO BILLS USING THE
      GROUP PROVIDER NUMBER
      MUST ALSO PUT PERFORMING
      PHYSICIAN NAME AND #.
249   PAYMENT OF CLAIM WAS           16        CLAIM/SERVICE LACKS INFORMATION       N382      MISSING/INCOMPLETE/INVALID PATIENT   153
      DELAYED BECAUSE RECIPIENT                WHICH IS NEEDED FOR ADJUDICATION.               IDENTIFIER.
      ID# SUBMITTED WAS INVALID
      FOR THE CLAIM DATE(S) OF
      SERVICE.
250   RECIPIENT NOT LISTED UNDER     16        CLAIM/SERVICE LACKS INFORMATION       N382      MISSING/INCOMPLETE/INVALID PATIENT   153
      ID # SUBMITTED. CORRECT ID #             WHICH IS NEEDED FOR ADJUDICATION.               IDENTIFIER.
      AND RESUBMIT A COMPLETED
      AND SIGNED CLAIM FOR
      PROCESSING.
251   GROUND TRANSPORT EXCEEDS       119       BENEFIT MAXIMUM FOR THE TIME PERIOD                                                  483
      $1000.00 PER ROUND TRIP PER              OR OCCURRENCE HAS BEEN REACHED.
      DAY
252   MEDICAID ID NUMBER             140       PATIENT/INSURED HEALTH                                                               124
      SUBMITTED DOES NOT MATCH                 IDENTIFICATION NUMBER AND NAME DO
      PATIENT'S NAME ON MEDICAID               NOT MATCH.
      ID CARD. PLEASE VERIFY CARD
      AND REBILL WITH CORRECT
      INFORMATION.
253   PATIENT DECEASED-NOT          13         THE DATE OF DEATH PRECEDES THE                                                       91
      ELIGIBLE FOR SERVICE.                    DATE OF SERVICE.
254   RECIPIENT IS NOT ELIGIBLE FOR 26         EXPENSES INCURRED PRIOR TO                                                           91
      MEDICAID ON DATE OF SERVICE.             COVERAGE.




                                                                                                                                             Effective 10/22/10
                                                                             EOB TO 277 & 835



                                                                                      835                                          277
                                      835 ADJ   835 ADJUSTMENT REASON CODE            REMIT     835 REMITTANCE REMARK CODE         CLAIM
EOB   HP DESCRIPTION                  REASON    DESCRIPTION                           REMARK    DESCRIPTION                        STATUS
255   LEVEL OF CARE IS INVALID.       16        CLAIM/SERVICE LACKS INFORMATION       MA130     YOUR CLAIM CONTAINS INCOMPLETE     21
                                                WHICH IS NEEDED FOR ADJUDICATION.               AND/OR INVALID INFORMATION, AND NO
                                                                                                APPEAL RIGHTS ARE AFFORDED BECAUSE
                                                                                                THE CLAIM IS UNPROCESSABLE. PLEASE
                                                                                                SUBMIT A NEW CLAIM WITH THE
                                                                                                COMPLETE/CORRECT INFORMATION.

256   RECIPIENT PARTIALLY OR          141       CLAIM SPANS ELIGIBLE AND INELIGIBLE                                                    91
      TOTALLY INELIGIBLE FOR                    PERIODS OF COVERAGE.
      WAIVER SERVICES ON DATES
      OF SERVICE BILLED
257   FOR REPAYMENT, REBILL CLAIM                                                     M117      NOT COVERED UNLESS SUBMITTED VIA
      ELECTRONICALLY.                                                                           ELECTRONIC CLAIM.
258   CLAIM PAYMENT AMOUNT
      INCLUDES $96.00 ADDITIONAL
      PAYMENT FOR NEWBORN
      PHYSIOLOGICAL BILATERAL
      HEARING SCREEN.
259   UNABLE TO DETERMINE                                                             N30       PATIENT INELIGIBLE FOR THIS SERVICE.   109
      RECIPIENT ELIGIBILITY.
260   RECIPIENT ELIGIBILITY                                                           N185      ALERT: DO NOT RESUBMIT THIS            56
      DETERMINATION IS BEING MADE.                                                              CLAIM/SERVICE.
      PLEASE DONOT REBILL.
261   PATIENT DECEASED. NOT        13           THE DATE OF DEATH PRECEDES THE                                                         88
      ELIGIBLE FOR SERVICE.                     DATE OF SERVICE.
262   DATES OF SERVICE SPAN                                                                                                            187
      FEDERAL FISCAL YEAR. PLEASE
      SUBMIT TWO SEPARATE BILLS.

263   THE RECIPIENT IS NOT ELIGIBLE   96        NON-COVERED CHARGE(S).                N30       PATIENT INELIGIBLE FOR THIS SERVICE.   91
      ON DATE OF SERVICE.

264   PAYMENT REDUCED BECAUSE         150       PAYER DEEMS THE INFORMATION           MA32      MISSING/INCOMPLETE/INVALID NUMBER      457
      OUR RECORDS SHOW                          SUBMITTED DOES NOT SUPPORT THIS                 OF COVERED DAYS DURING THE BILLING
      RECIPIENT WAS NOT IN                      LEVEL OF SERVICE.                               PERIOD.
      FACILITY FOR ALL OF TOTAL
      BILLED DAYS.
265   RECIPIENT ID NUMBER IS          16        CLAIM/SERVICE LACKS INFORMATION       N382      MISSING/INCOMPLETE/INVALID PATIENT     153
      MISSING OR INVALID.                       WHICH IS NEEDED FOR ADJUDICATION.               IDENTIFIER.
266   (TAPE CROSSOVERS ONLY.)         22        THIS CARE MAY BE COVERED BY           MA92      MISSING PLAN INFORMATION FOR OTHER     286
      PARTIAL MEDCAID ELIGIBILITY               ANOTHER PAYER PER COORDINATION OF               INSURANCE.
      FOR DATES OF SERVICE                      BENEFITS.
      LISTED. REBILL HARDCOPY
      CLAIM WITH     MEDICARE
      EXPLANATION OF BENEFITS.




                                                                                                                                             Effective 10/22/10
                                                                              EOB TO 277 & 835



                                                                                      835                                               277
                                     835 ADJ   835 ADJUSTMENT REASON CODE             REMIT      835 REMITTANCE REMARK CODE             CLAIM
EOB   HP DESCRIPTION                 REASON    DESCRIPTION                            REMARK     DESCRIPTION                            STATUS
267   PARTIALLY OR TOTALLY           141       CLAIM SPANS ELIGIBLE AND INELIGIBLE                                                      88
      INELIGIBLE FOR DATES OF                  PERIODS OF COVERAGE.
      SERVICE LISTED.PLEASE CHECK
      DATES RECIPIENT IS ELIGIBLE
      AND BILL      ACCORDINGLY.

268   PATIENT ON REVIEW.             133       THE DISPOSITION OF THIS CLAIM/SERVICE N35         PROGRAM INTEGRITY/UTILIZATION          46
      CHARGE(S) DENIED PER SUR                 IS PENDING FURTHER REVIEW.                        REVIEW DECISION.
      ANALYST REVIEW.
269   RECIPIENT NOT 21 YRS OLD AT                                                     N28        CONSENT FORM REQUIREMENTS NOT          467
      TIME OF SIGNATURE ON                                                                       FULFILLED.
      CONSENT.
270   RECIPIENT NOT ELIGIBLE FOR                                                      N30        PATIENT INELIGIBLE FOR THIS SERVICE.   88
      NURSING HOME CARE.
271   INVALID LOA CODE FOR           16        CLAIM/SERVICE LACKS INFORMATION        N225       INCOMPLETE/INVALID                  21
      FACILITY CLASS                           WHICH IS NEEDED FOR ADJUDICATION.                 DOCUMENTATION/ORDERS/NOTES/SUMMA
                                                                                                 RY/REPORT/CHART.
272   AUTHORIZED LEVEL OF CARE       16        CLAIM/SERVICE LACKS INFORMATION        N54        CLAIM INFORMATION IS INCONSISTENT   84
      NOT ON FILE FOR DATE OF                  WHICH IS NEEDED FOR ADJUDICATION.                 WITH PRE-CERTIFIED/AUTHORIZED
      SERVICE BILLED                                                                             SERVICES.
273   BENEFICIARY TURNS 21 DURING                                                     N61        REBILL SERVICES ON SEPARATE CLAIMS. 481
      INPATIENT STAY. PLEASE SPLIT
      BILL AND RESUBMIT.
274   NOT ELIGIBLE FOR NURSING                                                        N30        PATIENT INELIGIBLE FOR THIS SERVICE.   91
      HOME CARE FOR THESE DATES
      OF     SERVICE.
275   RECIPIENT NOT ELIGIBLE FOR     125       SUBMISSION/BILLING ERROR(S).           N30        PATIENT INELIGIBLE FOR THIS SERVICE.   91
      NURSING HOME CARE FOR
      THESE DATESOF SERVICE DUE
      TO PROVIDER BILLING ERROR.

276   THE BILLED LOC REPORTED ON     16        CLAIM/SERVICE LACKS INFORMATION        N225       INCOMPLETE/INVALID               65
      THE TAD IS DIFFERENT FROM                WHICH IS NEEDED FOR ADJUDICATION.                 DOCUMENTATION/ORDERS/NOTES/SUMMA
      THE LOCON THE LTC RECIPIENT                                                                RY/REPORT/CHART.
      FILE. THE CLAIM WAS PAID
      ACCORDING TO THE LOC ON
      FILE.
277   RECIPIENT PARTIALLLY OR        96        NON-COVERED CHARGE(S).                 N30        PATIENT INELIGIBLE FOR THIS SERVICE.   91
      TOTALLY INELIGIBLE FOR
      WAIVER     SERVICES FOR
      DATES OF SERVICE BILLED
278   RECIPIENT WAS RECEIVING                                                         MA134      MISSING/INCOMPLETE/INVALID PROVIDER    84
      CARE IN ANOTHER FACILITY                                                                   NUMBER OF THE FACILITY WHERE THE
                                                                                                 PATIENT RESIDES.
279   ADJUSTMENT RESULTING FROM      142       MONTHLY MEDICAID PATIENT LIABILITY                                                       101
      A CHANGE IN THE PATIENT                  AMOUNT.
      LIABILITY AMOUNT.




                                                                                                                                                 Effective 10/22/10
                                                                         EOB TO 277 & 835



                                                                                    835                                             277
                                  835 ADJ   835 ADJUSTMENT REASON CODE              REMIT    835 REMITTANCE REMARK CODE             CLAIM
EOB   HP DESCRIPTION              REASON    DESCRIPTION                             REMARK   DESCRIPTION                            STATUS
280   RECIPIENT HAS OTHER MEDICAL 22        THIS CARE MAY BE COVERED BY             MA92     MISSING/INCOMPLETE/INVALID PLAN        171
      COVERAGE BILL OTHER                   ANOTHER PAYER PER COORDINATION OF                INFORMATION FOR OTHER INSURANCE.
      INSURANCE FIRST                       BENEFITS.
281   SURGERY INFORMATION IS      17        REQUESTED INFORMATION WAS NOT           MA130    YOUR CLAIM CONTAINS INCOMPLETE     21
      INCOMPLETE                            PROVIDED OR WAS                                  AND/OR INVALID INFORMATION, AND NO
                                            INSUFFICINET/INCOMPLETE.                         APPEAL RIGHTS ARE AFFORDED BECAUSE
                                                                                             THE CLAIM IS UNPROCESSABLE. PLEASE
                                                                                             SUBMIT A NEW CLAIM WITH THE
                                                                                             COMPLETE/CORRECT INFORMATION.

282   UNDER AGE 65. HAS MEDICARE   B11      THE CLAIM/SERVICE HAS BEEN              N196     ALERT: PATIENT ELIGIBLE TO APPLY FOR   116
      COVERAGE. BILL MEDICARE               TRANSFERRED TO THE PROPER                        OTHER COVERAGE WHICH MAY BE
      FIRST.                                PAYER/PROCESSOR FOR PROCESSING.                  PRIMARY.
                                            CLAIM/SERVICE NOT COVERED BY THIS
                                            PAYER/PROCESSOR.
283   FRAGMENTED IMMUNIZATION                                                       M51      MISSING/INCOMPLETE/INVALID             84
      CODES SHOULD BE BILLED.                                                                PROCEDURE CODE(S).
284   HAS MEDICARE COVERAGE. BILL 22        THIS CARE MAY BE COVERED BY                                                             116
      MEDICARE FIRST.                       ANOTHER PAYER PER COORDINATION OF
                                            BENEFITS.
285   GLOBAL OB PROCEDURE                                                           N182     THIS CLAIM/SERVICE MUST BE BILLED      263
      REQUIRED MINIMUM 2 MONTHS                                                              ACCORDING TO THE SCHEDULE FOR THIS
      CARE.                                                                                  PLAN.
286   CLAIM DENIED DUE TO INJURY  20        THIS INJURY/ILLNESS IS COVERED BY THE                                                   255
      DIAGNOSIS. PLEASE                     LIABILITY CARRIER.
      INVESTIGATE POSSIBLE THIRD
      PARTY INVOLVEMENT.
287   THIS CLAIM PAYMENT WAS                                                                                                        101
      RECOUPED PER YOUR
      ADJUSTMENT REQUEST.
288   CLAIM BILLED BY MEDICARE                                                      MA64     OUR RECORDS INDICATE THAT WE        116
      TAPE CROSSOVER. RECIPIENT'S                                                            SHOULD BE THE THIRD PAYER FOR THIS
      OTHER MEDICAL COVERAGE                                                                 CLAIM. WE CANNOT PROCESS THIS CLAIM
      MUST BE BILLED PRIOR TO                                                                UNTIL WE HAVE RECEIVED PAYMENT
      MEDICAID.                                                                              INFORMATION FROM THE PRIMARY AND
                                                                                             SECONDARY PAYERS.
289   PSRO DATE ARE                16       CLAIM/SERVICE LACKS INFORMATION         MA130    YOUR CLAIM CONTAINS INCOMPLETE     21
      MISSING/INVALID.                      WHICH IS NEEDED FOR ADJUDICATION.                AND/OR INVALID INFORMATION, AND NO
                                                                                             APPEAL RIGHTS ARE AFFORDED BECAUSE
                                                                                             THE CLAIM IS UNPROCESSABLE. PLEASE
                                                                                             SUBMIT A NEW CLAIM WITH THE
                                                                                             COMPLETE/CORRECT INFORMATION.

290   PROVIDER TO RECIPIENT       170       PAYMENT IS DENIED WHEN                                                                  109
      MISMATCH FOR SCHOOL                   PERFORMED/BILLED BY THIS TYPE OF
      DISTRICT OUTREACH SERVICES.           PROVIDER.




                                                                                                                                             Effective 10/22/10
                                                                             EOB TO 277 & 835



                                                                                        835                                             277
                                     835 ADJ   835 ADJUSTMENT REASON CODE               REMIT    835 REMITTANCE REMARK CODE             CLAIM
EOB   HP DESCRIPTION                 REASON    DESCRIPTION                              REMARK   DESCRIPTION                            STATUS
291   MAXIMUM OF 24 PAID INPATIENT   119       BENEFIT MAXIMUM FOR THE TIME PERIOD                                                      483
      HOSPITAL DAYS PER SFY.                   OR OCCURRENCE HAS BEEN REACHED.

292   DISALLOWED BY VISUAL CARE      216       BASED ON THE FINDINGS OF A REVIEW                                                        84
      CONSULTANT.                              ORGANIZATION.
293   CMS NON-MEDICAID SERVICES                                                         N30      PATIENT INELIGIBLE FOR THIS SERVICE.   475
      FOR UNDER AGE 18 ONLY.
294   ELECTRONIC FUNDS TRANSFER                                                         N24      MISSING/INCOMPLETE/INVALID             24
      IS REQUIRED FOR PAYMENT OF                                                                 ELECTRONIC FUNDS TRANSFER (EFT)
         NON-MEDICAID SERVICES.                                                                  BANKING INFORMATION.

295   DUE TO NO PAID DETAILS ON                                                                                                         9
      CLAIM, ARKIDS FIRST-B COPAY
      WAS NOT WITHHELD.
296   RECIPIENT, PROVIDER OR BOTH    B7        THIS PROVIDER WAS NOT                                                                    84
      ARE INELIGIBLE FOR DDS                   CERTIFIED/ELIGIBLE TO BE PAID FOR THIS
      NON-MEDICAID SERVICES.                   PROCEDURE/SERVICE ON THIS DATE OF
                                               SERVICE.
297   DIAGNOSIS CODE AND             11        THE DIAGNOSIS IS INCONSISTENT WITH                                                       488
      PRESCRIPTION SERVICE                     THE PROCEDURE.
      CONFLICT.
298   YOUR CHARGES WERE                                                                                                                 247
      COMBINED TO FACILITE
      PROCESSING.
299   SERVICE NON-PAYABLE FOR                                                           N30      PATIENT INELIGIBLE FOR THIS SERVICE.   84
      THIS INDEPENDENT CHOICES
      CLIENT.
300   FEE ADJUSTED TO MAXIMUM        B5        COVERAGE/PROGRAM GUIDELINES WERE                                                         65
      ALLOWABLE.                               NOT MET OR WERE EXCEEDED.
301   THIS CLAIM IS AN ADJUSTMENT    142       MONTHLY MEDICAID PATIENT LIABILITY       N23      ALERT: PATIENT LIABILITY MAY BE     101
      RESULTING FROM A CHANGE IN               AMOUNT.                                           AFFECTED DUE TO COORDINATION OF
      THE RECIPIENT LIABILITY.                                                                   BENEFITS WITH OTHER CARRIERS AND/OR
                                                                                                 MAXIMUM BENEFIT PROVISIONS.
302   DAYS BILLED CUTBACK TO 'PRO'   197       PRECERTIFICATION/AUTHORIZATION/NOTIF N10          CLAIM/SERVICE ADJUSTED BASED ON THE
      CERTIFIED DAYS.                          ICATION ABSENT.                                   FINDINGS OF A REVIEW
                                                                                                 ORGANIZATION/PROFESSIONAL
                                                                                                 CONSULT/MANUAL
                                                                                                 ADJUDICATION/MEDICAL OR DENTAL
                                                                                                 ADVISOR.
303   YOUR CLAIM/CHARGE HAS BEEN                                                        MA15     YOUR CLAIM HAS BEEN SEPARATED TO
      SPLIT TO FACILITATE                                                                        EXPEDITE HANDLING. YOU WILL RECEIVE
      PROCESSING.                                                                                A SEPARATE NOTICE FOR THE OTHER
                                                                                                 SERVICES REPORTED.
304   ADJUSTMENT TO REFLECT AN       154       PAYER DEEMS THE INFORMATION                                                              101
      INCREASE IN RECIPIENT                    SUBMITTED DOES NOT SUPPORT THIS
      RESOURCES APPLIED TO                     DAY'S SUPPLY.
      ORIGINAL BILL.




                                                                                                                                                 Effective 10/22/10
                                                                               EOB TO 277 & 835



                                                                                       835                                               277
                                      835 ADJ   835 ADJUSTMENT REASON CODE             REMIT      835 REMITTANCE REMARK CODE             CLAIM
EOB   HP DESCRIPTION                  REASON    DESCRIPTION                            REMARK     DESCRIPTION                            STATUS
305   ADJUSTMENT REFLECTING           23        THE IMPACT OF PRIOR PAYER(S)                                                             101
      PATIENT THIRD PARTY LIABILITY             ADJUDICATION INCLUDING PAYMENTS
      APPLIED TO ORIGINAL BILL.                 AND/OR ADJUSTMENTS.

306   THIRD PARTY LIABILITY           109       CLAIM NOT COVERED BY THIS              MA64       OUR RECORDS INDICATE THAT WE        171
      SUSPECT.                                  PAYER/CONTRACTOR. YOU MUST SEND                   SHOULD BE THE THIRD PAYER FOR THIS
                                                THE CLAIM TO THE CORRECT                          CLAIM. WE CANNOT PROCESS THIS CLAIM
                                                PAYER/CONTRACTOR.                                 UNTIL WE HAVE RECEIVED PAYMENT
                                                                                                  INFORMATION FROM THE PRIMARY AND
                                                                                                  SECONDARY PAYERS.
307   AN ADJUSTMENT RESULTING  125              SUBMISSION/BILLING ERROR(S).           MA67       CORRECTION TO A PRIOR CLAIM.           101
      FROM A CLERICAL ERROR.
308   PROCEDURE NUMBER CHANGED 189              NOT OTHERWISE CLASSIFIED' OR         N22          THIS PROCEDURE CODE WAS                454
      TO MATCH DESCRIPTION.                     'UNLISTED' PROCEDURE CODE                         ADDED/CHANGED BECAUSE IT MORE
                                                (CPT/HCPCS) WAS BILLED WHEN THERE IS              ACCURATELY DESCRIBES THE SERVICES
                                                A SPECIFIC PROCEDURE CODE FOR THIS                RENDERED.
                                                PROCEDURE/SERVICE.
309   A MATH ERROR IN YOUR BILLING 125          SUBMISSION/BILLING ERROR(S).           MA67       CORRECTION TO A PRIOR CLAIM.           400
      HAS BEEN CORRECTED.

310   DISCHARGE. PATIENT         13             THE DATE OF DEATH PRECEDES THE         N30        PATIENT INELIGIBLE FOR THIS SERVICE.   88
      DECEASED. NOTIFY IF                       DATE OF SERVICE.
      INCORRECT.
311   CORRECTED PAYMENT PER      119            BENEFIT MAXIMUM FOR THE TIME PERIOD                                                      101
      ADJUSTMENT REQUEST. SEE                   OR OCCURRENCE HAS BEEN REACHED.
      FINANCIAL ITEMS FOR RECOUP
      OF INCORRECT PAYMENT.

312   YOU BILLED IMPROPER NUMBER 17             REQUESTED INFORMATION WAS NOT          M53        MISSING/INCOMPLETE/INVALID DAYS OR     456
      OF DAYS FOR MONTH.                        PROVIDED OR WAS                                   UNITS OF SERVICE.
                                                INSUFFICIENT/INCOMPLETE.
313   MULTIPLE RESTORATION FOR        97        THE BENEFIT FOR THIS SERVICE IS                                                          483
      SAME TOOTH COMBINED.                      INCLUDED IN THE PAYMENT/ALLOWANCE
                                                FOR ANOTHER SERVICE/PROCEDURE
                                                THAT HAS ALREADY BEEN ADJUDICATED.

314   ONLY ONE RESTORATION PER        119       BENEFIT MAXIMUM FOR THE TIME PERIOD                                                      483
      SURFACE ALLOWED.                          OR OCCURRENCE HAS BEEN REACHED.

315   PANOGRAPHIC SURVEY              97        THE BENEFIT FOR THIS SERVICE IS        N40        MISSING X-RAY.                         318
      INCLUDES NECESSARY BW X-                  INCLUDED IN THE PAYMENT/ALLOWANCE
      RAYS.                                     FOR ANOTHER SERVICE/PROCEDURE
                                                THAT HAS ALREADY BEEN ADJUDICATED.




                                                                                                                                                  Effective 10/22/10
                                                                             EOB TO 277 & 835



                                                                                     835                                              277
                                    835 ADJ   835 ADJUSTMENT REASON CODE             REMIT      835 REMITTANCE REMARK CODE            CLAIM
EOB   HP DESCRIPTION                REASON    DESCRIPTION                            REMARK     DESCRIPTION                           STATUS
316   PAYMENT OF YOUR CLAIM WAS     125       SUBMISSION/BILLING ERROR(S).           M54        MISSING/INCOMPLETE/INVALID TOTAL      400
      DELAYED BECAUSE YOUR                                                                      CHARGES.
      CHARGES    WERE NOT
      TOTALED.
317   CODE CHANGED TO MATCH         189       NOT OTHERWISE CLASSIFIED' OR                                                            15
      SURGEON'S CLAIM.                        'UNLISTED' PROCEDURE CODE
                                              (CPT/HCPCS) WAS BILLED WHEN THERE IS
                                              A SPECIFIC PROCEDURE CODE FOR THIS
                                              PROCEDURE/SERVICE.
318   ADJUSTED TO MAXIMUM           B5        COVERAGE/PROGRAM GUIDELINES WERE                                                        66
      ALLOWABLE NOT EXCEEDING                 NOT MET OR WERE EXCEEDED.
      THE USUAL    CUSTOMARY
      CHARGE ORIGINALLY BILLED.
319   INCORRECT PROVIDER NUMBER     16        CLAIM/SERVICE LACKS INFORMATION        N257       MISSING/INCOMPLETE/INVALID BILLING    153
      SUBMITTED - PAYMENT                     WHICH IS NEEDED FOR ADJUDICATION.                 PROVIDER/SUPPLIER PRIMARY IDENTIFIER.
      DELAYED.
320   DAYS BILLED CUTBACK TO THE    119       BENEFIT MAXIMUM FOR THE TIME PERIOD    MA33       MISSING/INCOMPLETE/INVALID            483
      NUMBER OF DAYS IN THE                   OR OCCURRENCE HAS BEEN REACHED.                   NONCOVERED DAYS DURING THE BILLING
      SERVICE MONTH.                                                                            PERIOD.
321   REDUCED TO ESTABLISHED                                                                                                          454
      PATIENT CPT CODE.
322   SURGERY PROVIDER NUMBER       16        CLAIM/SERVICE LACKS INFORMATION        M51        MISSING/INCOMPLETE/INVALID            454
      PRESENT/SURGERY                         WHICH IS NEEDED FOR ADJUDICATION.                 PROCEDURE CODE(S).
      PROCEDURE MISSING.
      PAYMENT OF CLAIM DELAYED.
323   PROCEDURE NUMBER CHANGED      216       BASED ON THE FINDINGS OF A REVIEW      N10        CLAIM/SERVICE ADJUSTED BASED ON THE 454
      BY MEDICAL CONSULTANT.                  ORGANIZATION.                                     FINDINGS OF A REVIEW
                                                                                                ORGANIZATION/PROFESSIONAL
                                                                                                CONSULT/MANUAL
                                                                                                ADJUDICATION/MEDICAL OR DENTAL
                                                                                                ADVISOR.
324   NUMBER CHANGED PER DENTAL B5            COVERAGE/PROGRAM GUIDELINES WERE       N37        MISSING/INCOMPLETE/INVALID TOOTH    454
      POLICY GUIDELINES.                      NOT MET OR WERE EXCEEDED.                         NUMBER/LETTER.
325   PROCEDURE NUMBER CHANGED 216            BASED ON THE FINDINGS OF A REVIEW      N10        CLAIM/SERVICE ADJUSTED BASED ON THE 454
      BY DENTAL CONSULTANT                    ORGANIZATION.                                     FINDINGS OF A REVIEW
      REVIEW.                                                                                   ORGANIZATION/PROFESSIONAL
                                                                                                CONSULT/MANUAL
                                                                                                ADJUDICATION/MEDICAL OR DENTAL
                                                                                                ADVISOR.
326   DATE OF DISCHARGE NOT PAID.   96        NON-COVERED CHARGE(S).                 N50        MISSING/INCOMPLETE/INVALID            190
                                                                                                DISCHARGE INFORMATION.
327   ADJUSTMENT RESULTING FROM     125       SUBMISSION/BILLING ERROR(S).           MA67       CORRECTION TO A PRIOR CLAIM.          101
      INCORRECT ORIGINAL BILL.




                                                                                                                                               Effective 10/22/10
                                                                           EOB TO 277 & 835



                                                                                    835                                           277
                                    835 ADJ   835 ADJUSTMENT REASON CODE            REMIT     835 REMITTANCE REMARK CODE          CLAIM
EOB   HP DESCRIPTION                REASON    DESCRIPTION                           REMARK    DESCRIPTION                         STATUS
328   PAID IN ACCORDANCE WITH                                                       N10       CLAIM/SERVICE ADJUSTED BASED ON THE 65
      MEDICAL CONSULTANT'S                                                                    FINDINGS OF A REVIEW
      REVIEW.                                                                                 ORGANIZATION/PROFESSIONAL
                                                                                              CONSULT/MANUAL
                                                                                              ADJUDICATION/MEDICAL OR DENTAL
                                                                                              ADVISOR.
329   PAYMENT REDUCED           119           BENEFIT MAXIMUM FOR THE TIME PERIOD                                                 65
      PROPORTIONATELY TO COMPLY               OR OCCURRENCE HAS BEEN REACHED.
      WITH MEDICAL    POLICY
      QUANTITY LIMITATION.
330   AN ADJUSTMENT FROM A      B5            COVERAGE/PROGRAM GUIDELINES WERE                                                    101
      CHANGE IN PATIENT'S DAYS                NOT MET OR WERE EXCEEDED.
      STAY.
331   PAYMENT REDUCED BY AMOUNT B13           PREVIOUSLY PAID. PAYMENT FOR THIS                                                   65
      PREVIOUSLY PAID. POST OP                CLAIM/SERVICE MAY HAVE BEEN
      INCLUDED IN PROCEDURE.                  PROVIDED IN A PREVIOUS PAYMENT.

332   PAID IN ACCORD WITH MEDICAL   B5        COVERAGE/PROGRAM GUIDELINES WERE                                                    65
      POLICY GUIDELINES.                      NOT MET OR WERE EXCEEDED.
333   THIS IS AN ADJUSTMENT         125       SUBMISSION/BILLING ERROR(S).          MA67      CORRECTION TO A PRIOR CLAIM.        101
      RESULTING FROM A CLERICAL
      ERROR.
334   EXCEEDS LIMIT OF ONE          119       BENEFIT MAXIMUM FOR THE TIME PERIOD                                                 483
      OCCUPATIONAL THERAPY                    OR OCCURRENCE HAS BEEN REACHED.
      EVALUATION PER STATE
      FISCAL YEAR.
335   LACKS REPORT TO JUSTIFY       16        CLAIM/SERVICE LACKS INFORMATION       N29       MISSING/INCOMPLETE/INVALID       294
      HIGHER FEE.                             WHICH IS NEEDED FOR ADJUDICATION.               DOCUMENTATION/ORDERS/NOTES/SUMMA
                                                                                              RY/REPORT/CHART.
336   ADJUSTMENT TO SERVICES        B13       PREVIOUSLY PAID. PAYMENT FOR THIS                                                101
      PREVIOUSLY PAID OR DENIED.              CLAIM/SERVICE MAY HAVE BEEN
                                              PROVIDED IN A PREVIOUS PAYMENT.
337   BILLED DAYS CUTBACK SINCE     17        REQUESTED INFORMATION WAS NOT         N50       MISSING/INCOMPLETE/INVALID          456
      DISCHARGE TIME NOT CODED                PROVIDED OR WAS                                 DISCHARGE INFORMATION.
      ON TAD.                                 INSUFFICIENT/INCOMPLETE.
338   DAYS REDUCED PER MEDICAL                                                      N10       CLAIM/SERVICE ADJUSTED BASED ON THE 456
      CONSULTANT COMMENT.                                                                     FINDINGS OF A REVIEW
                                                                                              ORGANIZATION/PROFESSIONAL
                                                                                              CONSULT/MANUAL
                                                                                              ADJUDICATION/MEDICAL OR DENTAL
                                                                                              ADVISOR.
339   NEGATIVE ADJUSTMENT -
      RECOUPMENT WILL FOLLOW.
340   REPORT DOES NOT JUSTIFY       16        CLAIM/SERVICE LACKS INFORMATION       N29       MISSING/INCOMPLETE/INVALID       294
      HIGHER FEE.                             WHICH IS NEEDED FOR ADJUDICATION.               DOCUMENTATION/ORDERS/NOTES/SUMMA
                                                                                              RY/REPORT/CHART.




                                                                                                                                           Effective 10/22/10
                                                                          EOB TO 277 & 835



                                                                                    835                                           277
                                    835 ADJ   835 ADJUSTMENT REASON CODE            REMIT    835 REMITTANCE REMARK CODE           CLAIM
EOB   HP DESCRIPTION                REASON    DESCRIPTION                           REMARK   DESCRIPTION                          STATUS
341   FEE REDUCED/PROCEDURE         97        THE BENEFIT FOR THIS SERVICE IS                                                     107
      CODE/UNITS CHANGE TO ALLOW              INCLUDED IN THE PAYMENT/ALLOWANCE
      STATE   MAXIMUM PER DENTAL              FOR ANOTHER SERVICE/PROCEDURE
      POLICY.                                 THAT HAS ALREADY BEEN ADJUDICATED.

342   PROCEDURE/FEE PAID IN         95        PLAN PROCEDURES NOT FOLLOWED.                                                       107
      ACCORDANCE WITH AUDIT.
343   PAID AS BILLED.                                                                                                             67
344   CLAIM DATES OF SERVICE ARE    B5        COVERAGE/PROGRAM GUIDELINES WERE                                                    187
      OUTSIDE THE PSRO APPROVED               NOT MET OR WERE EXCEEDED.
      DATES.
345   PAID IN ACCORD WITH DENTAL    95        PLAN PROCEDURES NOT FOLLOWED.                                                       107
      POLICY GUIDELINES.
346   SERVICES REDUCED PER                                                          N10      CLAIM/SERVICE ADJUSTED BASED ON THE 107
      MEDICAL CONSULTANT                                                                     FINDINGS OF A REVIEW
      COMMENT.                                                                               ORGANIZATION/PROFESSIONAL
                                                                                             CONSULT/MANUAL
                                                                                             ADJUDICATION/MEDICAL OR DENTAL
                                                                                             ADVISOR.
347   NON ALLOWABLE CHARGES      96           NON-COVERED CHARGE(S).                M79      MISSING/INCOMPLETE/INVALID CHARGE.   84
      DELETED.
348   ROOM CHARGES REDUCED TO    78           NON-COVERED DAYS/ROOM CHARGE                                                        180
      SEMI PRIVATE RATE.                      ADJUSTMENT.
349   RECIPIENT RESOURCE         177          PATIENT HAS NOT MET THE REQUIRED                                                    21
      REPORTING ON THE TAD                    ELIGIBILITY REQUIREMENTS.
      DIFFERS FROM THE RECIPIENT
      RESOURCE CONTAINED ON THE
      ELIGIBILITY FILE.

350   NDC HAS BEEN CHANGED TO       17        REQUESTED INFORMATION WAS NOT         M119     MISSING/INCOMPLETE/INVALID/DEACTIVAT 218
      CURRENT NUMBER.                         PROVIDED OR WAS                                ED/WITHDRAWN NATIONAL DRUG CODE
                                              INSUFFICIENT/INCOMPLETE.                       (NDC).
351   LIMIT EXCEEDED FOR ONE PAID   119       BENEFIT MAXIMUM FOR THE TIME PERIOD                                                 483
      EYE GLASSES EVERY 24                    OR OCCURRENCE HAS BEEN REACHED.
      MONTHS FOR RECIPIENTS 21
      AND OLDER.
352   ONLY ONE DISPENSING FEE       119       BENEFIT MAXIMUM FOR THE TIME PERIOD                                                 222
      ALLOWED PER MONTH.                      OR OCCURRENCE HAS BEEN REACHED.

353   DIAGNOSIS CODE CHANGED TO B22           THIS PAYMENT IS ADJUSTED BASED ON                                                   488
      MATCH DESCRIPTION.                      THE DIAGNOSIS.
354   YOUR CLAIM WAS DELAYED                                                        M50      MISSING/INCOMPLETE/INVALID REVENUE   455
      BECAUSE ONE OR MORE OF THE                                                             CODE(S).
      REVENUE CODES THAT WERE
      USED WERE NOT ACCEPTABLE
      IN OUR SYSTEM.




                                                                                                                                           Effective 10/22/10
                                                                           EOB TO 277 & 835



                                                                                   835                                         277
                                    835 ADJ   835 ADJUSTMENT REASON CODE           REMIT      835 REMITTANCE REMARK CODE       CLAIM
EOB   HP DESCRIPTION                REASON    DESCRIPTION                          REMARK     DESCRIPTION                      STATUS
355   NO CO-INSURANCE OR                                                                                                       9
      DEDUCTIBLE DUE BY MEDICAID

356   RECOUPMENT OF PAYMENT         B20       PROCEDURE/SERVICE WAS PARTIALLY OR                                               101
      WHICH BELONGS TO ANOTHER                FULLY FURNISHED BY ANOTHER
      PROVIDER.                               PROVIDER.
357   RECOUPMENT OF PAYMENT                                                                                                    101
      MADE FOR WRONG RECIPIENT.
      PLEASE    RESUBMIT YOUR
      CLAIM.
358   RECOUPMENT OF PAYMENT                                                                                                    101
      MADE FOR WRONG RECIPIENT.
      YOUR CLAIM IS BEING
      REPROCESSED.
359   RECOUPMENT OF PAID CLAIM                                                                                                 101
      WHICH WAS INCORRECTLY
      PROCESSED. CLAIM IS BEING
      REPROCESSED. DO NOT
      RESUBMIT CLAIM.
360   PAID IN PART BY MEDICARE.     23        THE IMPACT OF PRIOR PAYER(S)                                                     182
                                              ADJUDICATION INCLUDING PAYMENTS
                                              AND/OR ADJUSTMENTS.
361   RATE NOT VALID FOR DATES OF   147       PROVIDER CONTRACTED/NEGOTIATED       N65        PROCEDURE CODE OR PROCEDURE RATE 187
      SERVICE.                                RATE EXPIRED OR NOT ON FILE.                    COUNT CANNOT BE DETERMINED, OR
                                                                                              WAS NOT ON FILE, FOR THE DATE OF
                                                                                              SERVICE/PROVIDER.
362   THE CLAIM PATIENT LIABILITY   142       MONTHLY MEDICAID PATIENT LIABILITY                                               65
      AMOUNT HAS BEEN DEDUCTED                AMOUNT.
      FROM THE CLAIM PAYABLE
      AMOUNT.
363   ADDITIONAL PAYMENT CANNOT     23        THE IMPACT OF PRIOR PAYER(S)                                                     182
      BE MADE ON THE CLAIM AS THE             ADJUDICATION INCLUDING PAYMENTS
         RECIPIENT'S PRIVATE                  AND/OR ADJUSTMENTS.
      INSURANCE PAID AN AMOUNT
      GREATER THAN OREQUAL TO
      THE CLAIM'S MEDICAID
      ALLOWED AMOUNT.
364   MEDICAID ALLOWED AMOUNT       23        THE IMPACT OF PRIOR PAYER(S)                                                     182
      REDUCED BY OTHER                        ADJUDICATION INCLUDING PAYMENTS
      INSURANCE PAYMENT                       AND/OR ADJUSTMENTS.
365   FEE ADJUSTED TO MAXIMUM       45        CHARGES EXCEEDS FEE                                                              65
      ALLOWABLE.                              SCHEDULE/MAXIMUM ALLOWABLE OR
                                              CONTRACTED/LEGISLTATED FEE
                                              ARRANGMENT. (USE GROUPE CODES PR
                                              OR CO DEPENDING ON LIABILITY).




                                                                                                                                        Effective 10/22/10
                                                                            EOB TO 277 & 835



                                                                                      835                                           277
                                      835 ADJ   835 ADJUSTMENT REASON CODE            REMIT    835 REMITTANCE REMARK CODE           CLAIM
EOB   HP DESCRIPTION                  REASON    DESCRIPTION                           REMARK   DESCRIPTION                          STATUS
366   OTHER INSURANCE PAID AN         23        THE IMPACT OF PRIOR PAYER(S)                                                        182
      AMOUNT GREATER THAN OR                    ADJUDICATION INCLUDING PAYMENTS
      EQUAL TO OUR ALLOWED                      AND/OR ADJUSTMENTS.
      AMOUNT. MEDICAID CANNOT
      MAKE ANY ADDITIONAL
      PAYMENT.
367   EYE EXAM EXCEEDS ONE EVERY 119            BENEFIT MAXIMUM FOR THE TIME PERIOD                                                 483
      24 MONTHS FOR RECIPIENTS                  OR OCCURRENCE HAS BEEN REACHED.
      AGE 21 AND OLDER.

368   LOCK IN SERVICES TO BE                                                                                                        84
      ORDERED BY PRIMARY
      PHYSICIAN.
369   SUBMITTED LINE ITEM CHARGE 16             CLAIM/SERVICE LACKS INFORMATION       M79      MISSING/INCOMPLETE/INVALID CHARGE.   247
      MISSING OR INVALID.                       WHICH IS NEEDED FOR ADJUDICATION.
370   QUARTERLY AMOUNT FOR FUND 119             BENEFIT MAXIMUM FOR THE TIME PERIOD                                                 483
      CODE BILLED WAS EXCEEDED.                 OR OCCURRENCE HAS BEEN REACHED.

371   PATIENT LIABILITY EXCEEDS       142       MONTHLY MEDICAID PATIENT LIABILITY                                                  182
      ALLOWED AMOUNT.                           AMOUNT.
372   PAID IN FULL BY OTHER           23        THE IMPACT OF PRIOR PAYER(S)                                                        182
      INSURANCE.                                ADJUDICATION INCLUDING PAYMENTS
                                                AND/OR ADJUSTMENTS.
373   MUST BE INCLUDED IN FLAT FEE 97           THE BENEFIT FOR THIS SERVICE IS                                                     39
      FOR MATERNITY.                            INCLUDED IN THE PAYMENT/ALLOWANCE
                                                FOR ANOTHER SERVICE/PROCEDURE
                                                THAT HAS ALREADY BEEN ADJUDICATED.

374   REPAYMENT PORTION OF THIS                                                                                                     101
      ADJUSTMENT HAS BEEN
      DENIED.   RECOUPMENT IS
      UNDER FINANCIAL ITEMS.
375   ONLY ONE THIN PAP SMEAR         119       BENEFIT MAXIMUM FOR THE TIME PERIOD                                                 483
      ALLOWED PER SFY                           OR OCCURRENCE HAS BEEN REACHED.

376   INCLUDED IN FEE FOR OFFICE      97        THE BENEFIT FOR THIS SERVICE IS                                                     9
      CALL.                                     INCLUDED IN THE PAYMENT/ALLOWANCE
                                                FOR ANOTHER SERVICE/PROCEDURE
                                                THAT HAS ALREADY BEEN ADJUDICATED.

377   $2.00 DIFFERENTIAL DISPENSING                                                                                                 103
      FEE INCLUDED IN PAID AMOUNT




                                                                                                                                             Effective 10/22/10
                                                                             EOB TO 277 & 835



                                                                                     835                                               277
                                    835 ADJ   835 ADJUSTMENT REASON CODE             REMIT      835 REMITTANCE REMARK CODE             CLAIM
EOB   HP DESCRIPTION                REASON    DESCRIPTION                            REMARK     DESCRIPTION                            STATUS
378   INCLUDED IN FEE FOR           97        THE BENEFIT FOR THIS SERVICE IS                                                          103
      LABORATORY SERVICE.                     INCLUDED IN THE PAYMENT/ALLOWANCE
                                              FOR ANOTHER SERVICE/PROCEDURE
                                              THAT HAS ALREADY BEEN ADJUDICATED.

379   PAID IN FULL BY OTHER         23        THE IMPACT OF PRIOR PAYER(S)                                                             182
      INSURANCE. NO ADDL' PMT CAN             ADJUDICATION INCLUDING PAYMENTS
      BE MADE.                                AND/OR ADJUSTMENTS.
380   RECIPIENT SPENDDOWN           91        DISPENSING FEE ADJUSTMENT.
      REDUCED AMT/ADD $2 FOR DIF
      DISPENSING FEE.
381   ADJUSTMENT RESULTING FROM                                                      M53        MISSING/INCOMPLETE/INVALID DAYS OR     101
      INCORRECT AMOUNT OF                                                                       UNITS OF SERVICE.
      DOLLAR/SERVICE UNITS ON
      ORIGINAL CLAIM.
382   ADJUSTMENT RESULTING FROM     17        REQUESTED INFORMATION WAS NOT          MA130      YOUR CLAIM CONTAINS INCOMPLETE     101
      INCORRECT RECIPIENT ID# ON              PROVIDED OR WAS                                   AND/OR INVALID INFORMATION, AND NO
        ORIGINAL CLAIM.                       INSUFFICIENT/INCOMPLETE.                          APPEAL RIGHTS ARE AFFORDED BECAUSE
                                                                                                THE CLAIM IS UNPROCESSABLE. PLEASE
                                                                                                SUBMIT A NEW CLAIM WITH THE
                                                                                                COMPLETE/CORRECT INFORMATION.

383   ADJUSTMENT RESULTING FROM                                                      N30        PATIENT INELIGIBLE FOR THIS SERVICE.   101
      OVERPAYMENT -- PATIENT
      EXPIRED.
384   ADJUSTMENT RESULTING FROM                                                      M53        MISSING/INCOMPLETE/INVALID DAYS OR     101
      A CHANGE IN THE UNITS OF                                                                  UNITS OF SERVICE.
      SERVICE.
385   ADJUSTMENT --- ORIGINAL     125         SUBMISSION/BILLING ERROR(S).           N377       PAYMENT BASED ON A PROCESSED           101
      CLAIM PAID TO WRONG                                                                       REPLACEMENT CLAIM.
      PROVIDER.
386   ADJUSTMENT RESULTING FROM                                                      M119       MISSING/INCOMPLETE/INVALID/DEACTIVAT 101
      A CHANGE IN THE NDC NUMBER.                                                               ED/WITHDRAWN NATIONAL DRUG CODE
                                                                                                (NDC).
387   EFFECTIVE 07-01-88 IF PRIOR   197       PRECERTIFICATION/AUTHORIZATION/NOTIF                                                   252
      AUTHORIZATION NUMBER                    ICATION ABSENT.
      OMITTED CLAIM WILL BE
      DENIED
388   EXCEEDS LIMIT OF ONE          119       BENEFIT MAXIMUM FOR THE TIME PERIOD                                                      483
      PHYSICAL THERAPY                        OR OCCURRENCE HAS BEEN REACHED.
      EVALUATION PER       STATE
      FISCAL YEAR.
389   PRIOR AUTHORIZATION/PRE-      197       PRECERTIFICATION/AUTHORIZATION/NOTIF                                                     252
      CERTIFICATION NUMBER NOT                ICATION ABSENT.
      ON FILE.




                                                                                                                                                Effective 10/22/10
                                                                           EOB TO 277 & 835



                                                                                    835                                             277
                                     835 ADJ   835 ADJUSTMENT REASON CODE           REMIT     835 REMITTANCE REMARK CODE            CLAIM
EOB   HP DESCRIPTION                 REASON    DESCRIPTION                          REMARK    DESCRIPTION                           STATUS
390   CLAIM PROVIDER NUMBER IS       15        THE AUTHORIZATION NUMBER IS MISSING,                                                 252
      NOT ON PRIOR AUTHORIZATION/              INVALID, OR DOES NOT APPLY TO THE
         PRE-CERTIFICATION FILE.               BILLED SERVICES OR PROVIDER.

391   ARKIDS FIRST-B CLAIM                                                            N61     REBILL SERVICES ON SEPARATE CLAIMS.   121
      EXCEEDED 28 DETAILS. PLEASE
      SPLIT BILL AND RESUBMIT.

392   PRIOR AUTHORIZATION/PRE-       15        THE AUTHORIZATION NUMBER IS MISSING,                                                 252
      CERTIFICATION UNITS HAVE                 INVALID, OR DOES NOT APPLY TO THE
      BEEN    EXHAUSTED.                       BILLED SERVICES OR PROVIDER.

393   CLAIM RECIPIENT ID# DOES NOT   140       PATIENT/INSURED HEALTH                                                               252
      MATCH P.A. RECIPIENT ID#.                IDENTIFICATION NUMBER AND NAME DO
                                               NOT MATCH.
394   TOOTH NUMBER MUST BE PRIOR 15            THE AUTHORIZATION NUMBER IS MISSING,                                                 252
      AUTHORIZED.                              INVALID, OR DOES NOT APPLY TO THE
                                               BILLED SERVICES OR PROVIDER.

395   OUT-OF-STATE CARE NOT          197       PRECERTIFICATION/AUTHORIZATION/NOTIF                                                 84
      PREAUTHORIZED.                           ICATION ABSENT.
396   PRIOR AUTHORIZATION HAS        197       PRECERTIFICATION/AUTHORIZATION/NOTIF                                                 252
      NOT BEEN ISSUED FOR THE                  ICATION ABSENT.
      ASSISTANT SURGEON.
397   PRIOR AUTHORIZATION/PRE-       197       PRECERTIFICATION/AUTHORIZATION/NOTIF                                                 252
      CERTIFICATION NUMBER IS                  ICATION ABSENT.
      MISSING OR INVALID.
398   PRIOR AUTHORIZATION/PRE-       197       PRECERTIFICATION/AUTHORIZATION/NOTIF                                                 252
      CERTIFICATION NUMBER HAS                 ICATION ABSENT.
      EXPIRED.
399   PRIOR AUTHORIZATION/PRE-       197       PRECERTIFICATION/AUTHORIZATION/NOTIF                                                 252
      CERTIFICATION REQUIRED.                  ICATION ABSENT.
400   NO PAYMENT ALLOWED FOR         59        PROCESSED BASED ON MULTIPLE OR                                                       9
      INCIDENTAL SURGERY.                      CONCURRENT PROCEDURE RULES (FOR
                                               EXAMPLE MULTIPLE SURGERY OR
                                               DIAGNOSTIC IMAGING, CONCURRENT
                                               ANESTHESIA.)
401   THIS PROCEDURE IS INCLUDED     97        THE BENEFIT FOR THIS SERVICE IS                                                      107
      IN THE FEE FOR THE PRIMARY               INCLUDED IN THE PAYMENT/ALLOWANCE
       PROCEDURE.                              FOR ANOTHER SERVICE/PROCEDURE
                                               THAT HAS ALREADY BEEN ADJUDICATED.




                                                                                                                                             Effective 10/22/10
                                                                           EOB TO 277 & 835



                                                                                    835                                           277
                                    835 ADJ   835 ADJUSTMENT REASON CODE            REMIT     835 REMITTANCE REMARK CODE          CLAIM
EOB   HP DESCRIPTION                REASON    DESCRIPTION                           REMARK    DESCRIPTION                         STATUS
402   THIS SERVICE WAS REVIEWED     A1        CLAIM DENIED CHARGES.                 N10       CLAIM/SERVICE ADJUSTED BASED ON THE 9
      BY OUR MEDICAL CONSULTANT                                                               FINDINGS OF A REVIEW
      AND WAS DENIED.                                                                         ORGANIZATION/PROFESSIONAL
                                                                                              CONSULT/MANUAL
                                                                                              ADJUDICATION/MEDICAL OR DENTAL
                                                                                              ADVISOR.
403   PRICED AS MULTIPLE SURGERY. 59          PROCESSED BASED ON MULTIPLE OR                                                     65
                                              CONCURRENT PROCEDURE RULES (FOR
                                              EXAMPLE MULTIPLE SURGERY OR
                                              DIAGNOSTIC IMAGING, CONCURRENT
                                              ANESTHESIA.)
404   THIS SERVICE WAS PREVIOUSLY B13         PREVIOUSLY PAID. PAYMENT FOR THIS                                                  54
      SUBMITTED AND PAID.                     CLAIM/SERVICE MAY HAVE BEEN
                                              PROVIDED IN A PREVIOUS PAYMENT.
405   CLIA CERTIFICATION REQUIRED                                                   MA120     MISSING/INCOMPLETE/INVALID CLIA    142
      FOR LAB PROCEDURE.                                                                      CERTIFICATION NUMBER.

406   EXCEEDED ONE PREVENTATIVE     119       BENEFIT MAXIMUM FOR THE TIME PERIOD                                                483
      DENTAL SCREEN APPROPRIATE               OR OCCURRENCE HAS BEEN REACHED.
      FOR NEWBORN TO 12
      MONTHS.
407   EXCEEDS LIMIT OF ONE EYE      119       BENEFIT MAXIMUM FOR THE TIME PERIOD                                                483
      EXAM IN A 12 MONTH PERIOD               OR OCCURRENCE HAS BEEN REACHED.

408   TAX RECOUPMENT FROM
      VOIDED CHECK CREDITED NET
      1099 AMOUNT
409   ARKIDS FIRST-B PARTICIPANT  119         BENEFIT MAXIMUM FOR THE TIME PERIOD                                                483
      EXCEEDED BENEFIT LIMIT FOR              OR OCCURRENCE HAS BEEN REACHED.
        AGE APPROPRIATE
      PREVENTATIVE HEALTH SCREEN.

410   RESPITE CARE PROVIDED MORE 119          BENEFIT MAXIMUM FOR THE TIME PERIOD                                                483
      THAN 14 CONSECUTIVE DAYS                OR OCCURRENCE HAS BEEN REACHED.

411   TWO EPSDT HEARING SCREENS     119       BENEFIT MAXIMUM FOR THE TIME PERIOD                                                483
      APPROPRIATE PER YEAR                    OR OCCURRENCE HAS BEEN REACHED.

412   TWO EPSDT AGE APPROPRIATE     119       BENEFIT MAXIMUM FOR THE TIME PERIOD                                                483
      HEARING SCREENS PAYABLE                 OR OCCURRENCE HAS BEEN REACHED.
      FROM 16YRSTHRU 17YRS

413   TWO EPSDT AGE APPROPRIATE     119       BENEFIT MAXIMUM FOR THE TIME PERIOD                                                483
      HEARING SCREENS PAYABLE                 OR OCCURRENCE HAS BEEN REACHED.
      FROM 18YRSTHRU 20YRS




                                                                                                                                           Effective 10/22/10
                                                                        EOB TO 277 & 835



                                                                                  835                                   277
                                  835 ADJ   835 ADJUSTMENT REASON CODE            REMIT    835 REMITTANCE REMARK CODE   CLAIM
EOB   HP DESCRIPTION              REASON    DESCRIPTION                           REMARK   DESCRIPTION                  STATUS
414   TWO EPSDT AGE APPROPRIATE   119       BENEFIT MAXIMUM FOR THE TIME PERIOD                                         483
      HEARING SCREENS PAYABLE               OR OCCURRENCE HAS BEEN REACHED.
      FROM 12YRSTHRU 15 YRS

415   TWO EPSDT AGE APPROPRIATE   119       BENEFIT MAXIMUM FOR THE TIME PERIOD                                         483
      VISION SCREENS PAYABLE                OR OCCURRENCE HAS BEEN REACHED.
      FROM 6 YRS THRU 9 YEARS

416   TWO EPSDT AGE APPROPRIATE   119       BENEFIT MAXIMUM FOR THE TIME PERIOD                                         483
      VISION SCREENS PAYABLE                OR OCCURRENCE HAS BEEN REACHED.
      FROM 10 YRSTHRU 11 YEARS

417   TWO EPSDT AGE APPROPRIATE   119       BENEFIT MAXIMUM FOR THE TIME PERIOD                                         483
      VISION SCREENS PAYABLE                OR OCCURRENCE HAS BEEN REACHED.
      FROM 12 YRSTHRU 15 YRS

418   TWO EPSDT AGE APPROPRIATE   119       BENEFIT MAXIMUM FOR THE TIME PERIOD                                         483
      VISION SCREENS PAYABLE                OR OCCURRENCE HAS BEEN REACHED.
      FROM 16 YRSTHRU 17 YRS

419   TWO EPSDT AGE APPROPRIATE   119       BENEFIT MAXIMUM FOR THE TIME PERIOD                                         483
      VISION SCREENS PAYABLE                OR OCCURRENCE HAS BEEN REACHED.
      FROM 18 YRSTHRU 20 YRS

420   ADJUSTMENT RESULTING FROM                                                                                         101
      A CHANGE IN THE TYPE OF
      SERVICE.
421   ADJUSTMENT RESULTING FROM                                                                                         101
      A CHANGE IN THE PROCEDURE
      CODE.
422   CROSSOVER ADJUSTMENT        B5        COVERAGE/PROGRAM GUIDELINES WERE                                            101
      RESULTING FROM AN                     NOT MET OR WERE EXCEEDED.
      ADJUSTMENT MADE BY
      MEDICARE.
423   ADJUSTMENT RESULTING FROM   58        TREATMENT WAS DEEMED BY THE PAYER                                           101
      A CHANGE IN THE PLACE OF              TO HAVE BEEN RENDERED IN AN
      SERVICE.                              INAPPROPRIATE OR INVALID PLACE OF
                                            SERVICE.
424   TWO EPSDT AGE APPROPRIATE   119       BENEFIT MAXIMUM FOR THE TIME PERIOD                                         483
      HEARING SCREENS PAYABLE               OR OCCURRENCE HAS BEEN REACHED.
      FROM NEW- BORN TO 5 YEARS

425   TWO EPSDT AGE APPROPRIATE   119       BENEFIT MAXIMUM FOR THE TIME PERIOD                                         483
      HEARING SCREENS PAYABLE               OR OCCURRENCE HAS BEEN REACHED.
      FROM 8 YRSTO 11 YRS




                                                                                                                                 Effective 10/22/10
                                                                             EOB TO 277 & 835



                                                                                      835                                              277
                                      835 ADJ   835 ADJUSTMENT REASON CODE            REMIT     835 REMITTANCE REMARK CODE             CLAIM
EOB   HP DESCRIPTION                  REASON    DESCRIPTION                           REMARK    DESCRIPTION                            STATUS
426   GROUP I OUTPATIENT DENTAL       97        THE BENEFIT FOR THIS SERVICE IS                                                        107
      SURGERY NOT PAYABLE SAME                  INCLUDED IN THE PAYMENT/ALLOWANCE
      DOS GROUP II OUTPATIENT                   FOR ANOTHER SERVICE/PROCEDURE
      DENTAL SURGERY.                           THAT HAS ALREADY BEEN ADJUDICATED.

427   $5.00 ENROLLMENT FEE
      DEDUCTED FROM PAYMENT.
428   EXCEEDS TWO NORPLANT         119          BENEFIT MAXIMUM FOR THE TIME PERIOD                                                    483
      SYSTEMS WITHIN 5 YEAR PERIOD              OR OCCURRENCE HAS BEEN REACHED.

429   EXCEEDS TWO INSERTIONS          119       BENEFIT MAXIMUM FOR THE TIME PERIOD                                                    483
      WITHIN 5 YEAR PERIOD                      OR OCCURRENCE HAS BEEN REACHED.

430   $2.00 DISPENSING FEE        91            DISPENSING FEE ADJUSTMENT.
      INCLUDED/$5.00 ENROLLMENT
      FEE DEDUCTED.
431   EXCEEDS LIMIT OF ONE        119           BENEFIT MAXIMUM FOR THE TIME PERIOD                                                    483
      DIAGNOSIS - PSYCHOLOGICAL                 OR OCCURRENCE HAS BEEN REACHED.
      TEST EVALUATION PER STATE
      FISCAL YEAR
432   RECIPIENT LIMITED TO TB                                                         N30       PATIENT INELIGIBLE FOR THIS SERVICE.   84
      RELATED SERVICES ONLY.
433   EXCEEDS LIMIT OF ONE        119           BENEFIT MAXIMUM FOR THE TIME PERIOD                                                    483
      INTERPRETATION OF DIAGNOSIS               OR OCCURRENCE HAS BEEN REACHED.
      PER STATE FISCAL YEAR

434   EXCEEDED LIMIT OF 48 CRISIS     119       BENEFIT MAXIMUM FOR THE TIME PERIOD                                                    483
      MANAGEMENT SERVICE UNITS                  OR OCCURRENCE HAS BEEN REACHED.
      PER STATE FISCAL YEAR
435   EXCEEDS LIMIT OF SIX UNITS      119       BENEFIT MAXIMUM FOR THE TIME PERIOD                                                    483
      FAMILY THERAPY/MARITAL PER                OR OCCURRENCE HAS BEEN REACHED.
      WEEK
436   EXCEEDS LIMIT OF TWELVE         119       BENEFIT MAXIMUM FOR THE TIME PERIOD                                                    483
      UNITS INDIVIDUAL OUTPATIENT -             OR OCCURRENCE HAS BEEN REACHED.
         COLLATERAL SERVICES PER
      90 DAYS
437   NEW BIRTH STANDBY NON-          97        THE BENEFIT FOR THIS SERVICE IS                                                        107
      PAYABLE SAME DATE OF                      INCLUDED IN THE PAYMENT/ALLOWANCE
      SERVICE AS     PHYSICIAN                  FOR ANOTHER SERVICE/PROCEDURE
      STANDBY SERVICE.                          THAT HAS ALREADY BEEN ADJUDICATED.

438   UNITS * UNIT COST IS FOUR OR    154       PAYER DEEMS THE INFORMATION                                                            483
      MORE TIMES GREATER THAN                   SUBMITTED DOES NOT SUPPORT THIS
      BILLED AMOUNT. REBILL USING               DAY'S SUPPLY.
      CORRECT UNITS.




                                                                                                                                                Effective 10/22/10
                                                                           EOB TO 277 & 835



                                                                                     835                                           277
                                     835 ADJ   835 ADJUSTMENT REASON CODE            REMIT    835 REMITTANCE REMARK CODE           CLAIM
EOB   HP DESCRIPTION                 REASON    DESCRIPTION                           REMARK   DESCRIPTION                          STATUS
439   UNITS * UNIT COST IS LESS      154       PAYER DEEMS THE INFORMATION           M53      MISSING/INCOMPLETE/INVALID DAYS OR   476
      THAN HALF OF THE BILLED                  SUBMITTED DOES NOT SUPPORT THIS                UNITS OF SERVICE.
      AMOUNT. REBILL USING                     DAY'S SUPPLY.
      CORRECT UNITS.
440   NON-COVERED SERVICES MUST 96             NON-COVERED CHARGE(S).                N78      THE NECESSARY COMPONENTS OF THE     84
      BE RESULT OF EPSDT REFERRAL                                                             CHILD AND TEEN CHECKUP (EPSDT) WERE
                                                                                              NOT COMPLETED.
441   CLAIMS RELATED TO ORGAN        109       CLAIM NOT COVERED BY THIS             N59      ALERT: PLEASE REFER TO YOUR         23
      TRANSPLANT MUST BE                       PAYER/CONTRACTOR. YOU MUST SEND                PROVIDER MANUAL FOR ADDITIONAL
      SUBMITTED DIRECT-LY TO                   THE CLAIM TO THE CORRECT                       PROGRAM AND PROVIDER INFORMATION.
      UTILIZATION REVIEW WITHIN                PAYER/CONTRACTOR.
      SIXTY DAYS OF THE
      PROCEDURE. INSTRUCTION
      FOR FILING CLAIMS MAY BE
      FOUND IN PROV MANUAL.
442   THE CENSUS RECORD FOR THE      16        CLAIM/SERVICE LACKS INFORMATION       N29      MISSING/INCOMPLETE/INVALID       21
      MONTH JUST BEFORE THE                    WHICH IS NEEDED FOR ADJUDICATION.              DOCUMENTATION/ORDERS/NOTES/SUMMA
      FROM DATE OF SERVICE HAS                                                                RY/REPORT/CHART.
      NOT BEEN RECIEVED. PLEASE
      SUBMIT THE APPROPRIATE
      CENSUS DATA AND RESUBMIT
      THE CLAIM.
443   CLAIM IN EXCESS OF THE     119           BENEFIT MAXIMUM FOR THE TIME PERIOD                                                 483
      MAXIMUM 5 CONSECUTIVE DAYS               OR OCCURRENCE HAS BEEN REACHED.
      HOSPITAL LEAVE FROM THE
      NURSING HOME.
444   ABSENCE OF RESTORATIVE     107           THE RELATED OR QUALIFYING             M20      MISSING/INCOMPLETE/INVALID HCPCS.    42
      CODE PREVENTS PAYMENT OF                 CLAIM/SERVICE WAS NOT IDENTIFIED ON
      CLAIM                                    THIS CLAIM.
445   INVALID NCCI BILLING       97            THE BENEFIT FOR THIS SERVICE IS                                                     107
      COMBINATIONS - DENIED DUE                INCLUDED IN THE PAYMENT/ALLOWANCE
      TO RELATED PROCEDURE PAID                FOR ANOTHER SERVICE/PROCEDURE
      IN HISTORY. CMS DOES NOT                 THAT HAS ALREADY BEEN ADJUDICATED.
      ALLOW APPEAL.
446   CLAIM SPLIT INTO SEPARATE      178       PATIENT HAS NOT MET THE REQUIRED      N63      REBILL SERVICES ON SEPARATE CLAIM    247
      DETAILS TO ACCOMMODATE                   SPEND DOWN REQUIREMENTS.                       LINES.
      THE     SPENDDOWN
      REQUIREMENTS.
447   UNITS OF SERVICE DO NOT        178       PATIENT HAS NOT MET THE REQUIRED                                                    476
      CORRESPOND TO THE DATES                  SPEND DOWN REQUIREMENTS.
      BILLED FOR SPENDDOWN
448   SERVICE INCLUDED IN CRITICAL   97        THE BENEFIT FOR THIS SERVICE IS       M15      SEPARATELY BILLED SERVICES/TESTS   107
      CARE CODE.                               INCLUDED IN THE PAYMENT/ALLOWANCE              HAVE BEEN BUNDLED AS THEY ARE
                                               FOR ANOTHER SERVICE/PROCEDURE                  CONSIDERED COMPONENTS OF THE SAME
                                               THAT HAS ALREADY BEEN ADJUDICATED.             PROCEDURE. SEPARATE PAYMENT IS NOT
                                                                                              ALLOWED.




                                                                                                                                            Effective 10/22/10
                                                                           EOB TO 277 & 835



                                                                                      835                                             277
                                     835 ADJ   835 ADJUSTMENT REASON CODE             REMIT    835 REMITTANCE REMARK CODE             CLAIM
EOB   HP DESCRIPTION                 REASON    DESCRIPTION                            REMARK   DESCRIPTION                            STATUS
449   DIAGNOSIS NOT ON               146       DIAGNOSIS WAS INVALID FOR THE          M81      YOU ARE REQUIRED TO CODE TO THE        255
      INSTITUTIONAL CRITERIA FOR               DATE(S) OF SERVICE REPORTED.                    HIGHEST LEVEL OF SPECIFICITY.
      PAS DAYS.
450   REFILE WITH COPY OF            16        CLAIM/SERVICE LACKS INFORMATION        N29      MISSING/INCOMPLETE/INVALID       294
      PROGRESS NOTES.                          WHICH IS NEEDED FOR ADJUDICATION.               DOCUMENTATION/ORDERS/NOTES/SUMMA
                                                                                               RY/REPORT/CHART.
451   INVALID NCCI BILLING           97        THE BENEFIT FOR THIS SERVICE IS                                                  107
      COMBINATIONS - DENIED DUE                INCLUDED IN THE PAYMENT/ALLOWANCE
      TO RELATED PROCEDURE PAID                FOR ANOTHER SERVICE/PROCEDURE
      IN HISTORY. CMS ALLOWS                   THAT HAS ALREADY BEEN ADJUDICATED.
      APPEAL
452   CLAIM IN EXCESS OF THE         119       BENEFIT MAXIMUM FOR THE TIME PERIOD                                                    483
      MAXIMUM 14 CONSECUTIVE DAY               OR OCCURRENCE HAS BEEN REACHED.
      HOME     LEAVE FROM THE
      NURSING HOME.
453   CLAIM CUT BACK TO BENEFIT      119       BENEFIT MAXIMUM FOR THE TIME PERIOD                                                    483
      LIMIT                                    OR OCCURRENCE HAS BEEN REACHED.

454   PROCEDURE CODE CAN BE        B18         THIS PROCEDURE CODE AND MODIFIER                                                       454
      BILLED ON DATE OF BIRTH ONLY             WERE INVALID ON THE DATE OF SERVICE.

455   PROCEDURE CODE CANNOT BE       B18       THIS PROCEDURE CODE AND MODIFIER                                                       454
      BILLED ON DATE OF BIRTH                  WERE INVALID ON THE DATE OF SERVICE.

456   MAXIMUM OF 20 PAID INPATIENT   119       BENEFIT MAXIMUM FOR THE TIME PERIOD                                                    483
      HOSPITAL DAYS PER SFY                    OR OCCURRENCE HAS BEEN REACHED.

457   BENEFITS EXHAUSTED             119       BENEFIT MAXIMUM FOR THE TIME PERIOD                                                    483
                                               OR OCCURRENCE HAS BEEN REACHED.

458   MAXIMUM OF 30 PAID REHAB       119       BENEFIT MAXIMUM FOR THE TIME PERIOD                                                    483
      HOSPITAL DAYS OPTION PER                 OR OCCURRENCE HAS BEEN REACHED.
      CURRENT SFY
459   MAX TRANSPLANT                 119       BENEFIT MAXIMUM FOR THE TIME PERIOD                                                    483
      REIMBURSEMENT AMOUNT OF                  OR OCCURRENCE HAS BEEN REACHED.
      150,000.00 HAS BEEN
      EXCEEDED.
460   SERVICES COVERED ONLY FOR                                                       N30      PATIENT INELIGIBLE FOR THIS SERVICE.   84
      ASSISTED LIVING WAIVER
      CLIENTS.
461   EXCEEDED MAXIMUM OF THREE      119       BENEFIT MAXIMUM FOR THE TIME PERIOD                                                    483
      TREATMENTS PER WEEK FOR                  OR OCCURRENCE HAS BEEN REACHED.
      HEMODIALYSIS
462   LIMIT OF 3 UNITS PER DAY       119       BENEFIT MAXIMUM FOR THE TIME PERIOD                                                    483
      WITHOUT BENEFIT EXTENSION                OR OCCURRENCE HAS BEEN REACHED.




                                                                                                                                               Effective 10/22/10
                                                                               EOB TO 277 & 835



                                                                                          835                                               277
                                         835 ADJ   835 ADJUSTMENT REASON CODE             REMIT    835 REMITTANCE REMARK CODE               CLAIM
EOB   HP DESCRIPTION                     REASON    DESCRIPTION                            REMARK   DESCRIPTION                              STATUS
463   93543/93546 NOT ALLOWED            B18       THIS PROCEDURE CODE AND MODIFIER       M86      SERVICE DENIED BECAUSE PAYMENT           107
      SAME DOS AS CERTAIN                          WERE INVALID ON THE DATE OF SERVICE.            ALREADY MADE FOR SAME/SIMILAR
      COMPANION      RADIOLOGICAL                                                                  PROCEDURE WITHIN SET TIME FRAME.
      CODES
464   READMISSION 96 HOURS FROM                                                                                                             189
      DISCHARGE, PAS DAYS USED.

465   UNITS OF SERVICE EXCEED            154       PAYER DEEMS THE INFORMATION            M53      MISSING/INCOMPLETE/INVALID               476
      NCCI MEDICALLY UNLIKELY                      SUBMITTED DOES NOT SUPPORT THIS                 COMPETITIVE BIDDING DEMONSTRATION
      EDITS.                                       DAY'S SUPPLY.                                   PROJECT IDENTIFICATION.

466   PROVIDER FILE SUSPENDED                                                                                                               91
      DUE TO NONPAYMENT OF
      TAXES, CONTACT THE DHS
      ACCOUNTS RECIEVABLE
      SECTION AT 682-6506/ 6508/ 6511.

467   PROVIDER FILE CANCELLED DUE                                                                                                           91
      TO NONPAYMENT OF TAXES,
      CONTACT THE DHS ACCOUNTS
      RECIEVABLE SECTION AT 682-
      6506/ 6508/ 6511.

468   TIER OF NEED FOR ASST LIVING                                                        N30      PATIENT INELIGIBLE FOR THIS SERVICE.     84
      WVR SERV NOT APPROVED BY
      DAAS FOR THIS CLIENT.

469   DUPLICATE OF CLAIM NOT YET         18        DUPLICATE CLAIM/SERVICE.                                                                 78
      PAID
470   DUPLICATE OF CLAIM PAID            18        DUPLICATE CLAIM/SERVICE.                                                                 54

471   SERVICE IS A DUPLICATE OF          18        DUPLICATE CLAIM/SERVICE.                                                                 78
      SERVICE PAID ON SAME CLAIM.
472   SEALANT ONCE IN A LIFETIME         35        LIFETIME BENEFIT MAXIMUM HAS BEEN                                                        483
      FOR TOOTH.                                   REACHED.
473   PROCEDURE IS INCLUDED IN           97        THE BENEFIT FOR THIS SERVICE IS                                                          107
      93543/93546 FOR SAME DOS                     INCLUDED IN THE PAYMENT/ALLOWANCE
                                                   FOR ANOTHER SERVICE/PROCEDURE
                                                   THAT HAS ALREADY BEEN ADJUDICATED.

474   RENTAL WHEELCHAIR NON-             119       BENEFIT MAXIMUM FOR THE TIME PERIOD    N417     THIS SERVICE IS ALLOWED 1 TIME IN A 5-   107
      PAYABLE WITHIN 5 YEARS OF                    OR OCCURRENCE HAS BEEN REACHED.                 YEAR PERIOD.
      PURCHASED WHEELCHAIR




                                                                                                                                                     Effective 10/22/10
                                                                           EOB TO 277 & 835



                                                                                      835                                             277
                                     835 ADJ   835 ADJUSTMENT REASON CODE             REMIT    835 REMITTANCE REMARK CODE             CLAIM
EOB   HP DESCRIPTION                 REASON    DESCRIPTION                            REMARK   DESCRIPTION                            STATUS
475   A PAID PANEL CODE OR           B18       THIS PROCEDURE CODE AND MODIFIER       N61      REBILL SERVICES ON SEPARATE CLAIMS.    419
      ANOTHER PAID INDIVIDUAL TEST             WERE INVALID ON THE DATE OF SERVICE.
      PREVENTS PAYMENT OF THIS
      CLAIM PLEASE ADJUST FOR
      PAID PROCEDURES AND REBILL
      USING HIGHEST PANEL OR
      PROFILE CODE APPLICABLE

476   CLAIM NOT SUBMITTED USING                                                       M126     MISSING/INCOMPLETE/INVALID INDIVIDUAL 419
      HIGHEST LAB PANEL OR                                                                     LAB CODES INCLUDED IN THE TEST.
      PROFILE CODE APPLICABLE FOR
      SAME DOS RESUBMIT USING A
      SINGLE APPROPRIATE CODE

477   A PAID OR PENDING CLAIM FOR    45        CHARGES EXCEEDS FEE                    N45      PAYMENT BASED ON AUTHORIZED            419
      80019 REPRESENTS THE                     SCHEDULE/MAXIMUM ALLOWABLE OR                   AMOUNT.
      MAXIMUM ALLOWABLE PER                    CONTRACTED/LEGISLTATED FEE
      DOS NO OTHER INDIVIDUAL                  ARRANGMENT. (USE GROUPE CODES PR
      TESTS OR PANELS ARE                      OR CO DEPENDING ON LIABILITY).
      ALLOWED IN CONJUNCTION
      WITH 80019
478   93501-93529 NOT ALLOWED                                                         N20      SERVICE NOT PAYABLE WITH OTHER         107
      SAME DOS AS CERTAIN                                                                      SERVICE RENDERED ON THE SAME DATE.
      COMPANION RADIO-LOGICAL
      CODES
479   PROCEDURE IS INCLUDED IN       97        THE BENEFIT FOR THIS SERVICE IS                                                        107
      93501-93529 FOR SAME DOS                 INCLUDED IN THE PAYMENT/ALLOWANCE
                                               FOR ANOTHER SERVICE/PROCEDURE
                                               THAT HAS ALREADY BEEN ADJUDICATED.

480   REFILE ON PAPER CLAIM WITH     16        CLAIM/SERVICE LACKS INFORMATION        N29      MISSING/INCOMPLETE/INVALID       277
      APPROPRIATE DESCRIPTION                  WHICH IS NEEDED FOR ADJUDICATION.               DOCUMENTATION/ORDERS/NOTES/SUMMA
      AND/OR ATTACHMENT.                       ADDITIONAL INFORMATION IS SUPPLIED              RY/REPORT/CHART.
                                               USING REMITTANCE ADVICE REMARKS
                                               CODES WHENEVER APPROPRIATE.
481   PERSONAL CARE NOT ALLOWED                                                       N30      PATIENT INELIGIBLE FOR THIS SERVICE.   84
      TO ASSISTED LIVING WAIVER
      CLIENTS.
482   PATIENT WAS ADMITTED ON     60           CHARGES FOR OUTPATIENT SERVICES        M2       NOT PAID SEPARATELY WHEN THE           189
      SAME DOS AS PAID OR PENDING              WITH THIS PROXIMITY TO INPATIENT                PATIENT IS AN INPATIENT.
      CLAIM FOR OUTPATIENT                     SERVICES ARE NOT COVERED.
      SERVICES.




                                                                                                                                               Effective 10/22/10
                                                                         EOB TO 277 & 835



                                                                                  835                                          277
                                    835 ADJ   835 ADJUSTMENT REASON CODE          REMIT     835 REMITTANCE REMARK CODE         CLAIM
EOB   HP DESCRIPTION                REASON    DESCRIPTION                         REMARK    DESCRIPTION                        STATUS
483   PROCEDURE IS INCLUDED IN      B15       THIS SERVICE/PROCEDURE REQUIRES     M15       SEPARATELY BILLED SERVICES/TESTS   107
      93544 FOR SAME DOS                      THAT A QUALIFYING SERVICE/PROCEDURE           HAVE BEEN BUNDLED AS THEY ARE
                                              BE RECEIVED AND COVERED. THE                  CONSIDERED COMPONENTS OF THE SAME
                                              QUALIFYING OTHER SERVICE/PROCEDURE            PROCEDURE. SEPARATE PAYMENT IS NOT
                                              HAS NOT BEEN RECEIVED/ADJUDICATED.            ALLOWED.

484   THIS SERVICE HAS BEEN       B20         PROCEDURE/SERVICE WAS PARTIALLY OR                                                 65
      SUBMITTED AND PAID TO                   FULLY FURNISHED BY ANOTHER
      ANOTHER PROVIDERFOR THIS                PROVIDER.
      DATE OF SERVICE.
485   ONLY ONE HOSPITAL ADMISSION B14         ONLY ONE VISIT OR CONSULTATION PER                                                 483
      VISIT ALLOWED PER HOSPITAL              PHYSICIAN PER DAY IS COVERED.
      STAY
486   NEONATAL INTENSIVE CARE     B15         THIS SERVICE/PROCEDURE REQUIRES                                                    107
      CODE NOT PAID IN                        THAT A QUALIFYING SERVICE/PROCEDURE
      CONJUNCTION TO PAID                     BE RECEIVED AND COVERED. THE
      RELATED PROCEDURE                       QUALIFYING OTHER SERVICE/PROCEDURE
                                              HAS NOT BEEN RECEIVED/ADJUDICATED.

487   PROCEDURE INCLUDED IN CODE B15          THIS SERVICE/PROCEDURE REQUIRES                                                    107
      99295-99297 FOR SAME DOS.               THAT A QUALIFYING SERVICE/PROCEDURE
                                              BE RECEIVED AND COVERED. THE
                                              QUALIFYING OTHER SERVICE/PROCEDURE
                                              HAS NOT BEEN RECEIVED/ADJUDICATED.

488   93548 NOT ALLOWED SAME DOS    B15       THIS SERVICE/PROCEDURE REQUIRES                                                    107
      AS CERTAIN COMPANION                    THAT A QUALIFYING SERVICE/PROCEDURE
      RADIOLOGICALCODES                       BE RECEIVED AND COVERED. THE
                                              QUALIFYING OTHER SERVICE/PROCEDURE
                                              HAS NOT BEEN RECEIVED/ADJUDICATED.

489   PURCHASED WHEELCHAIR NON- 151           PAYMENT ADJUSTED BECAUSE THE                                                       107
      PAYABLE WITHIN 5 YEARS OF               PAYER DEEMS THE INFORMATION
       RENTED WHEELCHAIR                      SUBMITTED DOES NOT SUPPORT THIS
                                              MANY/FREQUENCY OF SERVICES.
490   ROUTINE INFANT/CHILD HEALTH   49        THESE ARE NON-COVERED SERVICES                                                     481
      CHECK NOT PAYABLE ON CLAIM              BECAUSE THIS IS A ROUTINE EXAM OR
      FORM BILLED                             SCREENING PROCEDURE DONE IN
                                              CONJUNCTION WITH A ROUTINE EXAM.
491   93542 NOT ALLOWED SAME DOS    B15       THIS SERVICE/PROCEDURE REQUIRES     N20       SERVICE NOT PAYABLE WITH OTHER       107
      AS CERTAIN COMPANION                    THAT A QUALIFYING SERVICE/PROCEDURE           SERVICE RENDERED ON THE SAME DATE.
      RADIOLOGICALCODES                       BE RECEIVED AND COVERED. THE
                                              QUALIFYING OTHER SERVICE/PROCEDURE
                                              HAS NOT BEEN RECEIVED/ADJUDICATED.




                                                                                                                                        Effective 10/22/10
                                                                         EOB TO 277 & 835



                                                                                   835                                           277
                                   835 ADJ   835 ADJUSTMENT REASON CODE            REMIT    835 REMITTANCE REMARK CODE           CLAIM
EOB   HP DESCRIPTION               REASON    DESCRIPTION                           REMARK   DESCRIPTION                          STATUS
492   PROCEDURE IS INCLUDED IN     97        THE BENEFIT FOR THIS SERVICE IS                                                     107
      93542 FOR SAME DOS                     INCLUDED IN THE PAYMENT/ALLOWANCE
                                             FOR ANOTHER SERVICE/PROCEDURE
                                             THAT HAS ALREADY BEEN ADJUDICATED.

493   93545 NOT ALLOWED SAME DOS   97        THE BENEFIT FOR THIS SERVICE IS       N20      SERVICE NOT PAYABLE WITH OTHER       107
      AS CERTAIN COMPANION                   INCLUDED IN THE PAYMENT/ALLOWANCE              SERVICE RENDERED ON THE SAME DATE.
      RADIOLOGICALCODES                      FOR ANOTHER SERVICE/PROCEDURE
                                             THAT HAS ALREADY BEEN ADJUDICATED.

494   PROCEDURE IS INCLUDED IN     97        THE BENEFIT FOR THIS SERVICE IS                                                     107
      93545 FOR SAME DOS                     INCLUDED IN THE PAYMENT/ALLOWANCE
                                             FOR ANOTHER SERVICE/PROCEDURE
                                             THAT HAS ALREADY BEEN ADJUDICATED.

495   EXCEEDED MAXIMUM OF 12       119       BENEFIT MAXIMUM FOR THE TIME PERIOD                                                 483
      TREATMENTS PER MONTH FOR               OR OCCURRENCE HAS BEEN REACHED.
      HEMODIALYSIS
496   EXACT DUPLICATE CROSSOVER    18        DUPLICATE CLAIM/SERVICE.              N8       CROSSOVER CLAIM DENIED BY PREVIOUS 54
                                                                                            PAYER AND COMPLETE CLAIM DATA NOT
                                                                                            FORWARDED. RESUBMIT THIS CLAIM TO
                                                                                            THIS PAYER TO PROVIDE ADEQUATE DATA
                                                                                            FOR ADJUDICATION.

497   93547/93549 NOT ALLOWED      B15       THIS SERVICE/PROCEDURE REQUIRES     N20        SERVICE NOT PAYABLE WITH OTHER       107
      SAME DOS AS CERTAIN                    THAT A QUALIFYING SERVICE/PROCEDURE            SERVICE RENDERED ON THE SAME DATE.
      COMPANION RADIO-LOGICAL                BE RECEIVED AND COVERED. THE
      CODES                                  QUALIFYING OTHER SERVICE/PROCEDURE
                                             HAS NOT BEEN RECEIVED/ADJUDICATED.

498   PROCEDURE INCLUDE IN         97        THE BENEFIT FOR THIS SERVICE IS                                                     107
      93547/93549 FOR SAME DOS               INCLUDED IN THE PAYMENT/ALLOWANCE
                                             FOR ANOTHER SERVICE/PROCEDURE
                                             THAT HAS ALREADY BEEN ADJUDICATED.

499   93544 NOT ALLOWED SAME DOS   B15       THIS SERVICE/PROCEDURE REQUIRES     N20        SERVICE NOT PAYABLE WITH OTHER       107
      AS CERTAIN COMPANION                   THAT A QUALIFYING SERVICE/PROCEDURE            SERVICE RENDERED ON THE SAME DATE.
      RADIOLOGICALCODES                      BE RECEIVED AND COVERED. THE
                                             QUALIFYING OTHER SERVICE/PROCEDURE
                                             HAS NOT BEEN RECEIVED/ADJUDICATED.




                                                                                                                                          Effective 10/22/10
                                                                             EOB TO 277 & 835



                                                                                     835                                           277
                                    835 ADJ   835 ADJUSTMENT REASON CODE             REMIT      835 REMITTANCE REMARK CODE         CLAIM
EOB   HP DESCRIPTION                REASON    DESCRIPTION                            REMARK     DESCRIPTION                        STATUS
500   INCORRECT BILLING.            125       SUBMISSION/BILLING ERROR(S).           MA130      YOUR CLAIM CONTAINS INCOMPLETE     481
                                                                                                AND/OR INVALID INFORMATION, AND NO
                                                                                                APPEAL RIGHTS ARE AFFORDED BECAUSE
                                                                                                THE CLAIM IS UNPROCESSABLE. PLEASE
                                                                                                SUBMIT A NEW CLAIM WITH THE
                                                                                                COMPLETE/CORRECT INFORMATION.

501   REFILE WITH MORE LEGIBLE                                                       N29        MISSING                           294
      CLAIM OR DOCUMENTATION.                                                                   DOCUMENTATION/ORDERS/NOTES/SUMMA
                                                                                                RY/REPORT/CHART.
502   INDICATE TIME INVOLVED.                                                        M125       MISSING/INCOMPLETE/INVALID        263
                                                                                                INFORMATION ON THE PERIOD OF TIME
                                                                                                FOR WHICH THE
                                                                                                SERVICE/SUPPLY/EQUIPMENT WILL BE
                                                                                                NEEDED.
503   LIST TESTS INCLUDED IN PANEL. 16        CLAIM/SERVICE LACKS INFORMATION        M126       MISSING/INCOMPLETE/INVALID INDIVIDUAL 419
                                              WHICH IS NEEDED FOR ADJUDICATION.                 LAB CODES INCLUDED IN THE TEST.

504   INDICATE IF TEST WAS          16        CLAIM/SERVICE LACKS INFORMATION        N396       INCOMPLETE/INVALID LABORATORY          473
      PERFORMED IN YOUR LAB.                  WHICH IS NEEDED FOR ADJUDICATION.                 REPORT.
505   REFILE WITH COPY OF HISTORY   16        CLAIM/SERVICE LACKS INFORMATION        N29        MISSING/INCOMPLETE/INVALID             331
      AND PHYSICAL.                           WHICH IS NEEDED FOR ADJUDICATION.                 DOCUMENTATION/ORDERS/NOTES/SUMMA
                                                                                                RY/REPORT/CHART.
506   REFILE WITH PROCEDURE         16        CLAIM/SERVICE LACKS INFORMATION        N29        MISSING                                306
      REPORT.                                 WHICH IS NEEDED FOR ADJUDICATION.                 DOCUMENTATION/ORDERS/NOTES/SUMMA
                                                                                                RY/REPORT/CHART.
507   REFILE WITH PATHOLOGY         16        CLAIM/SERVICE LACKS INFORMATION        N30        PATIENT INELIGIBLE FOR THIS SERVICE.   311
      REPORT.                                 WHICH IS NEEDED FOR ADJUDICATION.
508   REFILE WITH COPY OF           16        CLAIM/SERVICE LACKS INFORMATION        M29        MISSING OPERATIVE REPORT.              298
      OPERATIVE REPORT.                       WHICH IS NEEDED FOR ADJUDICATION.
509   REFILE WITH COPY OF           16        CLAIM/SERVICE LACKS INFORMATION        N29        MISSING/INCOMPLETE/INVALID           262
      ANESTHESIA REPORT.                      WHICH IS NEEDED FOR ADJUDICATION.                 DOCUMENTATION/ORDERS/NOTES/SUMMA
                                                                                                RY/REPORT/CHART.
510   REFILE WITH COPY OF           16        CLAIM/SERVICE LACKS INFORMATION        N50        MISSING/INCOMPLETE/INVALID           308
      DISCHARGE SUMMARY.                      WHICH IS NEEDED FOR ADJUDICATION.                 DISCHARGE INFORMATION.
511   INDICATE IF CHARGE IS FOR                                                      N249       MISSING/INCOMPLETE/INVALID ASSISTANT 414
      ASSISTANT SURGEON.                                                                        PRIMARY IDENTIFIER.
512   31 UNITS OF ASSISTED LIVING   119       BENEFIT MAXIMUM FOR THE TIME PERIOD                                                    483
      WAIVER SERVICES ALLOWED                 OR OCCURRENCE HAS BEEN REACHED.
      PER MONTH.
513   DENIED BY MEDICAL STAFF.      A1        CLAIM DENIED CHARGES.                  N10        CLAIM/SERVICE ADJUSTED BASED ON THE 9
                                                                                                FINDINGS OF A REVIEW
                                                                                                ORGANIZATION/PROFESSIONAL
                                                                                                CONSULT/MANUAL
                                                                                                ADJUDICATION/MEDICAL OR DENTAL
                                                                                                ADVISOR.




                                                                                                                                             Effective 10/22/10
                                                                         EOB TO 277 & 835



                                                                                    835                                       277
                                  835 ADJ   835 ADJUSTMENT REASON CODE              REMIT    835 REMITTANCE REMARK CODE       CLAIM
EOB   HP DESCRIPTION              REASON    DESCRIPTION                             REMARK   DESCRIPTION                      STATUS
514   VERIFY PROCEDURE                                                              M51      MISSING/INCOMPLETE/INVALID       454
      CODE/DESCRIPTION/CHARGE.                                                               PROCEDURE CODE(S).
515   INCORRECT PROCEDURE CODE.                                                     M51      MISSING/INCOMPLETE/INVALID       454
      CONTACT THE STATE PROVIDER                                                             PROCEDURE CODE(S).
      COMMUNICATIONS UNIT AT 1-
      800-482-1141
516   INADEQUATE PROCEDURE                                                          M51      MISSING/INCOMPLETE/INVALID       306
      DESCRIPTION.                                                                           PROCEDURE CODE(S).
517   ONLY ONE                   B14        ONLY ONE VISIT OR CONSULTATION PER                                                483
      CONSULTATION/OFFICE VISIT             PHYSICIAN PER DAY IS COVERED.
      PER DATE OF SERVICE PER
      RECIPIENT PER PERFORMING
      PROVIDER.
518   REFILE WITH COPY OF         16        CLAIM/SERVICE LACKS INFORMATION         N29      MISSING                          294
      MANUFACTURERS INVOICE.                WHICH IS NEEDED FOR ADJUDICATION.                DOCUMENTATION/ORDERS/NOTES/SUMMA
                                                                                             RY/REPORT/CHART.
519   LIST NAME OF DRUG AND       16        CLAIM/SERVICE LACKS INFORMATION         M123     MISSING/INCOMPLETE/INVALID NAME, 217
      DOSAGE.                               WHICH IS NEEDED FOR ADJUDICATION.                STRENGTH, OR DOSAGE OF THE DRUG
                                                                                             FURNISHED.
520   STERILITY ACKNOWLEDGE       133       THE DISPOSITION OF THIS CLAIM/SERVICE                                             294
      MENT SIGNED AFTER                     IS PENDING FURTHER REVIEW.
      HYSTERECTOMY MUST
      CLEARLY STATE PATIENT WAS
      INFORMED PRIOR TO SURGERY
      THAT THE HYSTERECTOMY
      WOULD RENDER HER
      PERMANATELY STERILE.


521   PLEASE ATTACH A COPY OF THE 133       THE DISPOSITION OF THIS CLAIM/SERVICE                                             311
      PATHOLOGY REPORT WHICH                IS PENDING FURTHER REVIEW.
      VERIFIES A DIAGNOSIS OF
      CANCER OR SEVERE DYSPLASIA
      PRIOR TO THE HYSTERECTOMY
      BEING PERFORMED

522   STATEMENT SIGNED BY THE    133        THE DISPOSITION OF THIS CLAIM/SERVICE                                             294
      PATIENT ACKNOWLEDGING                 IS PENDING FURTHER REVIEW.
      THAT THE HYSTERECTOMY WILL
      RENDER HER PERMANENTLY
      INCAPABLE OF REPRODUCING
      CHILDREN MUST ACCOMPANY
      CLAIM.
523   DEPARTMENT OF HUMAN                                                           N3       MISSING CONSENT FORM.            294
      SERVICES APPROVED CONSENT
      FORM MUST BE COMPLETED
      AND ATTACHED TO CLAIM FOR
      STERILIZATION




                                                                                                                                       Effective 10/22/10
                                                                            EOB TO 277 & 835



                                                                                      835                                            277
                                     835 ADJ   835 ADJUSTMENT REASON CODE             REMIT    835 REMITTANCE REMARK CODE            CLAIM
EOB   HP DESCRIPTION                 REASON    DESCRIPTION                            REMARK   DESCRIPTION                           STATUS
524   ALL BLANKS MUST BE FILLED IN                                                    N3       MISSING CONSENT FORM.                 21
      AND LEGIBLE ON CONSENT
      FORM.
525   PATIENT'S SIGNATURE IS                                                          N28      CONSENT FORM REQUIREMENTS NOT         466
      OMITTED OR ILLEGIBLE ON                                                                  FULFILLED.
      CONSENT FORM.
526   DATE PATIENT SIGNED            17        REQUESTED INFORMATION WAS NOT          N28      CONSENT FORM REQUIREMENTS NOT         467
      CONSENT FORM IS OMITTED,                 PROVIDED OR WAS                                 FULFILLED.
      INCORRECT, OR ILLEGIBLE.                 INSUFFICIENT/INCOMPLETE.
527   SIGNATURE AND/OR DATE OF                                                        N28      CONSENT FORM REQUIREMENTS NOT         21
      PERSON OBTAINING CONSENT                                                                 FULFILLED.
      IS OMITTED, INCORRECT OR
      ILLEGIBLE
528   DATE PHYSICIAN SIGNED                                                           N28      CONSENT FORM REQUIREMENTS NOT         467
      CONSENT FORM IS OMITTED OR                                                               FULFILLED.
      ILLEGIBLE.
529   PHYSICIAN'S SIGNATURE IS                                                        MA70     MISSING/INCOMPLETE/INVALID PROVIDER   466
      OMITTED.                                                                                 REPRESENTATIVE SIGNATURE.

530   DATE PHYSICIAN'S STATEMENT     129       PRIOR PROCESSING INFORMATION                                                          467
      IS SIGNED CANNOT BE MORE                 APPEARS INCORRECT.
      THAN ONEWEEK PRIOR TO
      SURGERY.
531   BIRTHDATE IS OMITTED,                                                           N3       MISSING CONSENT FORM.                 158
      INCORRECT OR ILLEGIBLE ON
      CONSENT FORM.
532   PLEASE REFILE --- OMITTING     15        THE AUTHORIZATION NUMBER IS MISSING,                                                  84
      THE CHARGES FOR                          INVALID, OR DOES NOT APPLY TO THE
      UNAUTHORIZED                             BILLED SERVICES OR PROVIDER.
      STERILIZATION PROCEDURE.
533   STERILIZATION WAS              116       THE ADVANCE INDEMNIFICATION NOTICE   N28        CONSENT FORM REQUIREMENTS NOT         467
      PERFORMED BEFORE 30 DAYS                 SIGNED BY THE PATIENT DID NOT COMPLY            FULFILLED.
      FROM TIME CONSENTFORM                    WITH REQUIREMENTS.
      WAS SIGNED BY PATIENT.
534   STERILIZATION WAS              116       THE ADVANCE INDEMNIFICATION NOTICE   N28        CONSENT FORM REQUIREMENTS NOT         467
      PERFORMED MORE THAN 180                  SIGNED BY THE PATIENT DID NOT COMPLY            FULFILLED.
      DAYS AFTER CONSENT FORM                  WITH REQUIREMENTS.
      WAS SIGNED BY THE PATIENT.
535   FAMILY PLANNING DIAGNOSIS      11        THE DIAGNOSIS IS INCONSISTENT WITH                                                    255
      NOT PRESENT WITH FAMILY                  THE PROCEDURE.
      PLANNING PROCEDURE
536   EXCEEDS LIMIT OF ONE GROUP     119       BENEFIT MAXIMUM FOR THE TIME PERIOD                                                   483
      OUTPATIENT GROUP THERAPY                 OR OCCURRENCE HAS BEEN REACHED.
      PER WEEK




                                                                                                                                              Effective 10/22/10
                                                                          EOB TO 277 & 835



                                                                                    835                                             277
                                    835 ADJ   835 ADJUSTMENT REASON CODE            REMIT    835 REMITTANCE REMARK CODE             CLAIM
EOB   HP DESCRIPTION                REASON    DESCRIPTION                           REMARK   DESCRIPTION                            STATUS
537   EXCEEDED BENEFIT LIMIT OF     119       BENEFIT MAXIMUM FOR THE TIME PERIOD                                                   483
      ONE GROUP OUTPATIENT-                   OR OCCURRENCE HAS BEEN REACHED.
      MEDICATION MAINTENANCE
      PER 30 DAYS
538   EXCEEDED BENEFIT LIMIT OF     119       BENEFIT MAXIMUM FOR THE TIME PERIOD                                                   483
      ONE PERITONEAL DIALYSIS FOR             OR OCCURRENCE HAS BEEN REACHED.
      SEVEN DAYS
539   EXCEEDED BENEFIT LIMIT OF                                                     M90      NOT COVERED MORE THAN ONCE IN A 12     483
      ONE(1) DIAGNOSIS AND                                                                   MONTH PERIOD.
      EVALUATION SERVICE PER 12
      MONTH PERIOD
540   CODED BY MEDICAL STAFF                                                                                                        454

541   SURGERY CHARGES COMBINED.                                                     M144     PRE-/POST-OPERATIVE CARE PAYMENT IS    12
                                                                                             INCLUDED IN THE ALLOWANCE FOR THE
                                                                                             SURGERY/PROCEDURE.
542   CLAIM CANNOT BE PROCESSED     16        CLAIM/SERVICE LACKS INFORMATION       N30      PATIENT INELIGIBLE FOR THIS SERVICE.   25
      B/C OF MISSING OR INVALID               WHICH IS NEEDED FOR ADJUDICATION.
      INFO IN THIS RECIPIENT'S
      MEDICAID FILE. PLEASE
      CONTACT THE EDS
      COMMUNICATIONS UNIT TO
      ASSIST US IN OBTAINING
      CURRENT RECIP INFO.
543   FUND CODE INVALID OR NOT ON 16          CLAIM/SERVICE LACKS INFORMATION       MA130    YOUR CLAIM CONTAINS INCOMPLETE     21
      PROVIDER OR RECIPIENT                   WHICH IS NEEDED FOR ADJUDICATION.              AND/OR INVALID INFORMATION, AND NO
      PROFILE                                                                                APPEAL RIGHTS ARE AFFORDED BECAUSE
                                                                                             THE CLAIM IS UNPROCESSABLE. PLEASE
                                                                                             SUBMIT A NEW CLAIM WITH THE
                                                                                             COMPLETE/CORRECT INFORMATION.

544   93541-NOT ALLOWED SAME DOS    97        THE BENEFIT FOR THIS SERVICE IS       N20      SERVICE NOT PAYABLE WITH OTHER         107
      AS CERTAIN COMPANION                    INCLUDED IN THE PAYMENT/ALLOWANCE              SERVICE RENDERED ON THE SAME DATE.
      RADIOLOGICALCODES                       FOR ANOTHER SERVICE/PROCEDURE
                                              THAT HAS ALREADY BEEN ADJUDICATED.

545   PROCEDURE IS INCLUDED IN      97        THE BENEFIT FOR THIS SERVICE IS                                                       107
      93541-FOR SAME DOS                      INCLUDED IN THE PAYMENT/ALLOWANCE
                                              FOR ANOTHER SERVICE/PROCEDURE
                                              THAT HAS ALREADY BEEN ADJUDICATED.

546   PROVIDER/RECIPIENT          22          THIS CARE MAY BE COVERED BY                                                           109
      INELIGIBLE FOR MANAGED CARE             ANOTHER PAYER PER COORDINATION OF
      NET SERVICES                            BENEFITS.




                                                                                                                                             Effective 10/22/10
                                                                           EOB TO 277 & 835



                                                                                     835                                           277
                                     835 ADJ   835 ADJUSTMENT REASON CODE            REMIT    835 REMITTANCE REMARK CODE           CLAIM
EOB   HP DESCRIPTION                 REASON    DESCRIPTION                           REMARK   DESCRIPTION                          STATUS
547   PROCEDURE IS INCLUDED IN       97        THE BENEFIT FOR THIS SERVICE IS                                                     107
      93550 FOR SAME DOS                       INCLUDED IN THE PAYMENT/ALLOWANCE
                                               FOR ANOTHER SERVICE/PROCEDURE
                                               THAT HAS ALREADY BEEN ADJUDICATED.

548   93551 NOT ALLOWED SAME DOS     97        THE BENEFIT FOR THIS SERVICE IS                                                     107
      AS CERTAIN COMPANION                     INCLUDED IN THE PAYMENT/ALLOWANCE
      RADIOLOGICALCODES                        FOR ANOTHER SERVICE/PROCEDURE
                                               THAT HAS ALREADY BEEN ADJUDICATED.

549   PROCEDURE IS INCLUDED IN       97        THE BENEFIT FOR THIS SERVICE IS                                                     107
      93551 FOR SAME DOS                       INCLUDED IN THE PAYMENT/ALLOWANCE
                                               FOR ANOTHER SERVICE/PROCEDURE
                                               THAT HAS ALREADY BEEN ADJUDICATED.

550   RECIPIENT HAS ALREADY          B5        COVERAGE/PROGRAM GUIDELINES WERE      N170     A NEW/REVISED/RENEWED CERTIFICATE    483
      RECIEVED PERIODIC EPSDT                  NOT MET OR WERE EXCEEDED.                      OF MEDICAL NECESSITY IS NEEDED.
      SCREENING FOR THIS AGE.IF
      SCREEN IS MEDICALLY
      NECESSARY PLEASE
      DOCUMENT ONCLAIM AND
      REBILL AS INTERPERIODIC
      SCREEN
551   EXCEEDED LIMIT OF 3 EPSDT   119          BENEFIT MAXIMUM FOR THE TIME PERIOD                                                 483
      MEDICAL SCREENS FOR AGES 12              OR OCCURRENCE HAS BEEN REACHED.

552   ONE EPSDT MEDICAL SCREENS                                                      M90      NOT COVERED MORE THAN ONCE IN A 12   483
      PAYABLE FROM 2 YEARS 1 DAY                                                              MONTH PERIOD.
      TO 3 YEARS
553   ONE EPSDT MEDICAL SCREENS                                                      M90      NOT COVERED MORE THAN ONCE IN A 12   483
      PAYABLE FROM 3 YEARS 1 DAY                                                              MONTH PERIOD.
      TO 4 YEARS
554   ONE EPSDT MEDICAL SCREENS                                                      M90      NOT COVERED MORE THAN ONCE IN A 12   483
      PAYABLE FROM 4 YEARS 1 DAY                                                              MONTH PERIOD.
      TO 5 YEARS
555   ONE EPSDT MEDICAL SCREENS                                                      M90      NOT COVERED MORE THAN ONCE IN A 12   483
      PAYABLE FROM 5 YEARS 1 DAY                                                              MONTH PERIOD.
      TO 6 YEARS
556   TWO EPSDT MEDICAL SCREENS      119       BENEFIT MAXIMUM FOR THE TIME PERIOD                                                 483
      PAYABLE FROM 6 YEARS 1 DAY               OR OCCURRENCE HAS BEEN REACHED.
      TO 8 YEARS
557   EXCEED LIMIT OF FOUR EPSDT     119       BENEFIT MAXIMUM FOR THE TIME PERIOD                                                 483
      MEDICAL SCREENS FOR AGES 8               OR OCCURRENCE HAS BEEN REACHED.
      YEARS AND 1 DAY TO 10 YEARS.




                                                                                                                                            Effective 10/22/10
                                                                           EOB TO 277 & 835



                                                                                     835                                         277
                                     835 ADJ   835 ADJUSTMENT REASON CODE            REMIT    835 REMITTANCE REMARK CODE         CLAIM
EOB   HP DESCRIPTION                 REASON    DESCRIPTION                           REMARK   DESCRIPTION                        STATUS
558   TWO EPSDT MEDICAL SCREENS      119       BENEFIT MAXIMUM FOR THE TIME PERIOD                                               483
      PAYABLE FROM 10 YEARS 1 DAY              OR OCCURRENCE HAS BEEN REACHED.
      TO 12 YEARS
559   FILLING NOT ALLOWED ON         119       BENEFIT MAXIMUM FOR THE TIME PERIOD                                               107
      TOOTH NUMBERS WITH                       OR OCCURRENCE HAS BEEN REACHED.
      CROWNS WITHIN ONE YEAR
      PERIOD.
560   TWO EPSDT MEDICAL SCREENS      119       BENEFIT MAXIMUM FOR THE TIME PERIOD                                               483
      PAYABLE FROM 14 YEARS 1 DAY              OR OCCURRENCE HAS BEEN REACHED.
      TO 16 YEARS
561   TWO EPSDT MEDICAL SCREENS      119       BENEFIT MAXIMUM FOR THE TIME PERIOD                                               483
      PAYABLE FROM 16 YEARS 1 DAY              OR OCCURRENCE HAS BEEN REACHED.
      TO 18 YEARS
562   TWO EPSDT MEDICAL SCREENS      119       BENEFIT MAXIMUM FOR THE TIME PERIOD                                               483
      PAYABLE FROM 18 YEARS 1 DAY              OR OCCURRENCE HAS BEEN REACHED.
      TO 21 YEARS
563   MEDICAID VISITS (OFFICE, ER,   97        THE BENEFIT FOR THIS SERVICE IS                                                   107
      HOSPITAL AND CONSULTS) ARE               INCLUDED IN THE PAYMENT/ALLOWANCE
      NON PAYABLE WHEN BILLED ON               FOR ANOTHER SERVICE/PROCEDURE
      THE SAME DAY AS A PRIMARY                THAT HAS ALREADY BEEN ADJUDICATED.
      PROCEDURE.
564   PAYMENT FOR A PRIMARY          97        THE BENEFIT FOR THIS SERVICE IS                                                   107
      SURGICAL PROCEDURE                       INCLUDED IN THE PAYMENT/ALLOWANCE
      INCLUDES PAYMENT FOR                     FOR ANOTHER SERVICE/PROCEDURE
      INCIDENTAL SURGERY.                      THAT HAS ALREADY BEEN ADJUDICATED.

565   A PAID SERVICE ON THE SAME     18        DUPLICATE CLAIM/SERVICE.                                                          54
      DATE DUPLICATES, OR
      INCLUDES, THIS SERVICE.
566   THE SYSTEM HAS REBUNDLED                                                       M15      SEPARATELY BILLED SERVICES/TESTS   15
      THIS PROCEDURE CODE INTO                                                                HAVE BEEN BUNDLED AS THEY ARE
      THE APPROPRIATE GLOBAL                                                                  CONSIDERED COMPONENTS OF THE SAME
      PROCEDURE CODE.                                                                         PROCEDURE. SEPARATE PAYMENT IS NOT
                                                                                              ALLOWED.
567   PERS INSTALLATION NOT          B15       THIS SERVICE/PROCEDURE REQUIRES                                                   84
      REQUIRED ON CONNECTED                    THAT A QUALIFYING SERVICE/PROCEDURE
      PERS UNIT.                               BE RECEIVED AND COVERED. THE
                                               QUALIFYING OTHER SERVICE/PROCEDURE
                                               HAS NOT BEEN RECEIVED/ADJUDICATED.

568   SURGICAL REVENUE CODE          16        CLAIM/SERVICE LACKS INFORMATION       M51      MISSING/INCOMPLETE/INVALID         490
      REQUIRES A SURGICAL                      WHICH IS NEEDED FOR ADJUDICATION.              PROCEDURE CODE(S).
      PROCEDURE CODE.
569   INVALID USE OF HOSPITAL PCP    16        CLAIM/SERVICE LACKS INFORMATION       M51      MISSING/INCOMPLETE/INVALID         227
      ENROLLMENT PCODE.                        WHICH IS NEEDED FOR ADJUDICATION.              PROCEDURE CODE(S).




                                                                                                                                          Effective 10/22/10
                                                                           EOB TO 277 & 835



                                                                                   835                                     277
                                     835 ADJ   835 ADJUSTMENT REASON CODE          REMIT      835 REMITTANCE REMARK CODE   CLAIM
EOB   HP DESCRIPTION                 REASON    DESCRIPTION                         REMARK     DESCRIPTION                  STATUS
570   PROVIDER LIMITED TO            24        CHARGES ARE COVERED UNDER A                                                 105
      CAPITATION CLAIMS ONLY                   CAPITATION AGREEMENT/MANAGED CARE
      (REGION 22)                              PLAN.
571   EXCEEDS LIMIT OF FOUR        119         BENEFIT MAXIMUM FOR THE TIME PERIOD                                         483
      EMERGENCY HOME DELIVERED                 OR OCCURRENCE HAS BEEN REACHED.
      MEALS PER STATE FISCAL YEAR.

572   EXCEEDS LIMIT OF ONE           119       BENEFIT MAXIMUM FOR THE TIME PERIOD                                         483
      INSTALLATION PER LIFETIME OR             OR OCCURRENCE HAS BEEN REACHED.
      PERIOD OF ELIGIBILITY.
573   HOME DELIVERED MEALS           119       BENEFIT MAXIMUM FOR THE TIME PERIOD                                         483
      LIMITED TO 31 PER MONTH.                 OR OCCURRENCE HAS BEEN REACHED.

574   OUTPATIENT SERVICES ARE      60          CHARGES FOR OUTPATIENT SERVICES                                             84
      NOT PAYABLE ON THE SAME                  WITH THIS PROXIMITY TO INPATIENT
      DATE OF SERVICE AS INPATIENT             SERVICES ARE NOT COVERED.
      SERVICES.
575   PRE-SCHOOL SERVICES LIMITED 119          BENEFIT MAXIMUM FOR THE TIME PERIOD                                         483
      TO 155 UNITS PER MONTH                   OR OCCURRENCE HAS BEEN REACHED.

576   EARLY INTERVENTION AND PRE- 119          BENEFIT MAXIMUM FOR THE TIME PERIOD                                         483
      SCHOOL I SERVICES LIMITED TO             OR OCCURRENCE HAS BEEN REACHED.
      1 UNIT PER DATE OF SERVICE

577   RECIPIENT ELIGIBLE FOR ONLY 2 119        BENEFIT MAXIMUM FOR THE TIME PERIOD                                         483
      TELEMEDICINE CONSUTATIONS                OR OCCURRENCE HAS BEEN REACHED.
      FROMJULY 1 THRU JUNE 30.

578   SPEECH THERAPY LIMITED TO 3    119       BENEFIT MAXIMUM FOR THE TIME PERIOD                                         483
      UNITS PER DATE OF SERVICE                OR OCCURRENCE HAS BEEN REACHED.

579   OCCUPATIONAL INDIVIDUAL        119       BENEFIT MAXIMUM FOR THE TIME PERIOD                                         483
      THERAPY LIMITED TO 3 UNITS               OR OCCURRENCE HAS BEEN REACHED.
      PER DATE OF SERVICE.
580   PA REQUIRED FOR ALL DAYS       197       PRECERTIFICATION/AUTHORIZATION/NOTIF                                        252
      AFTER RECIPIENT'S FIRST                  ICATION ABSENT.
      BIRTHDAY. CLAIM CUT BACK TO
      MAX ALLOWABLE DAYS.
581   PROVIDER MUST HAVE A           8         THE PROCEDURE CODE IS INCONSISTENT                                          145
      PROVIDER SPECIALTY OF WC,                WITH THE PROVIDER TYPE/SPECIALTY
      R1, RC   OR RH TO BILL                   (TAXONOMY).
      REVENUE CODE 128. CHECK
      FOR CORRECT BILLING
582   PROVIDER SPECIALITY WC        8          THE PROCEDURE CODE IS INCONSISTENT                                          145
      MUST BILL ONLY REV. CODE 128.            WITH THE PROVIDER TYPE/SPECIALTY
                                               (TAXONOMY).




                                                                                                                                    Effective 10/22/10
                                                                            EOB TO 277 & 835



                                                                                     835                                              277
                                     835 ADJ   835 ADJUSTMENT REASON CODE            REMIT     835 REMITTANCE REMARK CODE             CLAIM
EOB   HP DESCRIPTION                 REASON    DESCRIPTION                           REMARK    DESCRIPTION                            STATUS
583   RECIPIENT INELIGIBLE FOR W4                                                    N30       PATIENT INELIGIBLE FOR THIS SERVICE.   84
      SERVICE ON DOS - CONTACT
      COUNTY OFFICE FOR WAIVER
      ELIGIBILITY STATUS.

584   ONLY ONE DAY TREATMENT                                                         M86       SERVICE DENIED BECAUSE PAYMENT         483
      SERVICE ALLOWED PER DATE                                                                 ALREADY MADE FOR SAME/SIMILAR
      OF SERVICE                                                                               PROCEDURE WITHIN SET TIME FRAME.
585   REHABILITATIVE DAY SERVICE    119        BENEFIT MAXIMUM FOR THE TIME PERIOD                                                    483
      LIMITED TO 192 UNITS PER WEEK            OR OCCURRENCE HAS BEEN REACHED.

586   PROVIDER LIMITED TO BILLING    8         THE PROCEDURE CODE IS INCONSISTENT                                                     91
      FOR ARKANSAS BENEFIT                     WITH THE PROVIDER TYPE/SPECIALTY
      SERVICES.                                (TAXONOMY).
587   EXCEEDED BENEFIT LIMIT OF      119       BENEFIT MAXIMUM FOR THE TIME PERIOD                                                    483
      224-1/4 HOUR UNITS PER WEEK              OR OCCURRENCE HAS BEEN REACHED.
      FOR THERAPEUTIC DAY
      TREATMENT
588   DCFS RECIPIENTS/AID                                                            N30       PATIENT INELIGIBLE FOR THIS SERVICE.   84
      CATEGORY 02 AND 05 ELIGIBLE
      FOR ARKANSASBENEFIT
      PROGRAM ONLY.

589   SERVICES COVERED UNDER                                                         N61       REBILL SERVICES ON SEPARATE CLAIMS.    481
      MORE THAN ONE PROGRAM.
      PLEASE SPLIT CLAIM AND RE-
      BILL.
590   CLAIM/RECIPIENT NOT COVERED                                                    N30       PATIENT INELIGIBLE FOR THIS SERVICE.   91
      BY MENTAL HEALTH MANAGED
      CARE.
591   CHILD HEALTH MANAGEMENT     119          BENEFIT MAXIMUM FOR THE TIME PERIOD                                                    483
      SERVICES NOT TO EXCEED                   OR OCCURRENCE HAS BEEN REACHED.
      $95.00   PER DATE OF
      SERVICE.
592   PERSONAL CARE SERVICES      119          BENEFIT MAXIMUM FOR THE TIME PERIOD                                                    483
      LIMITED TO 256 DETAIL UNITS              OR OCCURRENCE HAS BEEN REACHED.

593   PERSONAL CARE AIDE FOR         119       BENEFIT MAXIMUM FOR THE TIME PERIOD                                                    483
      UNDER 21-96 DETAIL UNITS/DAY             OR OCCURRENCE HAS BEEN REACHED.

594   EXCEEDS BENEFIT LIMIT OF ONE 119         BENEFIT MAXIMUM FOR THE TIME PERIOD                                                    483
      PER FIVE YEAR PERIOD                     OR OCCURRENCE HAS BEEN REACHED.

595   BENEFITS EXCEEDED MAXIMUM      119       BENEFIT MAXIMUM FOR THE TIME PERIOD                                                    483
      OF $7500.00 PER LIFETIME.                OR OCCURRENCE HAS BEEN REACHED.




                                                                                                                                               Effective 10/22/10
                                                                            EOB TO 277 & 835



                                                                                      835                                            277
                                     835 ADJ   835 ADJUSTMENT REASON CODE             REMIT    835 REMITTANCE REMARK CODE            CLAIM
EOB   HP DESCRIPTION                 REASON    DESCRIPTION                            REMARK   DESCRIPTION                           STATUS
596   DUPLICATE OR FRAGMENTED        18        DUPLICATE CLAIM/SERVICE.                                                              54
      BILLING
597   EXCEEDS MAXIMUM HOME           119       BENEFIT MAXIMUM FOR THE TIME PERIOD                                                   483
      HEALTH VISITS OF 50 FOR                  OR OCCURRENCE HAS BEEN REACHED.
      MEDICAID AND 10 FOR ARKIDS
      FIRST-B PER STATE FISCAL
      YEAR.
598   FRAGMENTED LAB CODES ARE       B15       THIS SERVICE/PROCEDURE REQUIRES     M126        MISSING/INCOMPLETE/INVALID INDIVIDUAL 12
      COMBINED TO PANEL FEE                    THAT A QUALIFYING SERVICE/PROCEDURE             LAB CODES INCLUDED IN THE TEST.
      REIMBURSEMENT                            BE RECEIVED AND COVERED. THE
                                               QUALIFYING OTHER SERVICE/PROCEDURE
                                               HAS NOT BEEN RECEIVED/ADJUDICATED.

599   FRAGMENTED LAB CODES                                                            M126     MISSING/INCOMPLETE/INVALID INDIVIDUAL 15
      WERE REDUCED TO PANEL FEE                                                                LAB CODES INCLUDED IN THE TEST.
      REIMBURSEMENT
600   EXTRACTIONS MAY BE             35        LIFETIME BENEFIT MAXIMUM HAS BEEN                                                     483
      PERFORMED ONLY ONCE IN A                 REACHED.
      LIFETIME.
601   INITIAL SET UP OF APNEA        35        LIFETIME BENEFIT MAXIMUM HAS BEEN                                                     483
      MONITOR LIMITED TO ONCE IN A             REACHED.
      LIFETIME.
602   HOME DELIVERED MEALS           119       BENEFIT MAXIMUM FOR THE TIME PERIOD    M86      SERVICE DENIED BECAUSE PAYMENT        483
      LIMITED TO 23 MEALS PER                  OR OCCURRENCE HAS BEEN REACHED.                 ALREADY MADE FOR SAME/SIMILAR
      MONTH                                                                                    PROCEDURE WITHIN SET TIME FRAME.
603   ADULT DAY HEALTH CARE          119       BENEFIT MAXIMUM FOR THE TIME PERIOD    M86      SERVICE DENIED BECAUSE PAYMENT        483
      MONTHLY BENEFIT LIMIT                    OR OCCURRENCE HAS BEEN REACHED.                 ALREADY MADE FOR SAME/SIMILAR
      REACHED.                                                                                 PROCEDURE WITHIN SET TIME FRAME.
604   PROCEDURE CODE TO              8         THE PROCEDURE CODE IS INCONSISTENT     M51      MISSING/INCOMPLETE/INVALID            145
      PROVIDER SPECIALTY INVALID.              WITH THE PROVIDER TYPE/SPECIALTY                PROCEDURE CODE(S).
                                               (TAXONOMY).
605   FULL MOUTH X-RAYS ALLOWED      119       BENEFIT MAXIMUM FOR THE TIME PERIOD    M86      SERVICE DENIED BECAUSE PAYMENT        483
      ONLY ONCE PER THREE YEARS                OR OCCURRENCE HAS BEEN REACHED.                 ALREADY MADE FOR SAME/SIMILAR
      PER ATTENDING PROVIDER                                                                   PROCEDURE WITHIN SET TIME FRAME.
      WITHOUT PRIOR
      AUTHORIZATION

606   CMS COPAY CODE PAYABLE       197         PRECERTIFICATION/AUTHORIZATION/NOTIF                                                  171
      ONLY IF RECIPIENT HAS TPL ON             ICATION ABSENT.
      FILE.
607   HOMEMAKER SERVICES           119         BENEFIT MAXIMUM FOR THE TIME PERIOD    M86      SERVICE DENIED BECAUSE PAYMENT        483
      MONTHLY BENEFIT LIMIT                    OR OCCURRENCE HAS BEEN REACHED.                 ALREADY MADE FOR SAME/SIMILAR
      REACHED.                                                                                 PROCEDURE WITHIN SET TIME FRAME.
608   CHORE SERVICES LIMITED TO 20 119         BENEFIT MAXIMUM FOR THE TIME PERIOD    M86      SERVICE DENIED BECAUSE PAYMENT        483
      UNITS PER MONTH                          OR OCCURRENCE HAS BEEN REACHED.                 ALREADY MADE FOR SAME/SIMILAR
                                                                                               PROCEDURE WITHIN SET TIME FRAME.




                                                                                                                                              Effective 10/22/10
                                                                          EOB TO 277 & 835



                                                                                     835                                              277
                                    835 ADJ   835 ADJUSTMENT REASON CODE             REMIT    835 REMITTANCE REMARK CODE              CLAIM
EOB   HP DESCRIPTION                REASON    DESCRIPTION                            REMARK   DESCRIPTION                             STATUS
609   ADULT DAY CARE MONTHLY        119       BENEFIT MAXIMUM FOR THE TIME PERIOD    M86      SERVICE DENIED BECAUSE PAYMENT          483
      BENEFIT LIMIT REACHED.                  OR OCCURRENCE HAS BEEN REACHED.                 ALREADY MADE FOR SAME/SIMILAR
                                                                                              PROCEDURE WITHIN SET TIME FRAME.
610                                 119       BENEFIT MAXIMUM FOR THE TIME PERIOD    M86      SERVICE DENIED BECAUSE PAYMENT          483
                                              OR OCCURRENCE HAS BEEN REACHED.                 ALREADY MADE FOR SAME/SIMILAR
                                                                                              PROCEDURE WITHIN SET TIME FRAME.
611   EXCEEDS LIMIT OF ONE          119       BENEFIT MAXIMUM FOR THE TIME PERIOD    M86      SERVICE DENIED BECAUSE PAYMENT          483
      PURCHASE OF THIS DURABLE                OR OCCURRENCE HAS BEEN REACHED.                 ALREADY MADE FOR SAME/SIMILAR
      MEDICAL     EQUIPMENT PER                                                               PROCEDURE WITHIN SET TIME FRAME.
      YEAR.
612   EXCEEDS LIMIT OF ONE          119       BENEFIT MAXIMUM FOR THE TIME PERIOD    M86      SERVICE DENIED BECAUSE PAYMENT          483
      PURCHASE OF THIS DME EVERY              OR OCCURRENCE HAS BEEN REACHED.                 ALREADY MADE FOR SAME/SIMILAR
      TWO YEARS.                                                                              PROCEDURE WITHIN SET TIME FRAME.
613   THIS DURABLE MEDICAL          119       BENEFIT MAXIMUM FOR THE TIME PERIOD    M7       NO RENTAL PAYMENTS AFTER THE ITEM       483
      EQUIPMENT MAY BE                        OR OCCURRENCE HAS BEEN REACHED.                 IS PURCHASED, OR AFTER THE TOTAL OF
      PURCHASED ONLY ONCE INA                                                                 ISSUED RENTAL PAYMENTS EQUALS THE
      LIFETIME.                                                                               PURCHASE PRICE.
614   EXCEEDS LIMIT OF ONE          119       BENEFIT MAXIMUM FOR THE TIME PERIOD    M7       NO RENTAL PAYMENTS AFTER THE ITEM       483
      PURCHASE OF THIS DURABLE                OR OCCURRENCE HAS BEEN REACHED.                 IS PURCHASED, OR AFTER THE TOTAL OF
      MEDICAL     EQUIPMENT EVERY                                                             ISSUED RENTAL PAYMENTS EQUALS THE
      SIX MONTHS.                                                                             PURCHASE PRICE.
615   CLAIM EXCEEDS MAXIMUM         119       BENEFIT MAXIMUM FOR THE TIME PERIOD    M5       MONTHLY RENTAL PAYMENTS CAN             483
      PURCHASE ALLOWANCE.                     OR OCCURRENCE HAS BEEN REACHED.                 CONTINUE UNTIL THE EARLIER OF THE
      MEDICAID ALLOWS AMAXIMUM                                                                15TH MONTH FROM THE FIRST RENTAL
      OF 455 UNITS (15 MONTHS) OF                                                             MONTH, OR THE MONTH WHEN THE
      RENTAL PAYMENTS TOWARD                                                                  EQUIPMENT IS NO LONGER NEEDED.
      THE PURCHASE OF THIS
      DURABLE MEDICAL EQUIPMENT.

616   ONE EPSDT SCREEN PER YEAR     119       BENEFIT MAXIMUM FOR THE TIME PERIOD    M13      ONLY ONE INITIAL VISIT IS COVERED PER   483
      FROM BIRTH THROUGH 6                    OR OCCURRENCE HAS BEEN REACHED.                 SPECIALTY PER MEDICAL GROUP.
      MONTHS.
617   ONLY ONE EPSDT SCREEN IS      119       BENEFIT MAXIMUM FOR THE TIME PERIOD    M13      ONLY ONE INITIAL VISIT IS COVERED PER   483
      PAYABLE FROM AGE 6 MONTHS               OR OCCURRENCE HAS BEEN REACHED.                 SPECIALTY PER MEDICAL GROUP.
      THROUGH 1 YEAR.
618   DOCUMENTATION DOES NOT        54        MULTIPLE PHYSICIANS/ASSISTANTS ARE                                                      287
      SUPPORT THE MEDICAL                     NOT COVERED IN THIS CASE.
      NECESSITY OF ASSISTANT
      SURGEON SERVICES.
619   THE PROCEDURE CODE            96        NON-COVERED CHARGE(S).                 MA66     MISSING/INCOMPLETE/INVALID PRINCIPAL    454
      REPRESENTS AN OBSOLETE                                                                  PROCEDURE CODE.
      PROCEDURE.
620   MEDICAID DOES NOT COVER       96        NON-COVERED CHARGE(S).                 MA66     MISSING/INCOMPLETE/INVALID PRINCIPAL    84
      THIS SERVICE.                                                                           PROCEDURE CODE.
621   COSMETIC SURGICAL             197       PRECERTIFICATION/AUTHORIZATION/NOTIF                                                    252
      PROCEDURES REQUIRE PRIOR                ICATION ABSENT.
      AUTHORIZATION.




                                                                                                                                               Effective 10/22/10
                                                                        EOB TO 277 & 835



                                                                                   835                                              277
                                  835 ADJ   835 ADJUSTMENT REASON CODE             REMIT    835 REMITTANCE REMARK CODE              CLAIM
EOB   HP DESCRIPTION              REASON    DESCRIPTION                            REMARK   DESCRIPTION                             STATUS
622   ONE EPSDT SCREEN IS PAYABLE 119       BENEFIT MAXIMUM FOR THE TIME PERIOD    M13      ONLY ONE INITIAL VISIT IS COVERED PER   483
      FROM 10 - 12 YEARS OF AGE             OR OCCURRENCE HAS BEEN REACHED.                 SPECIALTY PER MEDICAL GROUP.

623   THIS PROCEDURE CODE IS      6         THE PROCEDURE/REVENUE CODE IS          M51      MISSING/INCOMPLETE/INVALID              475
      INAPPROPRIATE FOR THE                 INCONSISTENT WITH THE PATIENT'S AGE.            PROCEDURE CODE(S).
      RECIPIENT'S AGE.
624   ONE EPSDT SCREEN IS PAYABLE 119       BENEFIT MAXIMUM FOR THE TIME PERIOD    M13      ONLY ONE INITIAL VISIT IS COVERED PER   483
      FROM 16-20 YEARS OF AGE               OR OCCURRENCE HAS BEEN REACHED.                 SPECIALTY PER MEDICAL GROUP.

625   UNITS CUTBACK TO MAX          151     PAYMENT ADJUSTED BECAUSE THE           M25      THE INFORMATION FURNISHED DOES NOT 65
      ALLOWED FOR THIS DURABLE              PAYER DEEMS THE INFORMATION                     SUBSTANTIATE THE NEED FOR THIS
      MEDICAL EQUIPMENT.                    SUBMITTED DOES NOT SUPPORT THIS                 LEVEL OF SERVICE. IF YOU BELIEVE THE
                                            MANY/FREQUENCY OF SERVICES.                     SERVICE SHOULD HAVE BEEN FULLY
                                                                                            COVERED AS BILLED OR IF YOU DID NO
                                                                                            KNOW AND COULD NOT REASONABLY
                                                                                            HAVE BEEN EXPECTED TO KNOW THAT
                                                                                            WE WOULD NOT PAY FOR THIS LEVEL OF
                                                                                            SERVICE, OR IF YOU NOTIFIED THE
                                                                                            PATIENT IN WRITING IN ADVANCE THAT
                                                                                            WE WOULD NOT PAY FOR THIS LEVEL OF
                                                                                            SERVICE AND HE/SHE AGREED IN WRITING
                                                                                            TO PAY, ASK US TO REVIEW YOUR CLAIM
                                                                                            WITHIN 120 DAYS OF THE DATE OF THIS
                                                                                            NOTICE. IF YOU DO NOT REQUEST A
                                                                                            APPEAL, WE WILL, UPON APPLICATION
                                                                                            FROM THE PATIENT, REIMBURSE HIM/HER
                                                                                            FOR THE AMOUNT YOU HAVE COLLECTED
                                                                                            FROM HIM/HER IN EXCESS OF ANY
                                                                                            DEDUCTIBLE AND COINSURANCE
                                                                                            AMOUNTS. WE WILL RECOVER THE
                                                                                            REIMBURSEMENT FROM YOU AS AN
                                                                                            OVERPAYMENT.


626   X-RAYS LIMITED TO $52.00 PER 5 119    BENEFIT MAXIMUM FOR THE TIME PERIOD                                                     483
      YEARS WITHOUT PRIOR                   OR OCCURRENCE HAS BEEN REACHED.
      AUTHORIZATION.
627   THIS PROCEDURE CODE IS         7      THE PROCEDURE/REVENUE CODE IS                                                           474
      INAPPROPRIATE FOR THE                 INCONSISTENT WITH THE PATIENT'S
      PATIENT'S SEX.                        GENDER.
628   OUTPATIENT SERVICES LIMITED 119       BENEFIT MAXIMUM FOR THE TIME PERIOD                                                     483
      TO ONE ENCOUNTER PER CLAIM            OR OCCURRENCE HAS BEEN REACHED.




                                                                                                                                             Effective 10/22/10
                                                                          EOB TO 277 & 835



                                                                                     835                                         277
                                    835 ADJ   835 ADJUSTMENT REASON CODE             REMIT    835 REMITTANCE REMARK CODE         CLAIM
EOB   HP DESCRIPTION                REASON    DESCRIPTION                            REMARK   DESCRIPTION                        STATUS
629   THE SYSTEM REDUCED THE        59        PROCESSED BASED ON MULTIPLE OR                                                     107
      ALLOWED AMOUNT FOR THIS                 CONCURRENT PROCEDURE RULES (FOR
      PROCEDURE CODE IN                       EXAMPLE MULTIPLE SURGERY OR
      ACCORDANCE WITH ARKANSAS                DIAGNOSTIC IMAGING, CONCURRENT
      MEDICAID POLICY REGARDING               ANESTHESIA.)
      MULTIPLE SURGICAL
      PROCEDURES.
630   MORE THAN THREE SIMPLE        197       PRECERTIFICATION/AUTHORIZATION/NOTIF                                               252
      EXTRACTIONS ON THE SAME                 ICATION ABSENT.
      DOS REQUIRES PA.
631   DELETED PROCEDURE CODES       96        NON-COVERED CHARGE(S).                 M51      MISSING/INCOMPLETE/INVALID         84
      ARE NON-PAYABLE.                                                                        PROCEDURE CODE(S).
632   DME SERVICES ARE LIMITED TO   119       BENEFIT MAXIMUM FOR THE TIME PERIOD                                                483
      $1000.00 WITHOUT PRIOR                  OR OCCURRENCE HAS BEEN REACHED.
      AUTHORIZATION
633   ONLY ONE DDS CASE             119       BENEFIT MAXIMUM FOR THE TIME PERIOD                                                483
      MANAGEMENT SERVICE PER                  OR OCCURRENCE HAS BEEN REACHED.
      MONTH.
634   EXCEEDED 80 ACUTE             119       BENEFIT MAXIMUM FOR THE TIME PERIOD                                                483
      THERAPEUTIC DAY TREAT SRV               OR OCCURRENCE HAS BEEN REACHED.
      UNITS/STATE FISCAL YR
635   PC D2330-D2332 & D2335 WITH                                                    N39      PROCEDURE CODE IS NOT COMPATIBLE   244
      TOS K MAY ONLY BE BILLED                                                                WITH TOOTH NUMBER/LETTER.
      WITH PERMANENT TOOTH
      NUMBERS 6-11 & 22-27.
636   WAASDTEJ ERROR WITH 2 YEAR    119       BENEFIT MAXIMUM FOR THE TIME PERIOD                                                483
      AUDIT LOGIC - INTERNAL EDIT             OR OCCURRENCE HAS BEEN REACHED.
      346.
637   EXCEEDS BRIEF CONSULTATION    119       BENEFIT MAXIMUM FOR THE TIME PERIOD                                                483
      SERVICES LIMIT OF 24 PER 90             OR OCCURRENCE HAS BEEN REACHED.
      DAY P. A. CYCLE.

638   EXCEEDS LIMIT OF 2 DOS FOR    119       BENEFIT MAXIMUM FOR THE TIME PERIOD                                                483
      DIAGNOSIS PER STATE FISCAL              OR OCCURRENCE HAS BEEN REACHED.
      YEAR
639   OUTPATIENT ER AND NON-ER      97        THE BENEFIT FOR THIS SERVICE IS                                                    107
      SERVICES INCLUDE                        INCLUDED IN THE PAYMENT/ALLOWANCE
      ASSESSMENT.                             FOR ANOTHER SERVICE/PROCEDURE
                                              THAT HAS ALREADY BEEN ADJUDICATED.

640   EXCEEDS LIMIT OF 2 BATTERY    119       BENEFIT MAXIMUM FOR THE TIME PERIOD                                                483
      TESTING SERVICES PER YEAR               OR OCCURRENCE HAS BEEN REACHED.




                                                                                                                                          Effective 10/22/10
                                                                          EOB TO 277 & 835



                                                                                    835                                           277
                                    835 ADJ   835 ADJUSTMENT REASON CODE            REMIT    835 REMITTANCE REMARK CODE           CLAIM
EOB   HP DESCRIPTION                REASON    DESCRIPTION                           REMARK   DESCRIPTION                          STATUS
641   ONLY PCP ENROLLMENT FEE IS    97        THE BENEFIT FOR THIS SERVICE IS                                                     107
      ALLOWED WITH EMERGENCY                  INCLUDED IN THE PAYMENT/ALLOWANCE
      DEPARTMENTASSESSMENT FEE                FOR ANOTHER SERVICE/PROCEDURE
                                              THAT HAS ALREADY BEEN ADJUDICATED.

642   NO MEDICAL JUSTIFICATION      B14       ONLY ONE VISIT OR CONSULTATION PER                                                  287
      EXISTS FOR MORE THAN ONE                PHYSICIAN PER DAY IS COVERED.
      VISIT PER DATE OF SERVICE.
643   SERVICE HAS NOT BEEN          197       PRECERTIFICATION/AUTHORIZATION/NOTIF M62       MISSING/INCOMPLETE/INVALID           84
      AUTHORIZED.                             ICATION ABSENT.                                TREATMENT AUTHORIZATION CODE.
644   LAB PROCEDURE NOT             29        THE TIME LIMIT FOR FILING HAS EXPIRED.                                              107
      PERFORMED WITH 7 DAYS OF
      SCREENING
645   ARKIDS FIRST-B PARTICIPANT    119       BENEFIT MAXIMUM FOR THE TIME PERIOD                                                 483
      CUMULATIVE ALLOWED AMOUNT               OR OCCURRENCE HAS BEEN REACHED.
      EXCEEDS$500 FOR SFY '99 FOR
      OUTPATIENT MENTAL AND
      BEHAVIORAL     HEALTH
      SERVICES. PRIOR
      AUTHORIZATION REQUIRED.
646   ONLY ONE PROCEDURE            B14       ONLY ONE VISIT OR CONSULTATION PER    N20      SERVICE NOT PAYABLE WITH OTHER       483
      ALLOWED PER DOS PER                     PHYSICIAN PER DAY IS COVERED.                  SERVICE RENDERED ON THE SAME DATE.
      ATTENDING PROVIDER
647   THERAPY EXAM LIMITED TO       119       BENEFIT MAXIMUM FOR THE TIME PERIOD                                                 483
      ONCE PER STATE FISCAL YEAR.             OR OCCURRENCE HAS BEEN REACHED.

648   BENEFITS EXHAUSTED            119       BENEFIT MAXIMUM FOR THE TIME PERIOD                                                 483
                                              OR OCCURRENCE HAS BEEN REACHED.

649   GLOBAL SURGERY CHARGES        97        THE BENEFIT FOR THIS SERVICE IS       M15      SEPARATELY BILLED SERVICES/TESTS   263
      SHOULD BE INCLUDED IN FEE               INCLUDED IN THE PAYMENT/ALLOWANCE              HAVE BEEN BUNDLED AS THEY ARE
      FOR PRIMARY PROCEDURE                   FOR ANOTHER SERVICE/PROCEDURE                  CONSIDERED COMPONENTS OF THE SAME
                                              THAT HAS ALREADY BEEN ADJUDICATED.             PROCEDURE. SEPARATE PAYMENT IS NOT
                                                                                             ALLOWED.
650   INDICATE IF MULTIPLE          16        CLAIM/SERVICE LACKS INFORMATION       N29      MISSING/INCOMPLETE/INVALID       262
      ANESTHESIA PROCEDURES                   WHICH IS NEEDED FOR ADJUDICATION.              DOCUMENTATION/ORDERS/NOTES/SUMMA
      WERE DONE AT DIFFERENT                  ADDITIONAL INFORMATION IS SUPPLIED             RY/REPORT/CHART.
      SETTINGS.                               USING REMITTANCE ADVICE REMARKS
                                              CODES WHENEVER APPROPRIATE.
651   RECIPIENT IS BEING         119          BENEFIT MAXIMUM FOR THE TIME PERIOD   N45      PAYMENT BASED ON AUTHORIZED          107
      REIMBURSED FOR STANDARD                 OR OCCURRENCE HAS BEEN REACHED.                AMOUNT.
      OR SPECIALIZED WHEELCHAIR.
      RECIPIENT MAY NOT BE
      REIMBURSED FOR 2 WHEEL-
      CHAIRS CONCURRENTLY.




                                                                                                                                           Effective 10/22/10
                                                                          EOB TO 277 & 835



                                                                                    835                                              277
                                    835 ADJ   835 ADJUSTMENT REASON CODE            REMIT    835 REMITTANCE REMARK CODE              CLAIM
EOB   HP DESCRIPTION                REASON    DESCRIPTION                           REMARK   DESCRIPTION                             STATUS
652   EXCEEDS LIMIT OF 12           119       BENEFIT MAXIMUM FOR THE TIME PERIOD                                                    483
      OUTPATIENT VISITS PER STATE             OR OCCURRENCE HAS BEEN REACHED.
      FISCAL YEAR
653   EXCEEDS LIMIT OF 12 PHYSICIAN 119       BENEFIT MAXIMUM FOR THE TIME PERIOD                                                    483
      VISITS PER STATE FISCAL YEAR            OR OCCURRENCE HAS BEEN REACHED.

654   EXCEEDS 12 NURSE              119       BENEFIT MAXIMUM FOR THE TIME PERIOD                                                    483
      PRACTITIONER VISITS PER SFY             OR OCCURRENCE HAS BEEN REACHED.

655   ONLY ONE SERVICE ALLOWED                                                      M86      SERVICE DENIED BECAUSE PAYMENT          483
      PER DOS                                                                                ALREADY MADE FOR SAME/SIMILAR
                                                                                             PROCEDURE WITHIN SET TIME FRAME.
656   DENTAL SERVICES LIMITED TO    119       BENEFIT MAXIMUM FOR THE TIME PERIOD                                                    483
      ONCE PER STATE FISCAL YEAR.             OR OCCURRENCE HAS BEEN REACHED.

657   PHYSICIAN STANDBY SERVICE     97        THE BENEFIT FOR THIS SERVICE IS       N20      SERVICE NOT PAYABLE WITH OTHER          107
      NON-PAYABLE SAME DATE OF                INCLUDED IN THE PAYMENT/ALLOWANCE              SERVICE RENDERED ON THE SAME DATE.
      SERVICE AS NEW BIRTH                    FOR ANOTHER SERVICE/PROCEDURE
      STANDBY.                                THAT HAS ALREADY BEEN ADJUDICATED.

658   REBILL USING LAB PANEL CODE   16        CLAIM/SERVICE LACKS INFORMATION       M126     MISSING/INCOMPLETE/INVALID INDIVIDUAL 419
      FOR APPROPRIATE NUMBER OF               WHICH IS NEEDED FOR ADJUDICATION.              LAB CODES INCLUDED IN THE TEST.
      INDIV-IDUALS TESTS

659   IMMUNIZATION DPT AND        B5          COVERAGE/PROGRAM GUIDELINES WERE      N20      SERVICE NOT PAYABLE WITH OTHER          490
      HEMOPHILIUS INFLUENZA B                 NOT MET OR WERE EXCEEDED.                      SERVICE RENDERED ON THE SAME DATE.
      CANNOT BE BILLED ON THE
      SAME DOS.
660   ONLY ONE ADMISSION, HISTORY B14         ONLY ONE VISIT OR CONSULTATION PER    N20      SERVICE NOT PAYABLE WITH OTHER          483
      AND PHYSICAL IS ALLOWED PER             PHYSICIAN PER DAY IS COVERED.                  SERVICE RENDERED ON THE SAME DATE.
      DAY BY THE SAME OR
      DIFFERENT ATTENDING
      PROVIDER
661   NEW PATIENT VISIT             B1        NON-COVERED VISITS.                   M13      ONLY ONE INITIAL VISIT IS COVERED PER   454
      PREVIOUSLY BILLED WITHIN                                                               SPECIALTY PER MEDICAL GROUP.
      PAST 3 YEARS FOR THIS
      RECIPIENT. REBILL USING
      APPROPRIATE ESTABLISHED
      PATIENTCODE.
662   93552-93553 NOT ALLOWED       97        THE BENEFIT FOR THIS SERVICE IS       N20      SERVICE NOT PAYABLE WITH OTHER          107
      SAME DOS AS CERTAIN                     INCLUDED IN THE PAYMENT/ALLOWANCE              SERVICE RENDERED ON THE SAME DATE.
      COMPANION RADIO-LOGICAL                 FOR ANOTHER SERVICE/PROCEDURE
      CODES                                   THAT HAS ALREADY BEEN ADJUDICATED.

663   ONLY ONE DELIVERY IN A NINE   119       BENEFIT MAXIMUM FOR THE TIME PERIOD                                                    483
      MONTH PERIOD.                           OR OCCURRENCE HAS BEEN REACHED.




                                                                                                                                              Effective 10/22/10
                                                                           EOB TO 277 & 835



                                                                                     835                                           277
                                     835 ADJ   835 ADJUSTMENT REASON CODE            REMIT    835 REMITTANCE REMARK CODE           CLAIM
EOB   HP DESCRIPTION                 REASON    DESCRIPTION                           REMARK   DESCRIPTION                          STATUS
664   PROCEDURE IS INCLUDED IN       97        THE BENEFIT FOR THIS SERVICE IS       N20      SERVICE NOT PAYABLE WITH OTHER       107
      93552-93553 FOR SAME DOS                 INCLUDED IN THE PAYMENT/ALLOWANCE              SERVICE RENDERED ON THE SAME DATE.
                                               FOR ANOTHER SERVICE/PROCEDURE
                                               THAT HAS ALREADY BEEN ADJUDICATED.

665   ONLY ONE VISIT ALLOWED PER     119       BENEFIT MAXIMUM FOR THE TIME PERIOD   M86      SERVICE DENIED BECAUSE PAYMENT       483
      DAY.                                     OR OCCURRENCE HAS BEEN REACHED.                ALREADY MADE FOR SAME/SIMILAR
                                                                                              PROCEDURE WITHIN SET TIME FRAME.
666   IV INSERTION INCLUDED IN       97        THE BENEFIT FOR THIS SERVICE IS       N20      SERVICE NOT PAYABLE WITH OTHER       107
      CHEMOTHERAPY.                            INCLUDED IN THE PAYMENT/ALLOWANCE              SERVICE RENDERED ON THE SAME DATE.
                                               FOR ANOTHER SERVICE/PROCEDURE
                                               THAT HAS ALREADY BEEN ADJUDICATED.

667   EXCEEDS LIMIT OF ONE         119         BENEFIT MAXIMUM FOR THE TIME PERIOD                                                 483
      OCCUPATIONAL THERAPY                     OR OCCURRENCE HAS BEEN REACHED.
      EVALUATION PER STATE FISCAL
      YEAR.
668   CASE MANAGEMENT LIMITED TO 119           BENEFIT MAXIMUM FOR THE TIME PERIOD                                                 483
      6 UNITS PER DATE OF SERVVICE             OR OCCURRENCE HAS BEEN REACHED.
      PER ATTENDING PROVIDER.

669   OUTPATIENT FACILITY FEE        119       BENEFIT MAXIMUM FOR THE TIME PERIOD   M86      SERVICE DENIED BECAUSE PAYMENT       483
      LIMITED TO ONE PER DAY PER               OR OCCURRENCE HAS BEEN REACHED.                ALREADY MADE FOR SAME/SIMILAR
      PROVIDER                                                                                PROCEDURE WITHIN SET TIME FRAME.
670   CRISIS MANAGEMENT LIMITED      119       BENEFIT MAXIMUM FOR THE TIME PERIOD                                                 483
      TO 4 UNITS PER DATE OF                   OR OCCURRENCE HAS BEEN REACHED.
      SERVICE PER ATTENDING
      PROVIDER.
671   FILL OUT ONLY ONE SECTION OF   17        REQUESTED INFORMATION WAS NOT         N29      MISSING/INCOMPLETE/INVALID       294
      HYSTERECTOMY                             PROVIDED OR WAS                                DOCUMENTATION/ORDERS/NOTES/SUMMA
      ACKNOWLEDGMENT FORM                      INSUFFICIENT/INCOMPLETE.                       RY/REPORT/CHART.
      (DHS - 2606).
672   EXCEEDS TWO PAID COMPLEX       119       BENEFIT MAXIMUM FOR THE TIME PERIOD   N54      CLAIM INFORMATION IS INCONSISTENT  483
      VISITS PER STATE FISCAL YEAR             OR OCCURRENCE HAS BEEN REACHED.                WITH PRE-CERTIFIED/AUTHORIZED
      WITHOUT APPROVAL.                                                                       SERVICES.
673   THE SYSTEM ADDED THIS                                                          M15      SEPARATELY BILLED SERVICES/TESTS   15
      DETAIL. THE BILLED AMOUNT                                                               HAVE BEEN BUNDLED AS THEY ARE
      SHOWN IS THE SUM OF THE                                                                 CONSIDERED COMPONENTS OF THE SAME
      CHARGES FOR THE DETAILS                                                                 PROCEDURE. SEPARATE PAYMENT IS NOT
      DENIED AS A RESULT OF                                                                   ALLOWED.
      REBUNDLING.
674   DIAPERS AND UNDERPADS        119         BENEFIT MAXIMUM FOR THE TIME PERIOD                                                 483
      LIMITED TO $130 PER CALENDAR             OR OCCURRENCE HAS BEEN REACHED.
      MONTH.




                                                                                                                                            Effective 10/22/10
                                                                              EOB TO 277 & 835



                                                                                        835                                           277
                                        835 ADJ   835 ADJUSTMENT REASON CODE            REMIT    835 REMITTANCE REMARK CODE           CLAIM
EOB   HP DESCRIPTION                    REASON    DESCRIPTION                           REMARK   DESCRIPTION                          STATUS
675   RECIPIENT EXCEEDS LIMIT OF        119       BENEFIT MAXIMUM FOR THE TIME PERIOD                                                 483
      $4500.00 PER LIFETIME FOR APD               OR OCCURRENCE HAS BEEN REACHED.
       ENVIRONMENTAL
      ADAPTATIONS.
676   ONLY 12 NURSE PRACTITIONER        119       BENEFIT MAXIMUM FOR THE TIME PERIOD                                                 483
      VISITS ALLOWED PER SFY.                     OR OCCURRENCE HAS BEEN REACHED.

677   INDIVIDUAL OUTPATIENT -           119       BENEFIT MAXIMUM FOR THE TIME PERIOD                                                 483
      MEDICATION ADMIN. LIMITED TO                OR OCCURRENCE HAS BEEN REACHED.
      2 UNITSPER DATE OF SERVICE
      PER ATTENDING PROVIDER.

678   OB DELIVERY DENIED AS NOT         40        CHARGES DO NOT MEET QUALIFICATIONS                                                  84
      AN EMERGENCY.                               FOR EMERGENT/URGENT CARE.

679   INVALID TYPE OF BILL. VALID                                                       MA30     MISSING/INCOMPLETE/INVALID TYPE OF   228
      INPATIENT TYPES OF BILL ARE                                                                BILL.
      111-114. VALID OUTPATIENT
      TYPES OF BILL ARE 131-134, 141,
      711-714.
680   UNITS CUT BACK TO MAX             B10       ALLOWED AMOUNT HAS BEEN REDUCED       N45      PAYMENT BASED ON AUTHORIZED          65
      ALLOWED FOR PROCEDURES                      BECAUSE A COMPONENT OF THE BASIC               AMOUNT.
                                                  PROCEDURE/TEST WAS PAID. THE
                                                  BENEFICIARY IS NOT LIABLE FOR MORE
                                                  THAN THE CHARGE LIMIT FOR THE BASIC
                                                  PROCEDURE/TEST.
681   WHEELCHAIR VAN EXCEEDS 50         119       BENEFIT MAXIMUM FOR THE TIME PERIOD                                                 483
      UNITS PER DATE OF SERVICE.                  OR OCCURRENCE HAS BEEN REACHED.

682   TRANSPORTATION SERVICES           119       BENEFIT MAXIMUM FOR THE TIME PERIOD                                                 483
      LIMITED TO 15 MILES PER DOS.                OR OCCURRENCE HAS BEEN REACHED.

683   PUBLIC TRANSPORTATION         119           BENEFIT MAXIMUM FOR THE TIME PERIOD                                                 483
      EXCEEDS LIMTI OF 30 MILES PER               OR OCCURRENCE HAS BEEN REACHED.
      DATE OF SERVICE.
684   EXCEEDS LIMIT OF 50 MILES PER 119           BENEFIT MAXIMUM FOR THE TIME PERIOD                                                 483
      DOS.                                        OR OCCURRENCE HAS BEEN REACHED.

685   UNITS CUT BACK TO MAX             151       PAYMENT ADJUSTED BECAUSE THE          N45      PAYMENT BASED ON AUTHORIZED          483
      ALLOWABLE OF 224 UNITS FOR                  PAYER DEEMS THE INFORMATION                    AMOUNT.
      ADDITIONAL THERAPEUTIC DAY                  SUBMITTED DOES NOT SUPPORT THIS
      TREATMENT.                                  MANY/FREQUENCY OF SERVICES.

686   THIS PROCEDURE MAY BE             119       BENEFIT MAXIMUM FOR THE TIME PERIOD                                                 483
      PERFORMED ONCE IN A                         OR OCCURRENCE HAS BEEN REACHED.
      LIFETIME.




                                                                                                                                               Effective 10/22/10
                                                                          EOB TO 277 & 835



                                                                                    835                                             277
                                    835 ADJ   835 ADJUSTMENT REASON CODE            REMIT    835 REMITTANCE REMARK CODE             CLAIM
EOB   HP DESCRIPTION                REASON    DESCRIPTION                           REMARK   DESCRIPTION                            STATUS
687   PRIVATE NON EMERGENCY         119       BENEFIT MAXIMUM FOR THE TIME PERIOD                                                   483
      TRANSPORTATION PAYABLE                  OR OCCURRENCE HAS BEEN REACHED.
      ONLY ONCE PER DATE OF
      SERVICE.
688   EXCEEDS LIMIT OF 12           119       BENEFIT MAXIMUM FOR THE TIME PERIOD                                                   483
      ENCOUNTER SERVICES PER                  OR OCCURRENCE HAS BEEN REACHED.
      STATE FISCAL YEAR
689   NON PROFIT NON EMERGENCY      119       BENEFIT MAXIMUM FOR THE TIME PERIOD                                                   483
      TRANSPORTATION/PAYABLE                  OR OCCURRENCE HAS BEEN REACHED.
      ONLY ONCE PER DOS

690   HOME HEALTH SUPPLIES          119       BENEFIT MAXIMUM FOR THE TIME PERIOD                                                   483
      EXCEEDED LIMIT OF $100.00 PER           OR OCCURRENCE HAS BEEN REACHED.
      MONTH
691   DEDUCTIBLE LIMITED TO ONCE    119       BENEFIT MAXIMUM FOR THE TIME PERIOD                                                   483
      PER 60 DAY BENEFIT PERIOD.              OR OCCURRENCE HAS BEEN REACHED.

692   EXCEEDS BENEFIT LIMIT FOR     119       BENEFIT MAXIMUM FOR THE TIME PERIOD                                                   483
      CHIROPRACTIC X-RAY PER                  OR OCCURRENCE HAS BEEN REACHED.
      STATE     FISCAL YEAR
693   RECIPIENT AID CATEGORY                                                        N30      PATIENT INELIGIBLE FOR THIS SERVICE.   84
      INELIGIBLE FOR PERSONAL
      CARE SERVICE.
694   INDIVIDUAL OCCUPATIONAL       119       BENEFIT MAXIMUM FOR THE TIME PERIOD                                                   483
      THERAPY LIMITED TO 4 UNITS              OR OCCURRENCE HAS BEEN REACHED.
      PER DATE OF SERVICE.
695   REFILE WITH COPY OF                                                           N29      MISSING/INCOMPLETE/INVALID       294
      CONSULTING PHYSICIAN'S                                                                 DOCUMENTATION/ORDERS/NOTES/SUMMA
      REPORT.                                                                                RY/REPORT/CHART.
696   RECIPIENT ELIGIBLE FOR ONLY   119       BENEFIT MAXIMUM FOR THE TIME PERIOD                                             483
      12 VISITS FROM JULY 1 THRU              OR OCCURRENCE HAS BEEN REACHED.
      JUNE 30.
697   RECIPIENT PARTIALLLY OR                                                       N30      PATIENT INELIGIBLE FOR THIS SERVICE.   88
      TOTALLY INELIGIBLE FOR
      WAIVER SERVICES FOR DOS
      BILLED. CONTACT EDS AT 1-800-
      457-4455 OR 376-2211 LOCALLY
      TO VERIFY ELIGIBILITY DATES.

698   AUGMENTATIVE                  35        LIFETIME BENEFIT MAXIMUM HAS BEEN                                                     483
      COMMUNICATIVE DEVICES                   REACHED.
      EXCEED $7500 LIFETIME
      BENEFIT.




                                                                                                                                             Effective 10/22/10
                                                                             EOB TO 277 & 835



                                                                                        835                                          277
                                     835 ADJ   835 ADJUSTMENT REASON CODE               REMIT    835 REMITTANCE REMARK CODE          CLAIM
EOB   HP DESCRIPTION                 REASON    DESCRIPTION                              REMARK   DESCRIPTION                         STATUS
699   ADDITIONAL THERAPEUTIC DAY     119       BENEFIT MAXIMUM FOR THE TIME PERIOD                                                   483
      TREATMENT LIMITED TO 32                  OR OCCURRENCE HAS BEEN REACHED.
      UNITS PER DATE OF SERVICE
      PER ATTENDING PROVIDER.

700   HOME HEALTH SUPPLIES           119       BENEFIT MAXIMUM FOR THE TIME PERIOD                                                   483
      EXCEEDED LIMIT OF $ 250.00               OR OCCURRENCE HAS BEEN REACHED.
      PER MONTH.
701   THERAPEUTIC DAY - ACUTE        119       BENEFIT MAXIMUM FOR THE TIME PERIOD                                                   483
      LIMITED TO 32 UNITS PER DATE             OR OCCURRENCE HAS BEEN REACHED.
      OF SERVICE PER ATTENDING
      PROVIDER.
702   EMERGENCY PROCEDURE CODE       5         THE PROCEDURE CODE/BILL TYPE IS                                                       454
      INVALID IN A NON-EMERGENCY               INCONSISTENT WITH THE PLACE OF
      SETTING.                                 SERVICE.
703   EXCEEDS BENEFIT LIMIT OF       119       BENEFIT MAXIMUM FOR THE TIME PERIOD                                                   483
      $200.00 FOR DISPOSABLE                   OR OCCURRENCE HAS BEEN REACHED.
      DIAPERS.
704   EXCEEDS LIMIT OF TWO           119       BENEFIT MAXIMUM FOR THE TIME PERIOD                                                   483
      EVALUATIONS PER STATE                    OR OCCURRENCE HAS BEEN REACHED.
      FISCAL YEAR.
705   WHEELCHAIR VAN/LIMITED TO 50   119       BENEFIT MAXIMUM FOR THE TIME PERIOD                                                   483
      MILES PER DOS                            OR OCCURRENCE HAS BEEN REACHED.

706   INAPPROPRIATE BILLING OF       96        NON-COVERED CHARGE(S).                   M20      MISSING/INCOMPLETE/INVALID HCPCS.   84
      PROCEDURE CODE. PLEASE
      REBILL USING THE CPT, HCPCS,
      REVENUE, OTHER VALID
      NATIONAL CODE OR BUNDLED
      PROCEDURE CODE THAT
      APPLIES TO THE SERVICE.

707   ONLY ALLOW CERTAIN RSPMI       B7        THIS PROVIDER WAS NOT                    MA120    MISSING/INCOMPLETE/INVALID CLIA     109
      SERVICES TO BE PAYABLE FOR               CERTIFIED/ELIGIBLE TO BE PAID FOR THIS            CERTIFICATION NUMBER.
      NURSING HOME RESIDENTS                   PROCEDURE/SERVICE ON THIS DATE OF
                                               SERVICE.
708   EXCEEDS LIMIT OF ONE           119       BENEFIT MAXIMUM FOR THE TIME PERIOD                                                   483
      EVALUATION PER MONTH.                    OR OCCURRENCE HAS BEEN REACHED.

709   EXCEEDS LIMIT OF 832 UNITS     119       BENEFIT MAXIMUM FOR THE TIME PERIOD                                                   483
      PER STATE FISCAL YEAR.                   OR OCCURRENCE HAS BEEN REACHED.

710   DME PROCEDURE TOS I           119        BENEFIT MAXIMUM FOR THE TIME PERIOD                                                   483
      PREVIOUSLY BILLED AND PAID IN            OR OCCURRENCE HAS BEEN REACHED.
      CURRENT STATE FISCAL YEAR




                                                                                                                                              Effective 10/22/10
                                                                          EOB TO 277 & 835



                                                                                    835                                           277
                                    835 ADJ   835 ADJUSTMENT REASON CODE            REMIT    835 REMITTANCE REMARK CODE           CLAIM
EOB   HP DESCRIPTION                REASON    DESCRIPTION                           REMARK   DESCRIPTION                          STATUS
711   TOS I,6,9,H,OR U PREVIOUSLY   B13       PREVIOUSLY PAID. PAYMENT FOR THIS                                                   483
      BILLED AND PAID FOR SAME                CLAIM/SERVICE MAY HAVE BEEN
      PROCEDURE CODE WITHIN                   PROVIDED IN A PREVIOUS PAYMENT.
      CURRENT SFY CLAIM IS NOT
      FOR INITIAL CONTRACTPERIOD.

712   DME TOS 1,6,9,H,OR U NOT   B13          PREVIOUSLY PAID. PAYMENT FOR THIS     N20      SERVICE NOT PAYABLE WITH OTHER       107
      PAYABLE SAME TIME AS DME                CLAIM/SERVICE MAY HAVE BEEN                    SERVICE RENDERED ON THE SAME DATE.
      TOS I FOR SAME PROCEDURE                PROVIDED IN A PREVIOUS PAYMENT.
      CODE
713   EXCEEDS MAXIMUM OF 25 HOME 119          BENEFIT MAXIMUM FOR THE TIME PERIOD                                                 483
      HEALTH VISITS PER SFY                   OR OCCURRENCE HAS BEEN REACHED.

714   MAXIMUM PAYMENT OF 50 UNITS 119         BENEFIT MAXIMUM FOR THE TIME PERIOD                                                 84
      PERSONAL CARE NOT                       OR OCCURRENCE HAS BEEN REACHED.
      PREVIOUSLY BILLED FOR DDS
      WAIVER RECIPIENT
715   MAXIMUM PAYMENT OF 50 UNITS 119         BENEFIT MAXIMUM FOR THE TIME PERIOD                                                 483
      PER MONTH FOR PERSONAL                  OR OCCURRENCE HAS BEEN REACHED.
      CARE
716   EXCEEDS LIMIT OF $7500.00 PER 119       BENEFIT MAXIMUM FOR THE TIME PERIOD                                                 483
      STATE FISCAL YEAR.                      OR OCCURRENCE HAS BEEN REACHED.

717   EXCEEDS LIMIT OF 48 UNITS PER 119       BENEFIT MAXIMUM FOR THE TIME PERIOD                                                 483
      STATE FISCAL YEAR.                      OR OCCURRENCE HAS BEEN REACHED.

718   IN HOME RESPITE CARE SFY      119       BENEFIT MAXIMUM FOR THE TIME PERIOD                                                 483
      BENEFIT LIMIT REACHED.                  OR OCCURRENCE HAS BEEN REACHED.

719   TCM SERVICES PREVIOUSLY       B20       PROCEDURE/SERVICE WAS PARTIALLY OR                                                  84
      SUBMITTED AND PAID TO TCM               FULLY FURNISHED BY ANOTHER
      PROVIDER DIFFERENT TCM                  PROVIDER.
      PROVIDERS MAY NOT BILL FOR
      SAME DOS
720   ONE EPSDT DENTAL SCREEN       119       BENEFIT MAXIMUM FOR THE TIME PERIOD                                                 483
      APPROPRIATE PER 150 DAYS                OR OCCURRENCE HAS BEEN REACHED.

721   TWO EPSDT AGE APPROPRIATE 119           BENEFIT MAXIMUM FOR THE TIME PERIOD                                                 483
      DENTAL SCREENS PAYABLE FOR              OR OCCURRENCE HAS BEEN REACHED.
      NEWBORN(0-12 MONTHS)

722   TWO EPSDT AGE APPROPRIATE     119       BENEFIT MAXIMUM FOR THE TIME PERIOD                                                 483
      VISION SCREENS PAYABLE FOR              OR OCCURRENCE HAS BEEN REACHED.
      5 YEARS




                                                                                                                                           Effective 10/22/10
                                                                            EOB TO 277 & 835



                                                                                       835                                             277
                                    835 ADJ   835 ADJUSTMENT REASON CODE               REMIT    835 REMITTANCE REMARK CODE             CLAIM
EOB   HP DESCRIPTION                REASON    DESCRIPTION                              REMARK   DESCRIPTION                            STATUS
723   TWO EPSDT AGE APPROPRIATE     119       BENEFIT MAXIMUM FOR THE TIME PERIOD                                                      483
      VISION SCREENS PAYABLE                  OR OCCURRENCE HAS BEEN REACHED.
      FROM NEW- BORN THRU 4
      YEARS
724   PROVIDER CANCELED. DENY       B7        THIS PROVIDER WAS NOT                                                                    483
      ALL CLAIMS.                             CERTIFIED/ELIGIBLE TO BE PAID FOR THIS
                                              PROCEDURE/SERVICE ON THIS DATE OF
                                              SERVICE.
725   EXCEEDS LIMIT OF TWO        119         BENEFIT MAXIMUM FOR THE TIME PERIOD                                                      483
      DIAGNOSIS: SPEECH                       OR OCCURRENCE HAS BEEN REACHED.
      EVALUATION PER SFY
726   EXCEEDS LIMIT OF THREE PAIR 119         BENEFIT MAXIMUM FOR THE TIME PERIOD                                                      483
      OF INSERTS PER SHOE PER                 OR OCCURRENCE HAS BEEN REACHED.
      STATE FISCAL YEAR, OR SIX
      TOTAL
727   EXCEEDS LIMIT OF TWO POWER 119          BENEFIT MAXIMUM FOR THE TIME PERIOD                                                      483
      WHEELCHAIR ACCESSORIES,                 OR OCCURRENCE HAS BEEN REACHED.
      BATTERIES AND/OR CHARGERS,
      PER STATE FISCAL YEAR.

728   TRANSPORTATION SERVICES IN 119          BENEFIT MAXIMUM FOR THE TIME PERIOD                                                      483
      EXCESS OF 300 MILES PER DATE            OR OCCURRENCE HAS BEEN REACHED.
      OF SERVICE
729   STERILIZATIONS NOT COVERED 96           NON-COVERED CHARGE(S).                   N30      PATIENT INELIGIBLE FOR THIS SERVICE.   109
      FOR PREGNANT
      WOMEN/UNBORN CHILD GROUP

730   UNITS EXCEED 72 PER MONTH     119       BENEFIT MAXIMUM FOR THE TIME PERIOD                                                      483
      FOR PERSONAL CARE                       OR OCCURRENCE HAS BEEN REACHED.

731   EXCEEDED LIMIT OF 48 CRISIS   119       BENEFIT MAXIMUM FOR THE TIME PERIOD                                                      483
      MANAGEMENT SERVICE UNITS                OR OCCURRENCE HAS BEEN REACHED.
      PER SFY
732   EXCEEDED MAXIMUM OF TWO       119       BENEFIT MAXIMUM FOR THE TIME PERIOD                                                      483
      CONSULTATIONS PER STATE                 OR OCCURRENCE HAS BEEN REACHED.
      FISCAL YEAR.
733   CONSULT PREVIOUSLY BILLED     B13       PREVIOUSLY PAID. PAYMENT FOR THIS                                                        483
      FOR THIS RECIPIENT                      CLAIM/SERVICE MAY HAVE BEEN
                                              PROVIDED IN A PREVIOUS PAYMENT.
734   RECIPIENT AID CATEGORY                                                           N30      PATIENT INELIGIBLE FOR THIS SERVICE.   84
      LIMITED TO OB SERVICES.
735   PROVIDER TO CONTACT           A1        CLAIM DENIED CHARGES.                    N36      CLAIM MUST MEET PRIMARY PAYER’S        85
      PRIVATE TRUST FUND FOR                                                                    PROCESSING REQUIREMENTS BEFORE
      PAYMENT.                                                                                  WE CAN CONSIDER PAYMENT.




                                                                                                                                                Effective 10/22/10
                                                                             EOB TO 277 & 835



                                                                                     835                                             277
                                    835 ADJ   835 ADJUSTMENT REASON CODE             REMIT      835 REMITTANCE REMARK CODE           CLAIM
EOB   HP DESCRIPTION                REASON    DESCRIPTION                            REMARK     DESCRIPTION                          STATUS
736   PERIODIC FAMILY PLANNING      119       BENEFIT MAXIMUM FOR THE TIME PERIOD                                                    483
      VISIT EXCEEDS THE 3                     OR OCCURRENCE HAS BEEN REACHED.
      ALLOWABLE PER STATE FISCAL
      YEAR.
737   CLAIM CUT BACK TO BENEFIT  119          BENEFIT MAXIMUM FOR THE TIME PERIOD                                                    65
      LIMIT                                   OR OCCURRENCE HAS BEEN REACHED.

738   ALLOWED DAYS CUTBACK DUE                                                       N144       THE RATE CHANGED DURING THE DATES    456
      TO CHANGE IN AUTHORIZED                                                                   OF SERVICE BILLED.
      LEVEL OF CARE DURING
      BILLING PERIOD. REBILL
      REMAINING DAYS ON NEXT TAD
      AT NEW LEVEL OF CARE.

739   RECIPIENT EXCEEDS 2920 HOUR   119       BENEFIT MAXIMUM FOR THE TIME PERIOD                                                    483
      LIMIT OF APD ATTENDANT CARE             OR OCCURRENCE HAS BEEN REACHED.
      PER SFY
740   ADJUSTMENT RESULTING FROM     125       SUBMISSION/BILLING ERROR(S).           MA31       MISSING/INCOMPLETE/INVALID BEGINNING 101
      A CHANGE IN THE DATES OF                                                                  AND ENDING DATES OF THE PERIOD
      SERVICE                                                                                   BILLED.
741   ADJUSTMENT RESULTING FROM     125       SUBMISSION/BILLING ERROR(S).           M64        MISSING/INCOMPLETE/INVALID OTHER     101
      CHANGE IN THE DIAGNOSIS                                                                   DIAGNOSIS.
      CODE
742   ADJUSTMENT RESULTING FROM     125       SUBMISSION/BILLING ERROR(S).           N251       MISSING/INCOMPLETE/INVALID ATTENDING 101
      A CHANGE IN THE PERFORMING                                                                PROVIDER IDENTIFIER.
      PROVIDER
743   OP HEMODIALYSIS NOT                                                            M86        SERVICE DENIED BECAUSE PAYMENT       483
      PAYABLE SAME DOS AS HOME                                                                  ALREADY MADE FOR SAME/SIMILAR
      DIALYSIS                                                                                  PROCEDURE WITHIN SET TIME FRAME.
744   COMBINED LAB PROCEDURE        97        THE BENEFIT FOR THIS SERVICE IS                                                        419
      CODE                                    INCLUDED IN THE PAYMENT/ALLOWANCE
                                              FOR ANOTHER SERVICE/PROCEDURE
                                              THAT HAS ALREADY BEEN ADJUDICATED.

745   ADJUSTMENT RESULTING FROM     15        THE AUTHORIZATION NUMBER IS MISSING, N54          CLAIM INFORMATION IS INCONSISTENT    101
      A CHANGE IN THE PRIOR                   INVALID, OR DOES NOT APPLY TO THE                 WITH PRE-CERTIFIED/AUTHORIZED
      AUTHORIZATION NUMBER                    BILLED SERVICES OR PROVIDER.                      SERVICES.

746   ADJUSTMENT DUE TO             175       PRESCRIPTION IS INCOMPLETE.                                                            101
      MEDICALLY NECESSARY
      PRESCRIPTION
747   DENTAL SERVICE LIMITED TO     119       BENEFIT MAXIMUM FOR THE TIME PERIOD                                                    483
      FOUR PER VISIT                          OR OCCURRENCE HAS BEEN REACHED.

748   RECOUPMENT OF PAYMENT         23        THE IMPACT OF PRIOR PAYER(S)                                                           101
      PAID BY PATIENT'S OTHER                 ADJUDICATION INCLUDING PAYMENTS
      INSURANCE                               AND/OR ADJUSTMENTS.




                                                                                                                                              Effective 10/22/10
                                                                           EOB TO 277 & 835



                                                                                     835                                           277
                                     835 ADJ   835 ADJUSTMENT REASON CODE            REMIT    835 REMITTANCE REMARK CODE           CLAIM
EOB   HP DESCRIPTION                 REASON    DESCRIPTION                           REMARK   DESCRIPTION                          STATUS
749   HOME PERITONEAL DIALYSIS       B5        COVERAGE/PROGRAM GUIDELINES WERE      M86      SERVICE DENIED BECAUSE PAYMENT       84
      NOT PAYABLE SAME DOS OP                  NOT MET OR WERE EXCEEDED.                      ALREADY MADE FOR SAME/SIMILAR
      HEMODIALYSIS                                                                            PROCEDURE WITHIN SET TIME FRAME.
750   PAID ASSOCIATED PROCEDURE      97        THE BENEFIT FOR THIS SERVICE IS                                                     107
      PREVENTS PAYMENT OF                      INCLUDED IN THE PAYMENT/ALLOWANCE
      CRITICAL CARE CODE                       FOR ANOTHER SERVICE/PROCEDURE
                                               THAT HAS ALREADY BEEN ADJUDICATED.

751   PERITONEAL DIALYSIS TRNG       B5        COVERAGE/PROGRAM GUIDELINES WERE      M86      SERVICE DENIED BECAUSE PAYMENT       84
      NON-PAYABLE SAME DOS AS                  NOT MET OR WERE EXCEEDED.                      ALREADY MADE FOR SAME/SIMILAR
      DAILY PHYSICIAN RATE                                                                    PROCEDURE WITHIN SET TIME FRAME.
752   ONLY ONE PROPHY WITH           119       BENEFIT MAXIMUM FOR THE TIME PERIOD                                                 483
      FLUORIDE ALLOWED PER SIX                 OR OCCURRENCE HAS BEEN REACHED.
      MONTH PERIOD.
753   RECIPIENT HAS OTHER                                                            MA92     MISSING PLAN INFORMATION FOR OTHER   171
      INSURANCE COVERAGE                                                                      INSURANCE.

754   DENTAL SERVICE LIMITED TO      119       BENEFIT MAXIMUM FOR THE TIME PERIOD                                                 483
      ONCE PER FIVE YEAR PERIOD                OR OCCURRENCE HAS BEEN REACHED.

755   PROCEDURE NOT PAYABLE IN       97        THE BENEFIT FOR THIS SERVICE IS       N20      SERVICE NOT PAYABLE WITH OTHER       107
      CONJUNCTION, OR WITH PAID                INCLUDED IN THE PAYMENT/ALLOWANCE              SERVICE RENDERED ON THE SAME DATE.
      CRITICAL CARE CODE                       FOR ANOTHER SERVICE/PROCEDURE
                                               THAT HAS ALREADY BEEN ADJUDICATED.

756   ONLY ONE                      119        BENEFIT MAXIMUM FOR THE TIME PERIOD                                                 483
      SERVICE/PROCEDURE IS                     OR OCCURRENCE HAS BEEN REACHED.
      INDICATED PER 12 MONTHS
757   BITEWING NOT ALLOWED          119        BENEFIT MAXIMUM FOR THE TIME PERIOD                                                 483
      WITHIN 30 DAYS FROM FULL                 OR OCCURRENCE HAS BEEN REACHED.
      MOUTH X-RAY.
758   EXCEEDS LIMIT OF 12 PHYSICIAN 119        BENEFIT MAXIMUM FOR THE TIME PERIOD                                                 483
      VISITS PER STATE FISCAL YEAR.            OR OCCURRENCE HAS BEEN REACHED.

759   MENTAL HEALTH-ONLY ONE         119       BENEFIT MAXIMUM FOR THE TIME PERIOD   M86      SERVICE DENIED BECAUSE PAYMENT       483
      SERVICE ALLOWED PER DOS                  OR OCCURRENCE HAS BEEN REACHED.                ALREADY MADE FOR SAME/SIMILAR
                                                                                              PROCEDURE WITHIN SET TIME FRAME.
760   ONLY ONE OFFICE VISIT          B14       ONLY ONE VISIT OR CONSULTATION PER    M86      SERVICE DENIED BECAUSE PAYMENT       483
      ALLOWED PER DOS PER                      PHYSICIAN PER DAY IS COVERED.                  ALREADY MADE FOR SAME/SIMILAR
      ATTENDING PROVIDER                                                                      PROCEDURE WITHIN SET TIME FRAME.
761   ONLY ONE HOSPITAL VISIT        B14       ONLY ONE VISIT OR CONSULTATION PER    M86      SERVICE DENIED BECAUSE PAYMENT       483
      SERVICE ALLOWED PER DOS                  PHYSICIAN PER DAY IS COVERED.                  ALREADY MADE FOR SAME/SIMILAR
      PER ATTENDING PROVIDER                                                                  PROCEDURE WITHIN SET TIME FRAME.
762   ONLY ONE CARE FACILITY VISIT   B14       ONLY ONE VISIT OR CONSULTATION PER    M86      SERVICE DENIED BECAUSE PAYMENT       483
      ALLOWED PER DOS                          PHYSICIAN PER DAY IS COVERED.                  ALREADY MADE FOR SAME/SIMILAR
                                                                                              PROCEDURE WITHIN SET TIME FRAME.




                                                                                                                                            Effective 10/22/10
                                                                           EOB TO 277 & 835



                                                                                    835                                           277
                                    835 ADJ   835 ADJUSTMENT REASON CODE            REMIT     835 REMITTANCE REMARK CODE          CLAIM
EOB   HP DESCRIPTION                REASON    DESCRIPTION                           REMARK    DESCRIPTION                         STATUS
763   ONLY ONE TYPE OF THIS DME                                                     M86       SERVICE DENIED BECAUSE PAYMENT      483
      ALLOWED PER DOS.                                                                        ALREADY MADE FOR SAME/SIMILAR
                                                                                              PROCEDURE WITHIN SET TIME FRAME.
764   ONLY ONE FAMILY PLANNING                                                      M86       SERVICE DENIED BECAUSE PAYMENT      483
      VISIT ALLOWED PER DOS                                                                   ALREADY MADE FOR SAME/SIMILAR
                                                                                              PROCEDURE WITHIN SET TIME FRAME.
765   COMPLETE DENTURE              119       BENEFIT MAXIMUM FOR THE TIME PERIOD                                                 483
      ADJUSTMENTS OR                          OR OCCURRENCE HAS BEEN REACHED.
      REALIGNMENTS ARE NOT
      COVERED WITHIN SIX MONTHS
      OF APPLIANCE PLACEMENT.
766   PARTIAL DENTURE               119       BENEFIT MAXIMUM FOR THE TIME PERIOD                                                 483
      ADJUSTMENTS OR                          OR OCCURRENCE HAS BEEN REACHED.
      REALIGNMENTS ARE NOT
      COVERED WITHIN SIX MONTHS
      OF APPLIANCE PLACEMENT.
767   ONLY ONE AMALGAM OR        119          BENEFIT MAXIMUM FOR THE TIME PERIOD                                                 483
      COMPOSITE RESTORATION PER               OR OCCURRENCE HAS BEEN REACHED.
      SURFACE ALLOWED EVERY 2
      YEARS.
768   ONLY ONE EVALUATION        B14          ONLY ONE VISIT OR CONSULTATION PER    M86       SERVICE DENIED BECAUSE PAYMENT      483
      PROCEDURE ALLOWED PER                   PHYSICIAN PER DAY IS COVERED.                   ALREADY MADE FOR SAME/SIMILAR
      DOS PER ATTENDING PROVIDER                                                              PROCEDURE WITHIN SET TIME FRAME.

769   MULTIPLE AMALGAM              97        THE BENEFIT FOR THIS SERVICE IS                                                     12
      RESTORATIONS FOR SAME                   INCLUDED IN THE PAYMENT/ALLOWANCE
      TOOTH COMBINED.                         FOR ANOTHER SERVICE/PROCEDURE
                                              THAT HAS ALREADY BEEN ADJUDICATED.

770   MULTIPLE COMPOSITE            97        THE BENEFIT FOR THIS SERVICE IS                                                     12
      RESTORATIONS FOR SAME                   INCLUDED IN THE PAYMENT/ALLOWANCE
      TOOTH COMBINED AND                      FOR ANOTHER SERVICE/PROCEDURE
      PREVIOUSLY PAID AT MAX                  THAT HAS ALREADY BEEN ADJUDICATED.
      ALLOWABLE.
771   MORE THAN ONE CROWN OR        119       BENEFIT MAXIMUM FOR THE TIME PERIOD                                                 483
      BRIDGE RESTORATION PER                  OR OCCURRENCE HAS BEEN REACHED.
      TOOTH IS NOT COVERED.
772   FIRST EXTRACTION USE D7111.                                                   N22       THIS PROCEDURE CODE WAS             15
      EACH ADDITIONAL EXTRACTION                                                              ADDED/CHANGED BECAUSE IT MORE
      ON SAME DATE OF SERVICE                                                                 ACCURATELY DESCRIBES THE SERVICES
      USE CODE D7140.                                                                         RENDERED.
773   ONLY ONE HEARING AID EXAM     B14       ONLY ONE VISIT OR CONSULTATION PER    M86       SERVICE DENIED BECAUSE PAYMENT      483
      ALLOWED PER DOS PER                     PHYSICIAN PER DAY IS COVERED.                   ALREADY MADE FOR SAME/SIMILAR
      ATTENDING PROVIDER                                                                      PROCEDURE WITHIN SET TIME FRAME.




                                                                                                                                           Effective 10/22/10
                                                                           EOB TO 277 & 835



                                                                                    835                                              277
                                    835 ADJ   835 ADJUSTMENT REASON CODE            REMIT     835 REMITTANCE REMARK CODE             CLAIM
EOB   HP DESCRIPTION                REASON    DESCRIPTION                           REMARK    DESCRIPTION                            STATUS
774   ONLY ONE ELECTROACOUSTIC                                                      M86       SERVICE DENIED BECAUSE PAYMENT         483
      EVALUATION PROCEDURE                                                                    ALREADY MADE FOR SAME/SIMILAR
      ALLOWED PER DOS                                                                         PROCEDURE WITHIN SET TIME FRAME.

775   ONLY ONE PRESCHOOL VISIT      B14       ONLY ONE VISIT OR CONSULTATION PER    M86       SERVICE DENIED BECAUSE PAYMENT         483
      ALLOWED PER DOS                         PHYSICIAN PER DAY IS COVERED.                   ALREADY MADE FOR SAME/SIMILAR
                                                                                              PROCEDURE WITHIN SET TIME FRAME.
776   DENIED ADJUSTMENT             45        CHARGES EXCEEDS FEE                                                                    101
      RESULTING FROM AEVCS                    SCHEDULE/MAXIMUM ALLOWABLE OR
      REVERSAL OF A PAID CLAIM.               CONTRACTED/LEGISLTATED FEE
                                              ARRANGMENT. (USE GROUPE CODES PR
                                              OR CO DEPENDING ON LIABILITY).
777   ONLY A COLLECTION FEE IS      134       TECHNICAL FEES REMOVED FROM                                                            107
      ALLOWED ON TESTS NOT                    CHARGES.
      PERFORMED IN YOUR LAB
778   EXCEEDS LIMIT OF ONE Z0560    119       BENEFIT MAXIMUM FOR THE TIME PERIOD                                                    483
      DIAGNOSIS PER SFY                       OR OCCURRENCE HAS BEEN REACHED.

779   RECIPIENT EXCEEDS LIMIT OF    119       BENEFIT MAXIMUM FOR THE TIME PERIOD                                                    483
      $10,000.00 PER LIFETIME FOR             OR OCCURRENCE HAS BEEN REACHED.
      APD DME
780   RECIPIENT INELIGIBLE FOR                                                      N30       PATIENT INELIGIBLE FOR THIS SERVICE.   88
      WAIVER SERVICES SAME OR
      OVERLAPPING DOS AS
      INSTITUTIONAL CLAIM.
781   EXCEEDS LIMIT OF ONE          119       BENEFIT MAXIMUM FOR THE TIME PERIOD                                                    483
      INTERPRETATION OF DIAGNOSIS             OR OCCURRENCE HAS BEEN REACHED.
      PER SFY
782   EXCEEDS LIMIT OF SIX UNITS-   119       BENEFIT MAXIMUM FOR THE TIME PERIOD                                                    483
      GROUP OUTPATIENT THERAPY                OR OCCURRENCE HAS BEEN REACHED.
      PER WEEK
783   EPSDT SCREEN OR               119       BENEFIT MAXIMUM FOR THE TIME PERIOD                                                    107
      PREVENTATIVE SCREEN/OFFICE              OR OCCURRENCE HAS BEEN REACHED.
      VISITS NOT PAYABLE ON SAME
      DATE OF SERVICE.

784   EXCEEDS ONE REMOVAL WITHIN 119          BENEFIT MAXIMUM FOR THE TIME PERIOD                                                    483
      FIVE YEAR PERIOD                        OR OCCURRENCE HAS BEEN REACHED.

785   PARTIAL EPSDT SCREENS NOT     97        THE BENEFIT FOR THIS SERVICE IS                                                        107
      PAYABLE SAME DOS AS EPSDT               INCLUDED IN THE PAYMENT/ALLOWANCE
      FULL SCREEN                             FOR ANOTHER SERVICE/PROCEDURE
                                              THAT HAS ALREADY BEEN ADJUDICATED.




                                                                                                                                              Effective 10/22/10
                                                                           EOB TO 277 & 835



                                                                                    835                                          277
                                    835 ADJ   835 ADJUSTMENT REASON CODE            REMIT     835 REMITTANCE REMARK CODE         CLAIM
EOB   HP DESCRIPTION                REASON    DESCRIPTION                           REMARK    DESCRIPTION                        STATUS
786   TREATMENT/ THERAPY CODE                                                       M86       SERVICE DENIED BECAUSE PAYMENT     107
      NON PAYABLE WITH PAID                                                                   ALREADY MADE FOR SIMILAR PROCEDURE
      EMERGENCY PROCEDURE(S).                                                                 WITHIN SET TIME FRAME.
      SUBMIT AN ADJUSTMENT IF
      APPLICABLE.
787   92340 MUST BE BILLED WITH     119       BENEFIT MAXIMUM FOR THE TIME PERIOD   N20       SERVICE NOT PAYABLE WITH OTHER        107
      S0620, S0621 OR S0592 FOR               OR OCCURRENCE HAS BEEN REACHED.                 SERVICE RENDERED ON THE SAME DATE.
      SAME RECIPIENT AND SAME
      DATE OF SERVICE.
788   HOSPICE ROUTINE CARE NOT      A1        CLAIM DENIED CHARGES.                 N20       SERVICE NOT PAYABLE WITH OTHER        107
      PAYABLE SAME DAY AS PAID                                                                SERVICE RENDERED ON THE SAME DATE.
      CLAIM FOR INPATIENT RESPITE
      CARE.
789   HOSPICE ROUTINE CARE NOT      A1        CLAIM DENIED CHARGES.                 N20       SERVICE NOT PAYABLE WITH OTHER        107
      PAYABLE SAME DAY AS PAID                                                                SERVICE RENDERED ON THE SAME DATE.
      CLAIM FOR CONTINOUS HOME
      CARE.
790   CONTINUOUS HOME CARE NOT      B9        PATIENT IS ENROLLED IN A HOSPICE.                                                     107
      PAYABLE SAME DAY AS PAID
      CLAIM FOR HOSPICE ROUTINE
      CARE
791   INPATIENT RESPITE CARE NOT    B9        PATIENT IS ENROLLED IN A HOSPICE.                                                     107
      PAYABLE SAME DAY AS PAID
      CLAIM FOR HOSPICE ROUTINE
      CARE
792   ROUTINE POST-OP CARE IS                                                       M144      PRE-/POST-OPERATIVE CARE PAYMENT IS   107
      INCLUDED IN THE PAYMENT FOR                                                             INCLUDED IN THE ALLOWANCE FOR THE
      THE SURGICAL PROCEDURE.                                                                 SURGERY/PROCEDURE.

793   INPATIENT HOSPICE CARE        A1        CLAIM DENIED CHARGES.                 N20       SERVICE NOT PAYABLE WITH OTHER        107
      NON/PAYABLE SAME DOS AS                                                                 SERVICE RENDERED ON THE SAME DATE.
      HOSPICE CON- TINUOUS HOME
      CARE
794   ONLY ONE HEARING AID EXAM     119       BENEFIT MAXIMUM FOR THE TIME PERIOD   M86       SERVICE DENIED BECAUSE PAYMENT        483
      ALLOWED PER DOS.                        OR OCCURRENCE HAS BEEN REACHED.                 ALREADY MADE FOR SAME/SIMILAR
                                                                                              PROCEDURE WITHIN SET TIME FRAME.
795   HOSPICE CONTINUOUS HOME       A1        CLAIM DENIED CHARGES.                 N20       SERVICE NOT PAYABLE WITH OTHER        107
      CARE NONPAYABLE SAME DOS                                                                SERVICE RENDERED ON THE SAME DATE.
      AS IN-PATIENT HOSPICE CARE
796   FORM DHS-2606 MUST BE         16        CLAIM/SERVICE LACKS INFORMATION       N29       MISSING/INCOMPLETE/INVALID       294
      ATTACHED TO ANY                         WHICH IS NEEDED FOR ADJUDICATION.               DOCUMENTATION/ORDERS/NOTES/SUMMA
      HYSTERECTOMY CLAIM WITH                                                                 RY/REPORT/CHART.
      DATES OF SERVICE ON OR
      AFTER 11-01-93.
797   INPATIENT HOSPICE CARE        A1        CLAIM DENIED CHARGES.                 N20       SERVICE NOT PAYABLE WITH OTHER        107
      NONPAYABLE SAME DOS AS                                                                  SERVICE RENDERED ON THE SAME DATE.
      HOSPICE ROOM AND BOARD




                                                                                                                                          Effective 10/22/10
                                                                           EOB TO 277 & 835



                                                                                    835                                            277
                                    835 ADJ   835 ADJUSTMENT REASON CODE            REMIT     835 REMITTANCE REMARK CODE           CLAIM
EOB   HP DESCRIPTION                REASON    DESCRIPTION                           REMARK    DESCRIPTION                          STATUS
798   HOSPICE ROOM AND BOARD        A1        CLAIM DENIED CHARGES.                 N20       SERVICE NOT PAYABLE WITH OTHER       107
      NONPAYABLE SAME DOS AS                                                                  SERVICE RENDERED ON THE SAME DATE.
      INPATIENT HOS-PICE CARE
799   ONLY ONE PURE TONE            119       BENEFIT MAXIMUM FOR THE TIME PERIOD   M86       SERVICE DENIED BECAUSE PAYMENT       483
      AUDIOMETRY PROCEDURE                    OR OCCURRENCE HAS BEEN REACHED.                 ALREADY MADE FOR SAME/SIMILAR
      ALLOWED PER DOS                                                                         PROCEDURE WITHIN SET TIME FRAME.
800   DME RENTAL IS LIMITED TO      119       BENEFIT MAXIMUM FOR THE TIME PERIOD                                                  483
      ONCE PER MONTH                          OR OCCURRENCE HAS BEEN REACHED.

801   SINGLE FILM NOT ALLOWED       97        THE BENEFIT FOR THIS SERVICE IS                                                      107
      WITH FULL MOUTH SERIES                  INCLUDED IN THE PAYMENT/ALLOWANCE
                                              FOR ANOTHER SERVICE/PROCEDURE
                                              THAT HAS ALREADY BEEN ADJUDICATED.

802   HOSPICE SERVICES              A1        CLAIM DENIED CHARGES.                 N20       SERVICE NOT PAYABLE WITH OTHER       107
      NONPAYABLE ON SAME DOS AS                                                               SERVICE RENDERED ON THE SAME DATE.
      PAID/PENDING CLAIM FOR
      GENERAL INPATIENT HOSPICE.
803   SERVICE NOT PAYABLE IN        A1        CLAIM DENIED CHARGES.                 N20       SERVICE NOT PAYABLE WITH OTHER       107
      CONJUNCTION WITH 93503 SAME                                                             SERVICE RENDERED ON THE SAME DATE.
      DOS.
804   OFFICE VISIT AND VISUAL       B14       PAYMENT DENIED BECAUSE ONLY ONE       N20       SERVICE NOT PAYABLE WITH OTHER       107
      ANALYSIS NOT ALLOWED SAME               VISIT OR CONSULTATION PER PHYSICIAN             SERVICE RENDERED ON THE SAME DATE.
      DATE OF SERVICE                         PER DAY IS COVERED.
805   MULTIPLE SURGERY HAS BEEN     59        PROCESSED BASED ON MULTIPLE OR                                                       65
      SYSTEMATICALLY PRICED.                  CONCURRENT PROCEDURE RULES (FOR
                                              EXAMPLE MULTIPLE SURGERY OR
                                              DIAGNOSTIC IMAGING, CONCURRENT
                                              ANESTHESIA.)
806   AMOUNT REDUCED BY             178       PATIENT HAS NOT MET THE REQUIRED                                                     68
      SPENDDOWN AND RECIPIENT                 SPEND DOWN REQUIREMENTS.
      HAS OTHER INSURANCE
      COVERAGE.
807   GROUP OUTPATIENT/ THERAPY     B20       PROCEDURE/SERVICE WAS PARTIALLY OR                                                   107
      SERVICES HAVE BEEN                      FULLY FURNISHED BY ANOTHER
      SUBMITTED AND PAID TO                   PROVIDER.
      RSPMI FOR SAME DATE OF
      SERVICE.
808   MARITAL/FAMILY THERAPY        B20       PROCEDURE/SERVICE WAS PARTIALLY OR                                                   107
      SERVICES HAVE BEEN PAID TO              FULLY FURNISHED BY ANOTHER
      ANOTHER MENTAL HEALTH                   PROVIDER.
      PROVIDER FOR THE SAME DATE
      OF SERVICE.




                                                                                                                                            Effective 10/22/10
                                                                           EOB TO 277 & 835



                                                                                    835                                          277
                                    835 ADJ   835 ADJUSTMENT REASON CODE            REMIT     835 REMITTANCE REMARK CODE         CLAIM
EOB   HP DESCRIPTION                REASON    DESCRIPTION                           REMARK    DESCRIPTION                        STATUS
809   INDIVIDUAL                    A1        CLAIM DENIED CHARGES.                 N347      YOUR CLAIM FOR A REFERRED OR       107
      OUTPATIENT/COLLATERAL                                                                   PURCHASED SERVICE CANNOT BE PAID
      SERVICES NOT PAYABLE TO                                                                 BECAUSE PAYMENT HAS ALREADY BEEN
      MULTIPLE MENTAL HEALTH                                                                  MADE FOR THIS SAME SERVICE TO
      PROVIDERS FOR THE SAME                                                                  ANOTHER PROVIDER BY A PAYMENT
      DATE OF    SERVICE.                                                                     CONTRACTOR REPRESENTING THE PAYER.

810   DATE OF SERVICE ON CLAIM      129       PRIOR PROCESSING INFORMATION          MA31      MISSING/INCOMPLETE/INVALID BEGINNING 187
      FORM AND DATE OF SERVICE                APPEARS INCORRECT.                              AND ENDING DATES OF THE PERIOD
      ON ATTACH-MENTS DO NOT                                                                  BILLED.
      MATCH.
811   SURGEON'S LICENSE NUMBER                                                      N31       MISSING/INCOMPLETE/INVALID           142
      OMITTED.                                                                                PRESCRIBING PROVIDER IDENTIFIER.
812   LICENSE NUMBER OMITTED                                                        N31       MISSING/INCOMPLETE/INVALID           142
                                                                                              PRESCRIBING PROVIDER IDENTIFIER.
813   INDIVIDUAL OUTPATIENT/        B20       PROCEDURE/SERVICE WAS PARTIALLY OR                                                   107
      THERAPY SESSION HAS BEEN                FULLY FURNISHED BY ANOTHER
      PAID TO    ANOTHER MENTAL               PROVIDER.
      HEALTH PROVIDER FOR THE
      SAME DATE OF SERVICE.
814   CRISIS MANAGEMENT SERVICES B20          PROCEDURE/SERVICE WAS PARTIALLY OR                                                   107
      HAVE BEEN SUBMITTED AND                 FULLY FURNISHED BY ANOTHER
      PAID TO RSPMI FOR THIS DATE             PROVIDER.
      OF SERVICE.

815   BENEFITS EXCEED MAXIMUM OF 119          BENEFIT MAXIMUM FOR THE TIME PERIOD                                                  483
      $500.00 PER STATE FISCAL YEAR.          OR OCCURRENCE HAS BEEN REACHED.

816   LAST NAME OF RECIPIENT ON   140         PATIENT/INSURED HEALTH                                                               31
      DOCUMENTATION SUBMITTED                 IDENTIFICATION NUMBER AND NAME DO
      FOR REVIEWDOES NOT MATCH                NOT MATCH.
      LAST NAME ON FILE.
817   INTERPRETATION OF DIAGNOSIS B20         PROCEDURE/SERVICE WAS PARTIALLY OR                                                   107
      SERVICE HAS BEEN PAID TO                FULLY FURNISHED BY ANOTHER
      ANOTHER MENTAL HEALTH                   PROVIDER.
      PROVIDER FOR THE SAME DATE
      OF SERVICE.

818   $2.00 WAS ADDED FOR           91        DISPENSING FEE ADJUSTMENT.                                                           171
      DIFFERENTIAL DISPENSING FEE
      AND RECIPIENT HAS OTHER
      INSURANCE COVERAGE.




                                                                                                                                          Effective 10/22/10
                                                                          EOB TO 277 & 835



                                                                                 835                                              277
                                    835 ADJ   835 ADJUSTMENT REASON CODE         REMIT       835 REMITTANCE REMARK CODE           CLAIM
EOB   HP DESCRIPTION                REASON    DESCRIPTION                        REMARK      DESCRIPTION                          STATUS
819   DIAGNOSIS/ PSYCHOLOGICAL      B20       PROCEDURE/SERVICE WAS PARTIALLY OR                                                  107
      TESTING BATTERY SERVICE HAS             FULLY FURNISHED BY ANOTHER
      BEEN PAID TO ANOTHER                    PROVIDER.
      MENTAL HEALTH PROVIDER FOR
      THE SAME DATE OF SERVICE.

820   ONLY ONE PRE-NATAL LAB      119         BENEFIT MAXIMUM FOR THE TIME PERIOD                                                 483
      COVERED IN NINE MONTH SPAN.             OR OCCURRENCE HAS BEEN REACHED.

821   DIAGNOSIS/ PSYCHOLOGICAL    B20         PROCEDURE/SERVICE WAS PARTIALLY OR                                                  107
      TEST SERVICE NOT PAYABLE TO             FULLY FURNISHED BY ANOTHER
      MULTIPLE MENTAL HEALTH                  PROVIDER.
      PROVIDERS FOR THE SAME
      DATE OF    SERVICE.
822   DIAGNOSIS SERVICES HAS BEEN B20         PROCEDURE/SERVICE WAS PARTIALLY OR                                                  107
      SUBMITTED AND PAID TO                   FULLY FURNISHED BY ANOTHER
      ANOTHER MENTAL HEALTH                   PROVIDER.
      PROVIDER FOR THE SAME DATE
      OF SERVICE.
823   ATTACHMENT IS NOT DATED       16        CLAIM/SERVICE LACKS INFORMATION       N29      MISSING/INCOMPLETE/INVALID         395
                                              WHICH IS NEEDED FOR ADJUDICATION.              DOCUMENTATION/ORDERS/NOTES/SUMMA
                                                                                             RY/REPORT/CHART.
824   VENTIPUNCTURE/ANESTHESIOLO 97           THE BENEFIT FOR THIS SERVICE IS       N20      SERVICE NOT PAYABLE WITH OTHER     107
      GY CODE DISALLOWED SAME                 INCLUDED IN THE PAYMENT/ALLOWANCE              SERVICE RENDERED ON THE SAME DATE.
      DOS 90780.                              FOR ANOTHER SERVICE/PROCEDURE
                                              THAT HAS ALREADY BEEN ADJUDICATED.

825   PAPER CLAIMS ARE BEING PAID                                                                                                 277
      30 DAYS FROM RECEIPT PER
      STATE DIRECTIVE. DO NOT
      RESUBMIT. SEE OFFICIAL NOTE
      OMS-93-W-4 DATED DEC. 21,
      1993.
826   AMOUNT REDUCED BY             178       PATIENT HAS NOT MET THE REQUIRED                                                    68
      SPENDDOWN AND THE $2.00                 SPEND DOWN REQUIREMENTS.
      DISPENSING FEE WAS ADDED.
      THIS RECIPIENT ALSO HAS
      OTHER INSURANCE COVERAGE.

827   FRAGMENTED IMMUNIZATION                                                       N20      SERVICE NOT PAYABLE WITH OTHER       107
      CODES CANNOT BE BILLED ON                                                              SERVICE RENDERED ON THE SAME DATE.
      SAME DOS AS COMBINED CODE.




                                                                                                                                           Effective 10/22/10
                                                                          EOB TO 277 & 835



                                                                                   835                                               277
                                   835 ADJ   835 ADJUSTMENT REASON CODE            REMIT     835 REMITTANCE REMARK CODE              CLAIM
EOB   HP DESCRIPTION               REASON    DESCRIPTION                           REMARK    DESCRIPTION                             STATUS
828   OP TREATMENT/ THERAPY        97        THE BENEFIT FOR THIS SERVICE IS                                                         107
      CODES INCLUDE ALL RELATED              INCLUDED IN THE PAYMENT/ALLOWANCE
      PROCEDURES.                            FOR ANOTHER SERVICE/PROCEDURE
                                             THAT HAS ALREADY BEEN ADJUDICATED.

829   PROCEDURE NOT ALLOWED ON     96        NON-COVERED CHARGE(S).                N56       PROCEDURE CODE BILLED IS NOT            107
      NEWBORNS WITH                                                                          CORRECT/VALID FOR THE SERVICES
      COMPLICATIONS                                                                          BILLED OR THE DATE OF SERVICE BILLED.

830   DENTAL SERVICE LIMITED TO    119       BENEFIT MAXIMUM FOR THE TIME PERIOD                                                     483
      ONE PER 6 MONTH PERIOD                 OR OCCURRENCE HAS BEEN REACHED.

831   GENERAL INPATIENT HOSPICE   B9         PATIENT IS ENROLLED IN A HOSPICE.     N20       SERVICE NOT PAYABLE WITH OTHER          107
      NONPAYABLE IN CONJUNCTION                                                              SERVICE RENDERED ON THE SAME DATE.
      WITH OTHER HOSPICE SERVICES

832   PAYMENT FOR PHYSICAL         97        THE BENEFIT FOR THIS SERVICE IS                                                         107
      MEDICINE INCLUDES FEE FOR              INCLUDED IN THE PAYMENT/ALLOWANCE
      OFFICE VISIT.                          FOR ANOTHER SERVICE/PROCEDURE
                                             THAT HAS ALREADY BEEN ADJUDICATED.

833   FULL/PANO X-RAY NOT          96        NON-COVERED CHARGE(S).                N242      INCOMPLETE/INVALID X-RAY                107
      ALLOWED WITHIN 30 DAYS OF
      PAYMENT FOR BITEWINGS.
834   OFFICE, ER, NURSING HOME,    60        CHARGES FOR OUTPATIENT SERVICES                                                         107
      PSYCHOLOGY VISIT, OR                   WITH THIS PROXIMITY TO INPATIENT
      HOSPITAL DIS-CHARGE DAY                SERVICES ARE NOT COVERED.
      MANAGEMENT IS NOT ALLOWED
      THE SAME DOS AS
      HOSPITAL ADMISSION.
835   LEVEL IV ACS CASE           119        BENEFIT MAXIMUM FOR THE TIME PERIOD   M90       NOT COVERED MORE THAN ONCE IN A 12      483
      MANAGEMENT LIMITED TO 1 PER            OR OCCURRENCE HAS BEEN REACHED.                 MONTH PERIOD.
      12 MONTH PERIOD FOR DDS
      CLIENT.
836   NITROUS OXIDE NOT PAYABLE                                                    N20       SERVICE NOT PAYABLE WITH OTHER          107
      WITH EXAMINATIONS, PROPHYS,                                                            SERVICE RENDERED ON THE SAME DATE.
      FLUORIDES AND DENTAL
      SEALANTS FOR SAME DOS.

837   COMPONENT TESTS ARE          97        THE BENEFIT FOR THIS SERVICE IS                                                         107
      INCLUDED IN COMPLETE BLOOD             INCLUDED IN THE PAYMENT/ALLOWANCE
      COUNT.                                 FOR ANOTHER SERVICE/PROCEDURE
                                             THAT HAS ALREADY BEEN ADJUDICATED.




                                                                                                                                              Effective 10/22/10
                                                                          EOB TO 277 & 835



                                                                                  835                                             277
                                   835 ADJ   835 ADJUSTMENT REASON CODE           REMIT      835 REMITTANCE REMARK CODE           CLAIM
EOB   HP DESCRIPTION               REASON    DESCRIPTION                          REMARK     DESCRIPTION                          STATUS
838   GROUP OUTPATIENT/THERAPY     A1        CLAIM DENIED CHARGES.                N20        SERVICE NOT PAYABLE WITH OTHER       107
      SERVICE NOT PAYABLE TO                                                                 SERVICE RENDERED ON THE SAME DATE.
      MULTIPLE MENTAL HEALTH
      PROVIDERS ON THE SAME DATE
      OF SERVICE.
839   DIAGNOSIS SERVICES NOT      A1         CLAIM DENIED CHARGES.                N20        SERVICE NOT PAYABLE WITH OTHER       107
      PAYABLE TO RSPMI WHEN PAID                                                             SERVICE RENDERED ON THE SAME DATE.
      TO     PSYCHOLOGIST ON
      SAME DATE OF SERVICE.
840   DIAGNOSIS/ PSYCHOLOGICAL    A1         CLAIM DENIED CHARGES.                N20        SERVICE NOT PAYABLE WITH OTHER       107
      TEST SERVICE NOT PAYABLE TO                                                            SERVICE RENDERED ON THE SAME DATE.
      RSPMI WHEN PAID TO
      PSYCHOLOGIST ON SAME DOS.
841   DIAGNOSIS/ PSYCHOLOGICAL    A1         CLAIM DENIED CHARGES.                N20        SERVICE NOT PAYABLE WITH OTHER       107
      TESTING BATTERY SERVICE                                                                SERVICE RENDERED ON THE SAME DATE.
      NOT PAYABLE TO RSPMI WHEN
      PAID TO PSYCHOLOGIST ON
      SAME DATE OF SERVICE.
842   INTERPRETATION OF DIAGNOSIS A1         CLAIM DENIED CHARGES.                N20        SERVICE NOT PAYABLE WITH OTHER       107
      SERVICE NOT PAYABLE TO                                                                 SERVICE RENDERED ON THE SAME DATE.
      RSPMI WHEN PAID TO
      PSYCHOLOGIST ON SAME DOS.

843   MARITAL/FAMILY THERAPY       A1        CLAIM DENIED CHARGES.                N20        SERVICE NOT PAYABLE WITH OTHER       107
      SERVICES NOT PAYABLE TO                                                                SERVICE RENDERED ON THE SAME DATE.
      RSPMI WHEN PAID TO
      PSYCHOLOGIST ON SAME DATE
      OF SERVICE.
844   INDIVIDUAL                 A1          CLAIM DENIED CHARGES.                N20        SERVICE NOT PAYABLE WITH OTHER       107
      OUTPATIENT/THERAPY SESSION                                                             SERVICE RENDERED ON THE SAME DATE.
      NOT PAYABLE TO RSPMI WHEN
      PAID TO PSYCHOLOGIST ON
      SAME DATE OF SERVICE

845   INDIVIDUAL/COLLATERAL        B20       PROCEDURE/SERVICE WAS PARTIALLY OR                                                   107
      SERVICES HAVE BEEN                     FULLY FURNISHED BY ANOTHER
      SUBMITTED AND PAID TO                  PROVIDER.
      ANOTHER MENTAL HEALTH
      PROVIDER FOR THE SAME DATE
      OF SERVICE.
846   CRISIS MANAGEMENT SERVICES A1          CLAIM DENIED CHARGES.                N20        SERVICE NOT PAYABLE WITH OTHER       107
      HAVE BEEN SUBMITTED AND                                                                SERVICE RENDERED ON THE SAME DATE.
      PAID TO ANOTHER MENTAL
      HEALTH PROVIDER FOR THE
      SAME DATE OF SERVICE.




                                                                                                                                           Effective 10/22/10
                                                                             EOB TO 277 & 835



                                                                                        835                                             277
                                      835 ADJ   835 ADJUSTMENT REASON CODE              REMIT    835 REMITTANCE REMARK CODE             CLAIM
EOB   HP DESCRIPTION                  REASON    DESCRIPTION                             REMARK   DESCRIPTION                            STATUS
847   URINALYSIS INCLUDED IN          97        THE BENEFIT FOR THIS SERVICE IS                                                         107
      OBSTETRICAL CARE WITH                     INCLUDED IN THE PAYMENT/ALLOWANCE
      DELIVERY.                                 FOR ANOTHER SERVICE/PROCEDURE
                                                THAT HAS ALREADY BEEN ADJUDICATED.

848   SERVICE NON-PAYABLE FOR         96        NON-COVERED CHARGE(S).                  N30      PATIENT INELIGIBLE FOR THIS SERVICE.   84
      PACE RECIPIENT/PROVIDER.
849   ARKIDS B ANNUAL COST-           119       BENEFIT MAXIMUM FOR THE TIME PERIOD                                                     483
      SHARING CAP HAS BEEN MET                  OR OCCURRENCE HAS BEEN REACHED.
      FOR THE CURRENT STATE
      FISCAL YEAR.
850   STANDARD WHEELCHAIR             96        NON-COVERED CHARGE(S).                  N351     SERVICE DATE OUTSIDE OF THE            107
      NONPAYABLE WITHIN 2 YEARS                                                                  APPROVED TREATMENT PLAN SERVICE
      OF SPECIALIZEDWHEELCHAIR.                                                                  DATES.
851   OUTPATIENT HOSPITAL DRUGS,      96        NON-COVERED CHARGE(S).                  N20      SERVICE NOT PAYABLE WITH OTHER         107
      INJECTIONS, AND SUPPLIES                                                                   SERVICE RENDERED ON THE SAME DATE.
      NON-PAYABLE IN NON-
      EMERGENCY ROOM.
852   E0608 LIMITED TO ONE UNIT PER   119       BENEFIT MAXIMUM FOR THE TIME PERIOD     M86      SERVICE DENIED BECAUSE PAYMENT         483
      DATE OF SERVICE                           OR OCCURRENCE HAS BEEN REACHED.                  ALREADY MADE FOR SAME/SIMILAR
                                                                                                 PROCEDURE WITHIN SET TIME FRAME.
853   SERVICES NOT PAID IN            97        THE BENEFIT FOR THIS SERVICE IS         N20      SERVICE NOT PAYABLE WITH OTHER         107
      CONJUNCTION WITH OTHER                    INCLUDED IN THE PAYMENT/ALLOWANCE                SERVICE RENDERED ON THE SAME DATE.
      PAID ELDERCHOICESERVICES.                 FOR ANOTHER SERVICE/PROCEDURE
      CONTACT DHS REGISTERED                    THAT HAS ALREADY BEEN ADJUDICATED.
      NURSE FOR RECIPIENT.

854   SERVICE NOT PAYABLE ON                                                            N20      SERVICE NOT PAYABLE WITH OTHER         107
      SAME DOS AS LONG TERM                                                                      SERVICE RENDERED ON THE SAME DATE.
      FACILITY RESP- ITE CARE
855   ARKIDS B COST-SHARING HAS       119       BENEFIT MAXIMUM FOR THE TIME PERIOD                                                     483
      BEEN REDUCED DUE TO THE                   OR OCCURRENCE HAS BEEN REACHED.
      STATE FISCAL YEAR CAP.
856   INDIVIDUAL INTEGRATED           119       BENEFIT MAXIMUM FOR THE TIME PERIOD                                                     483
      SUPPORTS LIMITED TO $160.00               OR OCCURRENCE HAS BEEN REACHED.
      PER DATE OF SERVICE.

857   PROCEDURE NOT ALLOWED ON                                                          N20      SERVICE NOT PAYABLE WITH OTHER         107
      SAME DOS AS PC/RCF.                                                                        SERVICE RENDERED ON THE SAME DATE.

858   MEDICARE PAYMENT MANUALLY       133       THE DISPOSITION OF THIS CLAIM/SERVICE                                                   46
      REVIEWED.                                 IS PENDING FURTHER REVIEW.

859   ONLY ONE ADC OR ADHC            119       BENEFIT MAXIMUM FOR THE TIME PERIOD     M86      SERVICE DENIED BECAUSE PAYMENT         483
      SERVICE ALLOWED PER DOS.                  OR OCCURRENCE HAS BEEN REACHED.                  ALREADY MADE FOR SAME/SIMILAR
                                                                                                 PROCEDURE WITHIN SET TIME FRAME.




                                                                                                                                                 Effective 10/22/10
                                                                              EOB TO 277 & 835



                                                                                         835                                            277
                                      835 ADJ   835 ADJUSTMENT REASON CODE               REMIT    835 REMITTANCE REMARK CODE            CLAIM
EOB   HP DESCRIPTION                  REASON    DESCRIPTION                              REMARK   DESCRIPTION                           STATUS
860   ARKIDS B ANNUAL COST            91        DISPENSING FEE ADJUSTMENT.                                                              483
      SHARING HAS BEEN MET AND A
      $2.00 DIFFERENTIAL DISPENSING
      FEE HAS BEEN ADDED.

861   PLACE OF SERVICE INVALID        58        TREATMENT WAS DEEMED BY THE PAYER        M77      MISSING/INCOMPLETE/INVALID PLACE OF   249
      WITH RESPITE CARE AND PERS                TO HAVE BEEN RENDERED IN AN                       SERVICE.
      ON SAME DOS.                              INAPPROPRIATE OR INVALID PLACE OF
                                                SERVICE.
862   NO APNEA MONITOR BILLED         95        PLAN PROCEDURES NOT FOLLOWED.                                                           107
      PRIOR TO 30 DAYS OF INITIAL
      SET UP OF APNEA MONITOR.
863   PROCEDURE CODE IS OUTSIDE       B7        THIS PROVIDER WAS NOT                    MA120    MISSING/INCOMPLETE/INVALID CLIA       454
      OF AGREED UPON CONTRACT.                  CERTIFIED/ELIGIBLE TO BE PAID FOR THIS            CERTIFICATION NUMBER.
      PLEASE CONTACT PERSON                     PROCEDURE/SERVICE ON THIS DATE OF
      WITH WHOM YOU ESTABLISHED                 SERVICE.
      YOUR PRESENT CON- TRACT.
      REQUEST MMIS BE CONTACTED
      OF ANY CHANGE IN CONTRACT.



864   ADC OR ADHC NOT PAYABLE                                                            M86      SERVICE DENIED BECAUSE PAYMENT     107
      SAME DOS AS PAID HOMEMAKER                                                                  ALREADY MADE FOR SIMILAR PROCEDURE
      OR CHORE SEVICES.                                                                           WITHIN SET TIME FRAME.

865   HOMEMAKER OR CHORE                                                                 M86      SERVICE DENIED BECAUSE PAYMENT     107
      SERVICE NOT PAYABLE SAME                                                                    ALREADY MADE FOR SIMILAR PROCEDURE
      DOS AS ADC OR ADHC.                                                                         WITHIN SET TIME FRAME.
866   ADULT DAY HEALTH CARE       18            DUPLICATE CLAIM/SERVICE.                                                             107
      RECOUPED. SERVICE
      REPETITIOUS TO PHYSICAL
      THERAPY HOME HEALTH
      SERVICE BILLED ON SAME DATE
      OF SERVICE.
867   ADULT DAY HEALTH CARE                                                              M86      SERVICE DENIED BECAUSE PAYMENT     107
      SERVICES REVIEWED AND                                                                       ALREADY MADE FOR SIMILAR PROCEDURE
      DEEMED NOT PAYABLE ON                                                                       WITHIN SET TIME FRAME.
      SAME DOS AS PHYSICAL
      THERAPY HOME HEALTH
      SERVICE.
868   TARGETED CASE MANAGEMENT                                                           M86      SERVICE DENIED BECAUSE PAYMENT     107
      NOT PAYABLE SAME DOS AS                                                                     ALREADY MADE FOR SIMILAR PROCEDURE
      RSPMI   INTERVENTION                                                                        WITHIN SET TIME FRAME.




                                                                                                                                                 Effective 10/22/10
                                                                          EOB TO 277 & 835



                                                                                    835                                             277
                                    835 ADJ   835 ADJUSTMENT REASON CODE            REMIT    835 REMITTANCE REMARK CODE             CLAIM
EOB   HP DESCRIPTION                REASON    DESCRIPTION                           REMARK   DESCRIPTION                            STATUS
869   CLAIM EXCEEDS 50 UNITS        119       BENEFIT MAXIMUM FOR THE TIME PERIOD                                                   483
      ALLOWED PER DOS FOR                     OR OCCURRENCE HAS BEEN REACHED.
      PRIVATE CARE PERSONAL CARE
      TRANSPORTATION.
870   TCM SERVICE NOT PAYABLE                                                       N30      PATIENT INELIGIBLE FOR THIS SERVICE.   107
      FOR RECIPIENT AGE 21 THRU 59
      YEARS OF AGE
871   PAID AS CO-SURGEON.          172        PAYMENT IS ADJUSTED WHEN                                                              65
                                              PERFORMED/BILLED BY A PROVIDER OF
                                              THIS SPECIALTY.
872   ACS SPECIALIZED MEDICAL       119       BENEFIT MAXIMUM FOR THE TIME PERIOD                                                   483
      SUPPLIES EXCEEDS LIMIT OF               OR OCCURRENCE HAS BEEN REACHED.
      $300.00 PER CALENDAR MONTH.

873   ACS SUPPORTED EMPLOYMENT 119            BENEFIT MAXIMUM FOR THE TIME PERIOD                                                   483
      EXCEEDS LIMIT OF 32 UNITS PER           OR OCCURRENCE HAS BEEN REACHED.
      DATE OF SERVICE.

874   OFFICE VISIT INCLUDED WITH    97        THE BENEFIT FOR THIS SERVICE IS                                                       107
      CAST REMOVAL OR REPAIR                  INCLUDED IN THE PAYMENT/ALLOWANCE
                                              FOR ANOTHER SERVICE/PROCEDURE
                                              THAT HAS ALREADY BEEN ADJUDICATED.

875   CAST INCLUDED IN FEE FOR      97        THE BENEFIT FOR THIS SERVICE IS                                                       107
      SURGICAL PROCEDURE.                     INCLUDED IN THE PAYMENT/ALLOWANCE
                                              FOR ANOTHER SERVICE/PROCEDURE
                                              THAT HAS ALREADY BEEN ADJUDICATED.

876   INCLUDED IN FLAT FEE FOR      97        THE BENEFIT FOR THIS SERVICE IS                                                       107
      MAJOR PROCEDURE.                        INCLUDED IN THE PAYMENT/ALLOWANCE
                                              FOR ANOTHER SERVICE/PROCEDURE
                                              THAT HAS ALREADY BEEN ADJUDICATED.

877   FQHC ANCILLARY CHARGES FOR B5           COVERAGE/PROGRAM GUIDELINES WERE      N45      PAYMENT BASED ON AUTHORIZED            107
      COST SETTLEMENT ONLY.                   NOT MET OR WERE EXCEEDED.                      AMOUNT.
878   PROCEDURE INCLUDES OFFICE 97            THE BENEFIT FOR THIS SERVICE IS       N19      PROCEDURE CODE INCIDENTAL TO           107
      VISIT                                   INCLUDED IN THE PAYMENT/ALLOWANCE              PRIMARY PROCEDURE.
                                              FOR ANOTHER SERVICE/PROCEDURE
                                              THAT HAS ALREADY BEEN ADJUDICATED.

879   ARKIDS B ANNUAL COST          119       BENEFIT MAXIMUM FOR THE TIME PERIOD                                                   171
      SHARING HAS BEEN MET AND                OR OCCURRENCE HAS BEEN REACHED.
      RECIPIENT HAS OTHER
      INSURANCE COVERAGE.




                                                                                                                                             Effective 10/22/10
                                                                            EOB TO 277 & 835



                                                                                     835                                            277
                                     835 ADJ   835 ADJUSTMENT REASON CODE            REMIT     835 REMITTANCE REMARK CODE           CLAIM
EOB   HP DESCRIPTION                 REASON    DESCRIPTION                           REMARK    DESCRIPTION                          STATUS
880   PAYMENT FOR THIS CLAIM WAS     97        THE BENEFIT FOR THIS SERVICE IS       M86       SERVICE DENIED BECAUSE PAYMENT       107
      DENIED. PROCEDURE IS                     INCLUDED IN THE PAYMENT/ALLOWANCE               ALREADY MADE FOR SAME/SIMILAR
      INCLUDED IN THE PAYMENT                  FOR ANOTHER SERVICE/PROCEDURE                   PROCEDURE WITHIN SET TIME FRAME.
      FOR A COMPREHENSIVE                      THAT HAS ALREADY BEEN ADJUDICATED.
      SERVICE.
881   INDICATE IF ANY OR ALL DRUGS   96        NON-COVERED CHARGE(S).                N29       MISSING/INCOMPLETE/INVALID           216
      BILLED WERE TAKEN HOME.                                                                  DOCUMENTATION/ORDERS/NOTES/SUMMA
                                                                                               RY/REPORT/CHART.
882   NO PAYMENT ALLOWED FOR         96        NON-COVERED CHARGE(S).                M119      MISSING/INCOMPLETE/INVALID/DEACTIVAT 216
      TAKE HOME DRUGS.                                                                         ED/WITHDRAWN NATIONAL DRUG CODE
                                                                                               (NDC).
883   PROCEDURE BILLED INCLUDED      97        THE BENEFIT FOR THIS SERVICE IS       N19       PROCEDURE CODE INCIDENTAL TO         107
      IN PAYMENT FOR GLOBAL OB                 INCLUDED IN THE PAYMENT/ALLOWANCE               PRIMARY PROCEDURE.
      CARE.                                    FOR ANOTHER SERVICE/PROCEDURE
                                               THAT HAS ALREADY BEEN ADJUDICATED.

884   ACS CASE MANAGEMENT            119       BENEFIT MAXIMUM FOR THE TIME PERIOD   M139      DENIED SERVICES EXCEED THE           483
      LIMITED TO ONCE PER                      OR OCCURRENCE HAS BEEN REACHED.                 COVERAGE LIMIT FOR THE
      CALENDAR MONTH                                                                           DEMONSTRATION.
885   E0570 EXCEEDS TOTAL            119       BENEFIT MAXIMUM FOR THE TIME PERIOD   M139      DENIED SERVICES EXCEED THE           483
      REIMBURSEMENT OF $140.00                 OR OCCURRENCE HAS BEEN REACHED.                 COVERAGE LIMIT FOR THE
      FOR TOS U                                                                                DEMONSTRATION.
886   E0570 EXCEEDS TOTAL            119       BENEFIT MAXIMUM FOR THE TIME PERIOD   M139      DENIED SERVICES EXCEED THE           483
      REIMBURSEMENT OF $175.00                 OR OCCURRENCE HAS BEEN REACHED.                 COVERAGE LIMIT FOR THE
                                                                                               DEMONSTRATION.
887   EXCEED MAXIMUM 30 UNITS PER 119          BENEFIT MAXIMUM FOR THE TIME PERIOD                                                  483
      DATE OF SERVICE PER                      OR OCCURRENCE HAS BEEN REACHED.
      RECIPIENT.
888   THIS PROCEDURE ALLOWED      119          BENEFIT MAXIMUM FOR THE TIME PERIOD   N23       ALERT: PATIENT LIABILITY MAY BE     483
      ONLY TWICE IN A LIFETIME                 OR OCCURRENCE HAS BEEN REACHED.                 AFFECTED DUE TO COORDINATION OF
                                                                                               BENEFITS WITH OTHER CARRIERS AND/OR
                                                                                               MAXIMUM BENEFIT PROVISIONS.
889   ARKIDS B ANNUAL COST          91         DISPENSING FEE ADJUSTMENT.                                                          171
      SHARING HAS BEEN MET AND A
      $2.00 DIFFERENTIAL DISPENSING
      FEE HAS BEEN ADDED AND
      RECIPIENT HAS OTHER
      INSURANCE COVERAGE.

890   ARKIDS B COST-SHARING HAS     119        BENEFIT MAXIMUM FOR THE TIME PERIOD                                                  483
      BEEN REDUCED DUE TO THE                  OR OCCURRENCE HAS BEEN REACHED.
      STATE FISCAL YEAR CAP AND A
      $2.00 DIFFERENTIAL DISPENSING
      FEE HAS BEEN ADDED.




                                                                                                                                             Effective 10/22/10
                                                                           EOB TO 277 & 835



                                                                                    835                                             277
                                    835 ADJ   835 ADJUSTMENT REASON CODE            REMIT     835 REMITTANCE REMARK CODE            CLAIM
EOB   HP DESCRIPTION                REASON    DESCRIPTION                           REMARK    DESCRIPTION                           STATUS
891   ARKIDS B COST-SHARING HAS     119       BENEFIT MAXIMUM FOR THE TIME PERIOD                                                   171
      BEEN REDUCED DUE TO THE                 OR OCCURRENCE HAS BEEN REACHED.
      STATE FISCAL YEAR CAP AND
      RECIPIENT HAS OTHER
      INSURANCE COVERAGE.
892   ONLY ONE EYE EXAM PER 12   119          BENEFIT MAXIMUM FOR THE TIME PERIOD   N23       ALERT: PATIENT LIABILITY MAY BE     483
      MONTHS, EXCLUDING REPAIRS               OR OCCURRENCE HAS BEEN REACHED.                 AFFECTED DUE TO COORDINATION OF
      OR    REPLACEMENT OF                                                                    BENEFITS WITH OTHER CARRIERS AND/OR
      BROKEN OR LOST GLASSES FOR                                                              MAXIMUM BENEFIT PROVISIONS.
      RECIPIENTS UNDER 21.

893   ONLY ONE PAIR OF GLASSES   119          BENEFIT MAXIMUM FOR THE TIME PERIOD   N23       ALERT: PATIENT LIABILITY MAY BE     483
      PER 12 MONTHS EXCLUDING                 OR OCCURRENCE HAS BEEN REACHED.                 AFFECTED DUE TO COORDINATION OF
      REPAIRS OR REPLACEMENT OF                                                               BENEFITS WITH OTHER CARRIERS AND/OR
      BROKEN OR LOST GLASSES FOR                                                              MAXIMUM BENEFIT PROVISIONS.
      RECIPIENTS UNDER 21 YEARS
      OF AGE
894   ARKIDS B COST-SHARING HAS     119       BENEFIT MAXIMUM FOR THE TIME PERIOD                                                   171
      BEEN REDUCED DUE TO THE                 OR OCCURRENCE HAS BEEN REACHED.
      STATE FISCAL YEAR CAP AND A
      $2.00 DIFFERENTIAL DISPENSING
      FEE AND RECIPIENT HAS OTHER
      INSURANCE COVERAGE.

895   ONLY ONE ANNUAL FAMILY        119       BENEFIT MAXIMUM FOR THE TIME PERIOD   N23       ALERT: PATIENT LIABILITY MAY BE     483
      PLANNING VISIT ALLOWED PER              OR OCCURRENCE HAS BEEN REACHED.                 AFFECTED DUE TO COORDINATION OF
      STATE FISCAL YEAR.                                                                      BENEFITS WITH OTHER CARRIERS AND/OR
                                                                                              MAXIMUM BENEFIT PROVISIONS.
896   OUTPATIENT SURGICAL           97        PAYMENT IS INCLUDED IN THE            N23       ALERT: PATIENT LIABILITY MAY BE     107
      PROCEDURE INCLUDES ALL                  ALLOWANCE FOR ANOTHER                           AFFECTED DUE TO COORDINATION OF
      RELATED PROCEDURES.                     SERVICE/PROCEDURE.                              BENEFITS WITH OTHER CARRIERS AND/OR
                                                                                              MAXIMUM BENEFIT PROVISIONS.
897   DENIED IN CLAIMCHECK          97        THE BENEFIT FOR THIS SERVICE IS       M144      PRE-/POST-OPERATIVE CARE PAYMENT IS 107
      AUDITING DUE TO RELATED                 INCLUDED IN THE PAYMENT/ALLOWANCE               INCLUDED IN THE ALLOWANCE FOR THE
      PROCEDURE PAID IN HISTORY.              FOR ANOTHER SERVICE/PROCEDURE                   SURGERY/PROCEDURE.
      SUBMIT ADJUSTMENT IF                    THAT HAS ALREADY BEEN ADJUDICATED.
      APPLICABLE.
898   EXCEEDS 2 PR EYE GLASSES      119       BENEFIT MAXIMUM FOR THE TIME PERIOD                                                   483
      PER 12 MO. WITH CATARACT DX             OR OCCURRENCE HAS BEEN REACHED.

899   MULTIPLE COMPOSITE                                                            N149      REBILL ALL APPLICABLE SERVICES ON A   107
      RESTORATIONS FOR THE SAME                                                               SINGLE CLAIM.
      TOOTH WERE BILLED ON
      SEPARATE CLAIMS. PLEASE
      COMBINE RESTORATIONS AND
      RESUBMIT FOR PAYMENT.




                                                                                                                                             Effective 10/22/10
                                                                           EOB TO 277 & 835



                                                                                     835                                             277
                                     835 ADJ   835 ADJUSTMENT REASON CODE            REMIT    835 REMITTANCE REMARK CODE             CLAIM
EOB   HP DESCRIPTION                 REASON    DESCRIPTION                           REMARK   DESCRIPTION                            STATUS
900   PRICING OF THIS PROCEDURE      97        THE BENEFIT FOR THIS SERVICE IS       M144     PRE-/POST-OPERATIVE CARE PAYMENT IS    107
      INCLUDES RELATED SERVICES .              INCLUDED IN THE PAYMENT/ALLOWANCE              INCLUDED IN THE ALLOWANCE FOR THE
      A RE- LATED SERVICE HAS BEEN             FOR ANOTHER SERVICE/PROCEDURE                  SURGERY/PROCEDURE.
      PAID PREVENTING PAYMENT OF               THAT HAS ALREADY BEEN ADJUDICATED.
      THIS CODE SUBMIT
      ADJUSTMENT IF APPLICABLE.

901   COMPOUND DRUG               16           CLAIM/SERVICE LACKS INFORMATION       N29      MISSING/INCOMPLETE/INVALID       216
      STRENGTH/UNITS INCOMPLETE                WHICH IS NEEDED FOR ADJUDICATION.              DOCUMENTATION/ORDERS/NOTES/SUMMA
      FOR PRICING                                                                             RY/REPORT/CHART.
      DETERMINATION.
902   DAYS SUPPLY NOT NUMERIC OR 154           PAYER DEEMS THE INFORMATION           M53      MISSING/INCOMPLETE/INVALID DAYS OR     221
      IS ZERO, OR EXCEEDS 31 DAYS              SUBMITTED DOES NOT SUPPORT THIS                UNITS OF SERVICE.
                                               DAY'S SUPPLY.
903   PAYMENT REDUCED              B5          COVERAGE/PROGRAM GUIDELINES WERE      M139     DENIED SERVICES EXCEED THE             107
      PROPORTIONATELY TO COMPLY                NOT MET OR WERE EXCEEDED.                      COVERAGE LIMIT FOR THE
      WITH MEDICAL    POLICY                                                                  DEMONSTRATION.
      QUANTITY LIMITATION.
904   THE DRUG QUANTITY ENTERED 16             CLAIM/SERVICE LACKS INFORMATION       M125     MISSING/INCOMPLETE/INVALID             476
      IN THE QUANTITY FIELD ON THE             WHICH IS NEEDED FOR ADJUDICATION.              INFORMATION ON THE PERIOD OF TIME
      CLAIM FORM WAS EITHER                                                                   FOR WHICH THE
      MISSING OR INVALID                                                                      SERVICE/SUPPLY/EQUIPMENT WILL BE
                                                                                              NEEDED.
905   DRUG NOT COVERED, CHECK        96        NON-COVERED CHARGE(S).                M119     MISSING/INCOMPLETE/INVALID/DEACTIVAT 218
      NDC, MAY BE OBSOLETE                                                                    ED/WITHDRAWN NATIONAL DRUG CODE
                                                                                              (NDC).
906   DRUG CLASSIFICATION ON       133         THE DISPOSITION OF THIS CLAIM/SERVICE MA07     THE CLAIM INFORMATION HAS ALSO BEEN 46
      REVIEW FOR BILLING PROVIDER.             IS PENDING FURTHER REVIEW.                     FORWARDED TO MEDICAID FOR REVIEW.

907   PRESCRIBING PHYSICIAN                                                          N31      MISSING/INCOMPLETE/INVALID             153
      NUMBER INVALID/MISSING.                                                                 PRESCRIBING PROVIDER IDENTIFIER.
908   2 PR EYEGLASSES PER 12         119       BENEFIT MAXIMUM FOR THE TIME PERIOD                                                   483
      MONTHS UNDER AGE 21.                     OR OCCURRENCE HAS BEEN REACHED.

909   COMPOUND DRUG NOT              96        NON-COVERED CHARGE(S).                M119     MISSING/INCOMPLETE/INVALID/DEACTIVAT   216
      COVERED                                                                                 ED/WITHDRAWN NATIONAL DRUG CODE
                                                                                              (NDC).
910   NDC MISSING OR INVALID                                                         M119     MISSING/INCOMPLETE/INVALID/DEACTIVAT   218
                                                                                              ED/WITHDRAWN NATIONAL DRUG CODE
                                                                                              (NDC).
911   REFILL INDICATOR MISSING OR    16        CLAIM/SERVICE LACKS INFORMATION       N29      MISSING/INCOMPLETE/INVALID             216
      INVALID.                                 WHICH IS NEEDED FOR ADJUDICATION.              DOCUMENTATION/ORDERS/NOTES/SUMMA
                                                                                              RY/REPORT/CHART.
912   TAKE HOME DRUGS DENIED         96        NON-COVERED CHARGE(S).                M119     MISSING/INCOMPLETE/INVALID/DEACTIVAT   216
                                                                                              ED/WITHDRAWN NATIONAL DRUG CODE
                                                                                              (NDC).




                                                                                                                                              Effective 10/22/10
                                                                        EOB TO 277 & 835



                                                                                  835                                             277
                                  835 ADJ   835 ADJUSTMENT REASON CODE            REMIT    835 REMITTANCE REMARK CODE             CLAIM
EOB   HP DESCRIPTION              REASON    DESCRIPTION                           REMARK   DESCRIPTION                            STATUS
913   PRESCRIPTION NUMBER INVALID 16        CLAIM/SERVICE LACKS INFORMATION       N29      MISSING/INCOMPLETE/INVALID             219
      OR MISSING.                           WHICH IS NEEDED FOR ADJUDICATION.              DOCUMENTATION/ORDERS/NOTES/SUMMA
                                                                                           RY/REPORT/CHART.
914   NDC NOT LISTED IN REDBOOK                                                   M119     MISSING/INCOMPLETE/INVALID/DEACTIVAT   218
      OR BLUEBOOK. CHECK NDC                                                               ED/WITHDRAWN NATIONAL DRUG CODE
      AND    RESUBMIT ALONG WITH                                                           (NDC).
      THE MANUFACTURERS NAME.

915   DESI DRUG NOT PAYABLE BY       96     NON-COVERED CHARGE(S).                M119     MISSING/INCOMPLETE/INVALID/DEACTIVAT 218
      MEDICAID                                                                             ED/WITHDRAWN NATIONAL DRUG CODE
                                                                                           (NDC).
916   NDC NUMBER OBSOLETE.                                                        M119     MISSING/INCOMPLETE/INVALID/DEACTIVAT 218
      REBILL USING CURRENT NDC.                                                            ED/WITHDRAWN NATIONAL DRUG CODE
                                                                                           (NDC).
917   PRESCRIBING PHYSICIAN          173    SERVICE WAS NOT PRESCRIBED BY A       N29      MISSING/INCOMPLETE/INVALID           91
      INVALID/MISSING. EFFECTIVE            PHYSICIAN.                                     DOCUMENTATION/ORDERS/NOTES/SUMMA
      FOR CLAIMS WITH DATES OF                                                             RY/REPORT/CHART.
      SERVICE ON OR AFTER 6/1/89
      CLAIMS WILL DENY.
918   BENEFITS FOR AID CATEGORY =                                                 N30      PATIENT INELIGIBLE FOR THIS SERVICE.   88
      99 RECIPIENTS ARE LIMITED TO
       PRESCRIPTION DRUGS ONLY.

919   OVER THE COUNTER               96     NON-COVERED CHARGE(S).                N30      PATIENT INELIGIBLE FOR THIS SERVICE.   88
      PRESCRIPTION NOT PAYABLE
      TO LONG TERM CARE
      RECIPIENTS.
920   EXCEEDS ONE REPAIR PER 12      119    BENEFIT MAXIMUM FOR THE TIME PERIOD                                                   483
      MONTHS AGE 21 AND OLDER               OR OCCURRENCE HAS BEEN REACHED.

921   COVERAGE RESTRICTED DRUG       B5     COVERAGE/PROGRAM GUIDELINES WERE      M139     DENIED SERVICES EXCEED THE             216
      BILLED WITHOUT COVERAGE               NOT MET OR WERE EXCEEDED.                      COVERAGE LIMIT FOR THE
      RESTRICTED INDICATOR                                                                 DEMONSTRATION.

922   CLAIM MUST BE BILLED THRU                                                   M117     NOT COVERED UNLESS SUBMITTED VIA       481
      AEVCS                                                                                ELECTRONIC CLAIM.
923   EXCEEDS LIMIT OF 2 REPAIRS     119    BENEFIT MAXIMUM FOR THE TIME PERIOD                                                   483
      PER 12 MONTHS UNDER AGE 21            OR OCCURRENCE HAS BEEN REACHED.

924   PROCEDURE CODE REQUIRES   16          CLAIM/SERVICE LACKS INFORMATION       M119     MISSING/INCOMPLETE/INVALID/DEACTIVAT 218
      NDC(S) FOR ADMINISTERED               WHICH IS NEEDED FOR ADJUDICATION.              ED/WITHDRAWN NATIONAL DRUG CODE
      DRUG                                                                                 (NDC).
925   PROCEDURE CODE AND NDC DO 16          CLAIM/SERVICE LACKS INFORMATION       M119     MISSING/INCOMPLETE/INVALID/DEACTIVAT 218
      NOT MATCH                             WHICH IS NEEDED FOR ADJUDICATION.              ED/WITHDRAWN NATIONAL DRUG CODE
                                                                                           (NDC).




                                                                                                                                           Effective 10/22/10
                                                                           EOB TO 277 & 835



                                                                                     835                                             277
                                     835 ADJ   835 ADJUSTMENT REASON CODE            REMIT    835 REMITTANCE REMARK CODE             CLAIM
EOB   HP DESCRIPTION                 REASON    DESCRIPTION                           REMARK   DESCRIPTION                            STATUS
926   NDC &/OR LABELER NOT           B5        COVERAGE/PROGRAM GUIDELINES WERE      M119     MISSING/INCOMPLETE/INVALID/DEACTIVAT   218
      QUALIFIED FOR REBATE OR IS               NOT MET OR WERE EXCEEDED.                      ED/WITHDRAWN NATIONAL DRUG CODE
      OUTSIDE REBATE DATES                                                                    (NDC).
927   INCORRECT PROCEDURE CODE       16        CLAIM/SERVICE LACKS INFORMATION       M119     MISSING/INCOMPLETE/INVALID/DEACTIVAT   218
      FOR NDC BILLED.                          WHICH IS NEEDED FOR ADJUDICATION.              ED/WITHDRAWN NATIONAL DRUG CODE
                                                                                              (NDC).
928   NON LEGEND ITEM NOT            96        NON-COVERED CHARGE(S).                N59      ATTN: PLEASE REFER TO YOUR PROVIDER    84
      INCLUDED IN PROGRAM.                                                                    MANUAL FOR ADDITIONAL PROGRAM AND
                                                                                              PROVIDER INFORMATION.

929   PROCEDURE CODE-64763           35        LIFETIME BENEFIT MAXIMUM HAS BEEN                                                     483
      ALLOWED ONLY TWICE IN A                  REACHED.
      LIFETIME
930   DRUG NOT PAYABLE UNDER         96        NON-COVERED CHARGE(S).                M119     MISSING/INCOMPLETE/INVALID/DEACTIVAT 218
      TITLE XIX                                                                               ED/WITHDRAWN NATIONAL DRUG CODE
                                                                                              (NDC).
931   NAME BRAND DRUG BILLED         50        THESE ARE NON-COVERED SERVICES        N170     A NEW/REVISED/RENEWED CERTIFICATE    287
      WITHOUT MEDICAL NECESSITY                BECAUSE THIS IS NOT DEEMED A                   OF MEDICAL NECESSITY IS NEEDED.
                                               'MEDICAL NECESSITY' BY THE PAYER.
932   PAYMENT REDUCED TO         B10           ALLOWED AMOUNT HAS BEEN REDUCED                                                       65
      MAXIMUM ALLOWED MINUS                    BECAUSE A COMPONENT OF THE BASIC
      AMOUNT PREVIOUSLY PAID FOR               PROCEDURE/TEST WAS PAID. THE
      BITEWINGS.                               BENEFICIARY IS NOT LIABLE FOR MORE
                                               THAN THE CHARGE LIMIT FOR THE BASIC
                                               PROCEDURE/TEST.
933   ONE PAIR EYE GLASSES EVERY     119       BENEFIT MAXIMUM FOR THE TIME PERIOD   M90      NOT COVERED MORE THAN ONCE IN A 12     483
      12 MONTHS FOR RECIPIENTS                 OR OCCURRENCE HAS BEEN REACHED.                MONTH PERIOD.
      AGE 21 AND OLDER

934   ALS NON-PAYABLE SAME DOS       A1        CLAIM DENIED CHARGES.                 N20      SERVICE NOT PAYABLE WITH OTHER         107
      AS BLS                                                                                  SERVICE RENDERED ON THE SAME DATE.

935   PAYMENT EXCEEDS MAXIMUM        119       BENEFIT MAXIMUM FOR THE TIME PERIOD   M86      SERVICE DENIED BECAUSE PAYMENT         483
      OF $200.00 PER CALENDAR                  OR OCCURRENCE HAS BEEN REACHED.                ALREADY MADE FOR SAME/SIMILAR
      MONTH                                                                                   PROCEDURE WITHIN SET TIME FRAME.
936   NO JUSTIFICATION FOR BILLING   4         THE PROCEDURE CODE IS INCONSISTENT                                                    453
      "9" MODIFIER                             WITH THE MODIFIER USED OR A
                                               REQUIRED MODIFIER IS MISSING.

937   INTEGRATED GROUP SUPPORT       119       BENEFIT MAXIMUM FOR THE TIME PERIOD   M86      SERVICE DENIED BECAUSE PAYMENT         483
      LIMITED TO $102.00 PER DATE              OR OCCURRENCE HAS BEEN REACHED.                ALREADY MADE FOR SAME/SIMILAR
      OF SERVICE.                                                                             PROCEDURE WITHIN SET TIME FRAME.
938   EXCEEDS LIMIT OF TWO           119       BENEFIT MAXIMUM FOR THE TIME PERIOD   M86      SERVICE DENIED BECAUSE PAYMENT         483
      PODIATRY VISITS PER SFY.                 OR OCCURRENCE HAS BEEN REACHED.                ALREADY MADE FOR SAME/SIMILAR
                                                                                              PROCEDURE WITHIN SET TIME FRAME.




                                                                                                                                              Effective 10/22/10
                                                                           EOB TO 277 & 835



                                                                                    835                                              277
                                    835 ADJ   835 ADJUSTMENT REASON CODE            REMIT     835 REMITTANCE REMARK CODE             CLAIM
EOB   HP DESCRIPTION                REASON    DESCRIPTION                           REMARK    DESCRIPTION                            STATUS
939   BLS NON-PAYABLE SAME DOS      A1        CLAIM DENIED CHARGES.                 N20       SERVICE NOT PAYABLE WITH OTHER         107
      AS ALS                                                                                  SERVICE RENDERED ON THE SAME DATE.

940   RECIPIENT AGE 65 OR OLDER     96        NON-COVERED CHARGE(S).                N30       PATIENT INELIGIBLE FOR THIS SERVICE.   88
      NOT ENTITLED TO INPATIENT
      PSYCHIATRIC SERVICES
941   RECIPIENT COST SHARE          177       PATIENT HAS NOT MET THE REQUIRED                                                       483
      AMOUNT CUT BACK MONTHLY                 ELIGIBILITY REQUIREMENTS.
      COST SHARE LIMIT REACHED
942   INJECTION REQUIRES SPECIFIC   11        THE DIAGNOSIS IS INCONSISTENT WITH    MA63      MISSING/INCOMPLETE/INVALID PRINCIPAL   255
      DIAGNOSIS CODE                          THE PROCEDURE.                                  DIAGNOSIS.
943   W1 RECIPIENT NOT ELIGIBLE     96        NON-COVERED CHARGE(S).                N30       PATIENT INELIGIBLE FOR THIS SERVICE.   88
      FOR TCM SERVICE
944   CLAIM CAN NOT BE PROCESSED                                                    M53       MISSING/INCOMPLETE/INVALID DAYS OR     476
      WITHOUT UNITS ENTERED ON                                                                UNITS OF SERVICE.
      CLAIM FORM.
945   A VALID CLIA NUMBER IS                                                        MA51      MISSING/INCOMPLETE/INVALID CLIA        142
      REQUIRED FOR THIS                                                                       CERTIFICATION NUMBER FOR
      PROCEDURE                                                                               LABORATORY SERVICES BILLED BY
                                                                                              PHYSICIAN OFFICE LABORATORY.
946   ELIGIBLE FOR MEDICARE ONLY. 129         PRIOR PROCESSING INFORMATION          N30       PATIENT INELIGIBLE FOR THIS SERVICE.   109
      NO MEDICAID OR QMB BENEFITS.            APPEARS INCORRECT.

947   VISUAL OFFICE MEDICAL SERV    119       BENEFIT MAXIMUM FOR THE TIME PERIOD   M86       SERVICE DENIED BECAUSE PAYMENT         483
      LTD TO TWO PER SFY                      OR OCCURRENCE HAS BEEN REACHED.                 ALREADY MADE FOR SAME/SIMILAR
                                                                                              PROCEDURE WITHIN SET TIME FRAME.
948   PERSONAL CARE LIMITED TO 40 119         BENEFIT MAXIMUM FOR THE TIME PERIOD   M86       SERVICE DENIED BECAUSE PAYMENT         483
      UNITS PER MONTH WITHOUT PA.             OR OCCURRENCE HAS BEEN REACHED.                 ALREADY MADE FOR SAME/SIMILAR
                                                                                              PROCEDURE WITHIN SET TIME FRAME.
949   PULPOTOMY/PUPAL               119       BENEFIT MAXIMUM FOR THE TIME PERIOD   M86       SERVICE DENIED BECAUSE PAYMENT         107
      DEBRIDEMENT NOT PAYABLE                 OR OCCURRENCE HAS BEEN REACHED.                 ALREADY MADE FOR SAME/SIMILAR
      WITH IN TWO YEARS OF ROOT                                                               PROCEDURE WITHIN SET TIME FRAME.
      CANAL (SAME TOOTH).
950   ARKIDS FIRST-B PARTICIPANT    119       BENEFIT MAXIMUM FOR THE TIME PERIOD   M86       SERVICE DENIED BECAUSE PAYMENT         483
      CUMULATIVE ALLOWED                      OR OCCURRENCE HAS BEEN REACHED.                 ALREADY MADE FOR SAME/SIMILAR
      EXCEEDS $2500 FOR SFY '99                                                               PROCEDURE WITHIN SET TIME FRAME.
      FOR OUTPATIENT MENTAL AND
      BEHAVIORAL HEALTH
      SERVICES.
951   CLAIM CANNOT SPAN TWO                                                         N74       RESUBMIT WITH MULTIPLE CLAIMS, EACH    187
      MONTHS. PLEASE REBILL AS                                                                CLAIM COVERING SERVICES PROVIDED IN
      MULTIPLE CLAIMS.                                                                        ONLY ONE CALENDAR MONTH.

952   SERVICE REQUIRES PRIMARY                                                      M68       MISSING/INCOMPLETE/INVALID             94
      CARE PHYSICIAN REFERRAL.                                                                ATTENDING, ORDERING, RENDERING,
                                                                                              SUPERVISING OR REFERRING PHYSICIAN
                                                                                              IDENTIFICATION.




                                                                                                                                              Effective 10/22/10
                                                                            EOB TO 277 & 835



                                                                                       835                                             277
                                    835 ADJ   835 ADJUSTMENT REASON CODE               REMIT    835 REMITTANCE REMARK CODE             CLAIM
EOB   HP DESCRIPTION                REASON    DESCRIPTION                              REMARK   DESCRIPTION                            STATUS
953   ONLY ONE CHIROPRACTIC X-      119       BENEFIT MAXIMUM FOR THE TIME PERIOD      M90      NOT COVERED MORE THAN ONCE IN A 12     483
      RAY PER STATE FISCAL YEAR.              OR OCCURRENCE HAS BEEN REACHED.                   MONTH PERIOD.

954   ROOT CANAL NOT PAYABLE        119       BENEFIT MAXIMUM FOR THE TIME PERIOD      M86      SERVICE DENIED BECAUSE PAYMENT         107
      WITH IN TWO YEARS OF                    OR OCCURRENCE HAS BEEN REACHED.                   ALREADY MADE FOR SAME/SIMILAR
      PULPOTAMY/PUPAL                                                                           PROCEDURE WITHIN SET TIME FRAME.
      DEBRIDEMENT (SAME TOOTH).
955   A PAID PANEL CODE PREVENTS    97        THE BENEFIT FOR THIS SERVICE IS          M126     MISSING/INCOMPLETE/INVALID INDIVIDUAL 419
      PAYMENT OF THIS INDIVIDUAL              INCLUDED IN THE PAYMENT/ALLOWANCE                 LAB CODES INCLUDED IN THE TEST.
      TEST FOR SAME DATE OF                   FOR ANOTHER SERVICE/PROCEDURE
      SERVICE.                                THAT HAS ALREADY BEEN ADJUDICATED.

956   ABSENCE OF ANESTHESIA         107       THE RELATED OR QUALIFYING                M20      MISSING/INCOMPLETE/INVALID HCPCS.      42
      PROCEDURE CODE PREVENTS                 CLAIM/SERVICE WAS NOT IDENTIFIED ON
      PAYMENT OF CLAIM.                       THIS CLAIM.

957   PANEL TEST NONPAYABLE IN      97        THE BENEFIT FOR THIS SERVICE IS                                                          419
      ADDITION TO INDIVIDUAL OR               INCLUDED IN THE PAYMENT/ALLOWANCE
      PANEL TEST ON THE SAME                  FOR ANOTHER SERVICE/PROCEDURE
      DOS.                                    THAT HAS ALREADY BEEN ADJUDICATED.

958   CLAIM EXCEEDS LIMIT OF        119       BENEFIT MAXIMUM FOR THE TIME PERIOD                                                      483
      $250.00 PER CALENDAR MONTH              OR OCCURRENCE HAS BEEN REACHED.
      FOR     MEDICAL SUPPLIES.

959   CLAIM EXCEEDS LIMIT OF $80.00 119       BENEFIT MAXIMUM FOR THE TIME PERIOD                                                      483
      PER CALENDAR MONTH FOR                  OR OCCURRENCE HAS BEEN REACHED.
      MEDICAL SUPPLIES.
960   ONLY LTC PROVIDERS MAY BILL B7          THIS PROVIDER WAS NOT                                                                    88
      FOR NON-HOSPICE PATIENT LTC             CERTIFIED/ELIGIBLE TO BE PAID FOR THIS
        SERVICES.                             PROCEDURE/SERVICE ON THIS DATE OF
                                              SERVICE.
961   HOSPICE RECIPIENT IS NOT                                                         N30      PATIENT INELIGIBLE FOR THIS SERVICE.   88
      MEDICAID AND MEDICARE PART
      A    ELIGIBLE.
962   PAID PANEL CODE 77419         97        THE BENEFIT FOR THIS SERVICE IS                                                          419
      PREVENTS PAYMENT OF THIS                INCLUDED IN THE PAYMENT/ALLOWANCE
      RELATED     PROCEDURE CODE              FOR ANOTHER SERVICE/PROCEDURE
      FOR SAME DOS.                           THAT HAS ALREADY BEEN ADJUDICATED.

963   77419 NONPAYABLE ON SAME                                                         M86      SERVICE DENIED BECAUSE PAYMENT         107
      DOS AS PAID CODES 77420-                                                                  ALREADY MADE FOR SAME/SIMILAR
      77431.                                                                                    PROCEDURE WITHIN SET TIME FRAME.




                                                                                                                                                Effective 10/22/10
                                                                              EOB TO 277 & 835



                                                                                         835                                            277
                                      835 ADJ   835 ADJUSTMENT REASON CODE               REMIT    835 REMITTANCE REMARK CODE            CLAIM
EOB   HP DESCRIPTION                  REASON    DESCRIPTION                              REMARK   DESCRIPTION                           STATUS
964   EFFECTIVE 2/8/97, DRUG CLAIMS                                                      M117     NOT COVERED UNLESS SUBMITTED VIA      481
      MUST BE BILLED THROUGH                                                                      ELECTRONIC CLAIM.
      AEVCS. PAPER CLAIMS MAY BE
      SUBMITTED WHEN NECESSARY.

965   ONLY HOSPICE PROVIDERS MAY B7             THIS PROVIDER WAS NOT                                                                   88
      BILL FOR LTC HOSPICE PATIENT              CERTIFIED/ELIGIBLE TO BE PAID FOR THIS
        SERVICES.                               PROCEDURE/SERVICE ON THIS DATE OF
                                                SERVICE.
966   EXCEEDS BENEFIT LIMIT OF        119       BENEFIT MAXIMUM FOR THE TIME PERIOD                                                     483
      THREE PER LIFETIME                        OR OCCURRENCE HAS BEEN REACHED.

967   01996-PAIN MANAGEMENT           119       BENEFIT MAXIMUM FOR THE TIME PERIOD      M86      SERVICE DENIED BECAUSE PAYMENT        483
      LIMITED TO ONCE PER DOS.                  OR OCCURRENCE HAS BEEN REACHED.                   ALREADY MADE FOR SAME/SIMILAR
                                                                                                  PROCEDURE WITHIN SET TIME FRAME.
968   NOT ENROLLED AS EPSDT       B7            THIS PROVIDER WAS NOT                    N34      INCORRECT CLAIM FORM/FORMAT FOR       481
      PROVIDER. RESUBMIT CLAIM ON               CERTIFIED/ELIGIBLE TO BE PAID FOR THIS            THIS SERVICE.
      DIFFERENT CLAIM FORM.                     PROCEDURE/SERVICE ON THIS DATE OF
                                                SERVICE.
969   ROOM AND BOARD REVENUE                                                             M50      MISSING/INCOMPLETE/INVALID REVENUE    455
      CODE(S) NOT ALLOWED WITH                                                                    CODE(S).
      REVENUE CODE 128, 129 OR 249.

970   BILLING PERIOD CANNOT SPAN                                                         N61      REBILL SERVICES ON SEPARATE CLAIMS.   187
      TWO LOC. PLEASE RESUBMIT
      WITH EACH LOC AS A SEPARATE
      DETAIL OR CLAIM.
971   ANESTHESIOLOGIST MAY NOT      97          THE BENEFIT FOR THIS SERVICE IS                                                         107
      RECEIVE PAYMENT FOR                       INCLUDED IN THE PAYMENT/ALLOWANCE
      HOSPITAL VISITSIN ADDITION TO             FOR ANOTHER SERVICE/PROCEDURE
      PAIN MANAGEMENT.                          THAT HAS ALREADY BEEN ADJUDICATED.

972   EXCEEDS LIMIT OF THREE UNITS 119          BENEFIT MAXIMUM FOR THE TIME PERIOD                                                     483
      PER DOS FOR INDIVIDUAL                    OR OCCURRENCE HAS BEEN REACHED.
      SPEECH SESSIONS.

973   EXCEEDS LIMIT OF 4 SPEECH       119       BENEFIT MAXIMUM FOR THE TIME PERIOD                                                     483
      EVALUATIONS PER STATE                     OR OCCURRENCE HAS BEEN REACHED.
      FISCAL YEAR.
974   EXCEEDS LIMIT OF ONE            119       BENEFIT MAXIMUM FOR THE TIME PERIOD                                                     483
      PHYSICAL THERAPY                          OR OCCURRENCE HAS BEEN REACHED.
      EVALUATION PER SFY.
975   EXCEEDS LIMIT OF ONE            119       BENEFIT MAXIMUM FOR THE TIME PERIOD                                                     483
      OCCUPATIONAL THERAPY                      OR OCCURRENCE HAS BEEN REACHED.
      EVALUATION




                                                                                                                                                 Effective 10/22/10
                                                                           EOB TO 277 & 835



                                                                                      835                                             277
                                   835 ADJ   835 ADJUSTMENT REASON CODE               REMIT    835 REMITTANCE REMARK CODE             CLAIM
EOB   HP DESCRIPTION               REASON    DESCRIPTION                              REMARK   DESCRIPTION                            STATUS
976   EXCEEDS LIMIT OF THREE UNITS 119       BENEFIT MAXIMUM FOR THE TIME PERIOD                                                      483
      PER DOS FOR INDIVIDUAL                 OR OCCURRENCE HAS BEEN REACHED.
      OCCUPATIONAL THERAPY.

977   EXCEEDS LIMIT OF O.T.           119    BENEFIT MAXIMUM FOR THE TIME PERIOD                                                      483
      EVALUATION PER SFY                     OR OCCURRENCE HAS BEEN REACHED.

978   IN RELATION TO EFFECTIVE        B7     THIS PROVIDER WAS NOT                    N95      THIS PROVIDER TYPE/PROVIDER            145
      DATE OF PROVIDER SPECIALTY,            CERTIFIED/ELIGIBLE TO BE PAID FOR THIS            SPECIALTY MAY NOT BILL THIS SERVICE.
          PROVIDER IS INELIGIBLE TO          PROCEDURE/SERVICE ON THIS DATE OF
      RENDER THIS SERVICE.                   SERVICE.

979   FORM EMS-2698 MUST BE           17     REQUESTED INFORMATION WAS NOT            N29      MISSING/INCOMPLETE/INVALID             294
      COMPLETED AND ATTACHED TO              PROVIDED OR WAS                                   DOCUMENTATION/ORDERS/NOTES/SUMMA
      THE CLAIM.                             INSUFFICIENT/INCOMPLETE.                          RY/REPORT/CHART.
980   FORM EMS-2698 MUST INCLUDE      17     REQUESTED INFORMATION WAS NOT            N29      MISSING/INCOMPLETE/INVALID             294
      THE NAME AND ADDRESS OF                PROVIDED OR WAS                                   DOCUMENTATION/ORDERS/NOTES/SUMMA
      THE   PATIENT.                         INSUFFICIENT/INCOMPLETE.                          RY/REPORT/CHART.
981   FORM EMS-2698 MUST BE           17     REQUESTED INFORMATION WAS NOT            N29      MISSING/INCOMPLETE/INVALID             294
      COMPLETED PRIOR TO THE                 PROVIDED OR WAS                                   DOCUMENTATION/ORDERS/NOTES/SUMMA
      PROCEDURE.                             INSUFFICIENT/INCOMPLETE.                          RY/REPORT/CHART.
982   SECTION I OF FORM EMS-2698 IS   17     REQUESTED INFORMATION WAS NOT            N29      MISSING/INCOMPLETE/INVALID             294
      INCOMPLETE.                            PROVIDED OR WAS                                   DOCUMENTATION/ORDERS/NOTES/SUMMA
                                             INSUFFICIENT/INCOMPLETE.                          RY/REPORT/CHART.
983   SECTION II OF FORM EMS-2698     17     REQUESTED INFORMATION WAS NOT            N29      MISSING/INCOMPLETE/INVALID             294
      IS INCOMPLETE.                         PROVIDED OR WAS                                   DOCUMENTATION/ORDERS/NOTES/SUMMA
                                             INSUFFICIENT/INCOMPLETE.                          RY/REPORT/CHART.
984   00857/00955 NOT PAYABLE SAME                                                    M86      SERVICE DENIED BECAUSE PAYMENT         107
      DOS AS 62278/62279.                                                                      ALREADY MADE FOR SAME/SIMILAR
                                                                                               PROCEDURE WITHIN SET TIME FRAME.
985   62278/62279 NOT PAYABLE SAME                                                    M86      SERVICE DENIED BECAUSE PAYMENT         107
      DOS AS 00857/00955.                                                                      ALREADY MADE FOR SAME/SIMILAR
                                                                                               PROCEDURE WITHIN SET TIME FRAME.
986   FQHC CLAIMS WITH DOS                                                            N61      REBILL SERVICES ON SEPARATE CLAIMS.    187
      SPANNING 11/01/94 MUST BE
      SPLIT AND REBILLED.
987   EXCEEDS BENEFIT LIMIT OF ONE 119       BENEFIT MAXIMUM FOR THE TIME PERIOD                                                      483
      PER THREE YEARS                        OR OCCURRENCE HAS BEEN REACHED.

988   OB/ROUTINE NEWBORN CARE         177    PATIENT HAS NOT MET THE REQUIRED                                                         84
      SERVICES IN WAIVER COUNTY              ELIGIBILITY REQUIREMENTS.
      REQUIRES WAIVER COUNTY
      CONTRACT HOSPITAL.
989   PATIENT REQUIRES WAIVER         177    PATIENT HAS NOT MET THE REQUIRED                                                         84
      COUNTY CONTRACT HOSPITAL               ELIGIBILITY REQUIREMENTS.
      FOR OB/ ROUTINE NEWBORN
      CARE SERVICES.




                                                                                                                                               Effective 10/22/10
                                                                            EOB TO 277 & 835



                                                                                       835                                           277
                                    835 ADJ   835 ADJUSTMENT REASON CODE               REMIT    835 REMITTANCE REMARK CODE           CLAIM
EOB   HP DESCRIPTION                REASON    DESCRIPTION                              REMARK   DESCRIPTION                          STATUS
990   INVALID REVENUE CODE FOR      8         THE PROCEDURE CODE IS INCONSISTENT       M50      MISSING/INCOMPLETE/INVALID REVENUE   455
      PROVIDER SPECIALTY. CHECK               WITH THE PROVIDER TYPE/SPECIALTY                  CODE(S).
      FOR CORRECT BILLING                     (TAXONOMY).
      PROVIDER NUMBER.
991   INVALID TYPE OF ADMISSION   16          CLAIM/SERVICE LACKS INFORMATION          MA41     MISSING/INCOMPLETE/INVALID ADMISSION 231
      CODE.                                   WHICH IS NEEDED FOR ADJUDICATION.                 TYPE.
992   RECIPIENT MUST BE UNDER AGE 8           THE PROCEDURE CODE IS INCONSISTENT       N95      THIS PROVIDER TYPE/PROVIDER          88
      21 TO BILL USING PROVIDER               WITH THE PROVIDER TYPE/SPECIALTY                  SPECIALTY MAY NOT BILL THIS SERVICE.
      SPECIALTY RC.                           (TAXONOMY).
993   PROVIDER SPECIALTIES RC OR  B7          THIS PROVIDER WAS NOT                                                                  455
      RH CAN ONLY BILL WITH                   CERTIFIED/ELIGIBLE TO BE PAID FOR THIS
      REVENUE CODE 249. CHECK                 PROCEDURE/SERVICE ON THIS DATE OF
      FOR CORRECT BILLING                     SERVICE.
      PROVIDER NUMBER.
994   CLAIM PAID AT MAXIMUM      150          PAYER DEEMS THE INFORMATION                                                            65
      ALLOWABLE PAS OR PSRO DAYS              SUBMITTED DOES NOT SUPPORT THIS
      FOR PERCENTAGE ON FILE.                 LEVEL OF SERVICE.

995   CLAIM PAYMENT REDUCED DUE     178       PATIENT HAS NOT MET THE REQUIRED                                                       68
      TO RECIPIENT'S SPENDDOWN                SPEND DOWN REQUIREMENTS.
      AMOUNT.
996   CLAIMS REIMBURSED             B5        COVERAGE/PROGRAM GUIDELINES WERE                                                       65
      ACCORDING TO ADEMS                      NOT MET OR WERE EXCEEDED.
      GUIDELINES.
997   RECIPIENT 21 OR OVER ON DOS   N30       PATIENT INELIGIBLE FOR THIS SERVICE.                                                   109
      NOT ELIGIBLE FOR EPSDT
      SERVICES.
998   CLAIM PAID AT MAXIMUM         119       BENEFIT MAXIMUM FOR THE TIME PERIOD                                                    483
      ALLOWABLE DAYS.                         OR OCCURRENCE HAS BEEN REACHED.

999   CLAIM HAS BEEN SUSPENDED      133       THE DISPOSITION OF THIS CLAIM/SERVICE                                                  20
      TEMPORARILY AND WILL                    IS PENDING FURTHER REVIEW.
      RELEASE NEXT CYCLE.




                                                                                                                                              Effective 10/22/10
                                                                      EOB TO 277 & 835



Arkansas Medicaid Revised 03/16/12


                                     277
                                     CLAIM
277 CLAIM STATUS CODE DESCRIPTION    STATUS   277 CLAIM STATUS CODE DESCRIPTION
STATEMENT FROM-THROUGH DATES.

FACILITY ADMISSION DATE.


STATEMENT FROM-THROUGH DATES.

DATE(S) OF SERVICE.


DATE(S) OF SERVICE.


FACILITY DISCHARGE DATE.


STATEMENT FROM-THROUGH DATES.


NO PAYMENT WILL BE MADE FOR THIS
CLAIM.


NO PAYMENT WILL BE MADE FOR THIS
CLAIM.

MAXIMUM LEAVE DAYS EXHAUSTED.

MISSING OR INVALID INFORMATION.      554      DATE CLAIM PAID

NUBC CONDITION CODE(S).




LINE INFORMATION.




ACCEPTED FOR PROCESSING.




                                                                                         Effective 10/22/10
                                                                         EOB TO 277 & 835



                                        277
                                        CLAIM
277 CLAIM STATUS CODE DESCRIPTION       STATUS   277 CLAIM STATUS CODE DESCRIPTION




MISSING OR INVALID INFORMATION.         677      ENTITY NOT AFFILIATED


NUBC CONDITION CODE(S).




DUPLICATE OF A PREVIOUSLY
PROCESSED CLAIM/LINE.




MISSING OR INVALID INFORMATION.         294      SUPPORTING DOCUMENTATION.


LINE INFORMATION.

OTHER INSURANCE COVERAGE
INFORMATION (HEALTH, LIABILITY, AUTO,
ETC).

COVERED DAY(S).


COVERED DAY(S).




CLAIM IS OUT OF BALANCE.

PATIENT DISCHARGE STATUS.

TYPE OF SERVICE.


SUPPORTING DOCUMENTATION.




                                                                                            Effective 10/22/10
                                                                        EOB TO 277 & 835



                                       277
                                       CLAIM
277 CLAIM STATUS CODE DESCRIPTION      STATUS   277 CLAIM STATUS CODE DESCRIPTION
AUTHORIZATION/CERTIFICATION NUMBER.




CLAIM WAS PROCESSED AS ADJUSTMENT
TO PREVIOUS CLAIM.




SERVICE NOT AUTHORIZED.




NUBC CONDITION CODE(S).




CLAIM/LINE HAS BEEN PAID.




ENTITY NOT ELIGIBLE.

MISSING OR INVALID UNITS OF SERVICE.


MISSING OR INVALID UNITS OF SERVICE.

SERVICE NOT AUTHORIZED.




STATEMENT FROM-THROUGH DATES.


CLAIM/SUBMISSION FORMAT IS INVALID.

TYPE OF SERVICE.




                                                                                           Effective 10/22/10
                                                                         EOB TO 277 & 835



                                        277
                                        CLAIM
277 CLAIM STATUS CODE DESCRIPTION       STATUS   277 CLAIM STATUS CODE DESCRIPTION
TYPE OF SERVICE.




INTERNAL REVIEW/AUDIT.


AUTHORIZATION/CERTIFICATION NUMBER.

OTHER INSURANCE COVERAGE
INFORMATION (HEALTH, LIABILITY, AUTO,
ETC).
CLAIM SUBMISSION FORMAT IS INVALID.




SERVICE NOT AUTHORIZED.




THIS AMOUNT IS NOT ENTITY'S
RESPONSIBILITY.

PARTIAL PAYMENT MADE FOR THIS CLAIM.


PROCESSED ACCORDING TO
CONTRACT/PLAN PROVISIONS.


PROCESSED ACCORDING TO
CONTRACT/PLAN PROVISIONS.


MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.

MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.




                                                                                            Effective 10/22/10
                                                                     EOB TO 277 & 835



                                    277
                                    CLAIM
277 CLAIM STATUS CODE DESCRIPTION   STATUS   277 CLAIM STATUS CODE DESCRIPTION
PROCESSED ACCORDING TO
CONTRACT/PLAN PROVISIONS.




PROCEDURE CODE NOT VALID FOR
PATIENT AGE.

ENTITY'S MEDICAID PROVIDER ID.


MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.

MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.

CLAIM HAS BEEN ADJUDICATED AND IS
AWAITING PAYMENT CYCLE.
INTERNAL REVIEW/AUDIT.


DATE(S) OF SERVICE.




PAYMENT MADE IN FULL.

MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.

DATE(S) OF SERVICE.




MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.


COVERED DAY(S).




                                                                                        Effective 10/22/10
                                                                     EOB TO 277 & 835



                                    277
                                    CLAIM
277 CLAIM STATUS CODE DESCRIPTION   STATUS   277 CLAIM STATUS CODE DESCRIPTION
MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.


MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.

MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.


MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.
NO PAYMENT WILL BE MADE FOR THIS
CLAIM.


MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.


MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.

NO PAYMENT WILL BE MADE FOR THIS
CLAIM.
PROCESSED ACCORDING TO
CONTRACT/PLAN PROVISIONS.




MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.

MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.

MISSING OR INVALID INFORMATION.     677      ENTITY NOT AFFILIATED




NO PAYMENT WILL BE MADE FOR THIS
CLAIM.




                                                                                        Effective 10/22/10
                                                                     EOB TO 277 & 835



                                    277
                                    CLAIM
277 CLAIM STATUS CODE DESCRIPTION   STATUS   277 CLAIM STATUS CODE DESCRIPTION
NO PAYMENT WILL BE MADE FOR THIS
CLAIM.


CLAIM/LINE HAS BEEN PAID.


DUPLICATE OF A PREVIOUSLY
PROCESSED CLAIM/LINE.

NO PAYMENT WILL BE MADE FOR THIS
CLAIM.


MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.

AWAITING RELATED CHARGES.




NON-COVERED DAY(S).

MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.




OPERATIVE REPORT.




MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.




MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.

FACILITY DISCHARGE DATE.

MISSING OR INVALID INFORMATION.     475      PROCEDURE CODE NOT VALID FOR PATIENT
                                             AGE.




                                                                                        Effective 10/22/10
                                                                       EOB TO 277 & 835



                                      277
                                      CLAIM
277 CLAIM STATUS CODE DESCRIPTION     STATUS   277 CLAIM STATUS CODE DESCRIPTION
MISSING OR INVALID INFORMATION.       145      ENTITY'S SPECIALTY/TAXONOMY CODE.


MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.

MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.

PROCESSED ACCORDING TO
CONTRACT/PLAN PROVISIONS.




CLAIM/SUBMISSION FORMAT IS INVALID.

CLAIM SUBMITTED TO INCORRECT PAYER.




PROCESSED ACCORDING TO
CONTRACT/PLAN PROVISIONS.

DATE(S) OF SERVICE.




NO PAYMENT WILL BE MADE FOR THIS
CLAIM.

SUPPORTING DOCUMENTATION.




NO PAYMENT WILL BE MADE FOR THIS
CLAIM.




                                                                                          Effective 10/22/10
                                                                       EOB TO 277 & 835



                                      277
                                      CLAIM
277 CLAIM STATUS CODE DESCRIPTION     STATUS   277 CLAIM STATUS CODE DESCRIPTION
NO PAYMENT WILL BE MADE FOR THIS
CLAIM.

MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.

MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.

MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.

AUTHORIZATION/CERTIFICATION NUMBER.




DATES OF SERVICE




TOTAL ANESTHESIA MINUTES.

NO PAYMENT WILL BE MADE FOR THIS
CLAIM.




CLAIM/LINE HAS BEEN PAID.




CLAIM WAS PROCESSED AS ADJUSTMENT
TO PREVIOUS CLAIM.




                                                                                          Effective 10/22/10
                                                                     EOB TO 277 & 835



                                    277
                                    CLAIM
277 CLAIM STATUS CODE DESCRIPTION   STATUS   277 CLAIM STATUS CODE DESCRIPTION
CLAIM/LINE HAS BEEN PAID.




ACCEPTED FOR PROCESSING.


DUPLICATE OF A PREVIOUSLY
PROCESSED CLAIM/LINE.


NO PAYMENT WILL BE MADE FOR THIS
CLAIM.
PROCESSED ACCORDING TO
CONTRACT/PLAN PROVISIONS.

SERVICE NOT AUTHORIZED.


CLAIM WAS PROCESSED AS ADJUSTMENT
TO PREVIOUS CLAIM.

ENTITY'S SPECIALTY/TAXONOMY CODE.




NUBC CONDITION CODE(S).




MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.




TOOTH NUMBER OR LETTER.

TOOTH SURFACE(S) INVOLVED.




                                                                                        Effective 10/22/10
                                                                      EOB TO 277 & 835



                                     277
                                     CLAIM
277 CLAIM STATUS CODE DESCRIPTION    STATUS   277 CLAIM STATUS CODE DESCRIPTION
MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.


TOOTH NUMBER OR LETTER.




MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.

MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.

SERVICE NOT AUTHORIZED.




NO PAYMENT WILL BE MADE FOR THIS
CLAIM.




MISSING OR INVALID INFORMATION.      294      SUPPORTING DOCUMENTATION.




ADDITIONAL INFORMATION REQUESTED
FROM ENTITY.

SERVICE NOT AUTHORIZED.


PLACE OF SERVICE.

PROCESSED ACCORDING TO
CONTRACT/PLAN PROVISIONS.




DIAGNOSIS CODE(S) FOR THE SERVICES
RENDERED.




                                                                                         Effective 10/22/10
                                                                      EOB TO 277 & 835



                                     277
                                     CLAIM
277 CLAIM STATUS CODE DESCRIPTION    STATUS   277 CLAIM STATUS CODE DESCRIPTION
PROCEDURE CODE FOR SERVICES
RENDERED.


PROCEDURE CODE MODIFIER(S) FOR
SERVICE(S) RENDERED.


MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.

MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.

MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.

MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.

DIAGNOSIS CODE(S) FOR THE SERVICES
RENDERED.
ENTITY NOT ELIGIBLE.




PROCEDURE CODE FOR SERVICES
RENDERED.

PLACE OF SERVICE.


PROCEDURE CODE NOT VALID FOR
PATIENT AGE.

PROCEDURE CODE AND PATIENT GENDER
MISMATCH.

PROCEDURE CODE FOR SERVICES
RENDERED.

PROCEDURE CODE FOR SERVICES
RENDERED.
DIAGNOSIS CODE(S) FOR THE SERVICES
RENDERED.




                                                                                         Effective 10/22/10
                                                                          EOB TO 277 & 835



                                       277
                                       CLAIM
277 CLAIM STATUS CODE DESCRIPTION      STATUS   277 CLAIM STATUS CODE DESCRIPTION
AMBULANCE
CERTIFICATION/DOCUMENTATION.

MISSING OR INVALID INFORMATION.        294      SUPPORTING DOCUMENTATION.




MISSING OR INVALID INFORMATION.        476      MISSING OR INVALID UNITS OF SERVICE.


DIAGNOSIS CODE(S) FOR THE SERVICES
RENDERED.
ENTITY NOT ELIGIBLE FOR BENEFITS FOR
SUBMITTED DATES OF SERVICE.


MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.

TOOTH SURFACE(S) INVOLVED.


PROCEDURE CODE FOR SERVICES
RENDERED.


DAYS/UNITS FOR PROCEDURE/REVENUE
CODE.


PROCEDURE CODE FOR SERVICES
RENDERED.

TYPE OF SERVICE.




ENTITY NOT ELIGIBLE FOR BENEFITS FOR
SUBMITTED DATES OF SERVICE.




PROCEDURE CODE FOR SERVICES
RENDERED.




                                                                                             Effective 10/22/10
                                                                         EOB TO 277 & 835



                                        277
                                        CLAIM
277 CLAIM STATUS CODE DESCRIPTION       STATUS   277 CLAIM STATUS CODE DESCRIPTION
ENTITIES ORIGINAL SIGNATURE.

PROCEDURE CODE MODIFIER(S) FOR
SERVICE(S) RENDERED.


PROCEDURE CODE FOR SERVICES
RENDERED.


PROCEDURE CODE FOR SERVICES
RENDERED.

DATE(S) OF SERVICE.


PROCESSED ACCORDING TO
CONTRACT/PLAN PROVISIONS.




DATE(S) OF SERVICE.


DATE(S) OF SERVICE.


OTHER INSURANCE COVERAGE
INFORMATION (HEALTH, LIABILITY, AUTO,
ETC).


FACILITY ADMISSION DATE.

MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.

PROCEDURE CODE FOR SERVICES
RENDERED.




                                                                                            Effective 10/22/10
                                                                     EOB TO 277 & 835



                                    277
                                    CLAIM
277 CLAIM STATUS CODE DESCRIPTION   STATUS   277 CLAIM STATUS CODE DESCRIPTION
PROCESSED ACCORDING TO
CONTRACT/PLAN PROVISIONS.




PROCESSED ACCORDING TO
CONTRACT/PLAN PROVISIONS.




NUBC CONDITION CODE(S).




PROCESSED ACCORDING TO
CONTRACT/PLAN PROVISIONS.

DAYS/UNITS FOR PROCEDURE/REVENUE
CODE.

ITEMIZED CLAIM.

PROCESSED ACCORDING TO
CONTRACT/PLAN PROVISIONS.

ENTITY NOT ELIGIBLE.


DIAGNOSIS CODE.




DIAGNOSIS CODE.




PRIMARY DIAGNOSIS CODE.

DIAGNOSIS CODE.




                                                                                        Effective 10/22/10
                                                                      EOB TO 277 & 835



                                     277
                                     CLAIM
277 CLAIM STATUS CODE DESCRIPTION    STATUS   277 CLAIM STATUS CODE DESCRIPTION
ALL CURRENT DIAGNOSES.


DIAGNOSIS CODE.


DIAGNOSIS AND PATIENT GENDER
MISMATCH.
DIAGNOSIS AND PATIENT GENDER
MISMATCH.

DIAGNOSIS CODE(S) FOR THE SERVICES
RENDERED.

MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.

MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.

ENTITY NOT ELIGIBLE.


CLAIM WAS PROCESSED AS ADJUSTMENT
TO PREVIOUS CLAIM.

DIAGNOSIS CODE.

ADMITTING DIAGNOSIS.


MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.


ENTITY'S SPECIALTY/TAXONOMY CODE.

MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.

DIAGNOSIS AND PATIENT GENDER
MISMATCH.
DIAGNOSIS CODE.

ENTITY NOT ELIGIBLE.




                                                                                         Effective 10/22/10
                                                                         EOB TO 277 & 835



                                        277
                                        CLAIM
277 CLAIM STATUS CODE DESCRIPTION       STATUS   277 CLAIM STATUS CODE DESCRIPTION
MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.


DIAGNOSIS CODE.

NO PAYMENT WILL BE MADE FOR THIS
CLAIM.
MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.

PROCESSED ACCORDING TO
CONTRACT/PLAN PROVISIONS.

MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.

ITEMIZED CLAIM.


DATE(S) OF SERVICE.

NON-COVERED DAY(S).

ENTITY NOT ELIGIBLE FOR BENEFITS FOR
SUBMITTED DATES OF SERVICE.




OTHER INSURANCE COVERAGE
INFORMATION (HEALTH, LIABILITY, AUTO,
ETC).




MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.

ENTITY NOT ELIGIBLE/NOT APPROVED
FOR DATES OF SERVICE.




                                                                                            Effective 10/22/10
                                                                       EOB TO 277 & 835



                                      277
                                      CLAIM
277 CLAIM STATUS CODE DESCRIPTION     STATUS   277 CLAIM STATUS CODE DESCRIPTION
ENTITY NOT ELIGIBLE/NOT APPROVED
FOR DATES OF SERVICE.


ENTITY NOT ELIGIBLE/NOT APPROVED
FOR DATES OF SERVICE.




SERVICE NOT AUTHORIZED.

PROCESSED ACCORDING TO
CONTRACT/PLAN PROVISIONS.


AUTHORIZATION/CERTIFICATION NUMBER.


MISSING OR INVALID INFORMATION.

ENTITY NOT ELIGIBLE/NOT APPROVED
FOR DATES OF SERVICE.




REVENUE CODE FOR SERVICES
RENDERED.


ENTITY'S LICENSE/CERTIFICATION
NUMBER.


MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.


SERVICE NOT AUTHORIZED.

MEDICAL NECESSITY FOR SERVICE.




                                                                                          Effective 10/22/10
                                                                       EOB TO 277 & 835



                                      277
                                      CLAIM
277 CLAIM STATUS CODE DESCRIPTION     STATUS   277 CLAIM STATUS CODE DESCRIPTION
ENTITY NOT ELIGIBLE/NOT APPROVED
FOR DATES OF SERVICE.




SERVICE NOT AUTHORIZED.




ENTITY NOT ELIGIBLE/NOT APPROVED
FOR DATES OF SERVICE.




ENTITY'S ID NUMBER.




ENTITY'S ID NUMBER.




AWAITING ELIGIBILITY DETERMINATION.




ENTITY'S ID NUMBER.




SERVICE NOT AUTHORIZED.


CLAIM/SUBMISSION FORMAT IS INVALID.

PROCESSED ACCORDING TO
CONTRACT/PLAN PROVISIONS.


CLAIM/SUBMISSION FORMAT IS INVALID.




                                                                                          Effective 10/22/10
                                                                        EOB TO 277 & 835



                                       277
                                       CLAIM
277 CLAIM STATUS CODE DESCRIPTION      STATUS   277 CLAIM STATUS CODE DESCRIPTION
CLAIM/SUBMISSION FORMAT IS INVALID.




MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.

MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.

ENTITY'S ID NUMBER.




ENTITY'S ID NUMBER.




ENTITY'S ID NUMBER.




MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.

ENTITY'S NAME, ADDRESS, PHONE AND ID
NUMBER.




ENTITY NOT ELIGIBLE/NOT APPROVED
FOR DATES OF SERVICE.
ENTITY NOT ELIGIBLE/NOT APPROVED
FOR DATES OF SERVICE.




                                                                                           Effective 10/22/10
                                                                        EOB TO 277 & 835



                                       277
                                       CLAIM
277 CLAIM STATUS CODE DESCRIPTION      STATUS   277 CLAIM STATUS CODE DESCRIPTION
MISSING OR INVALID INFORMATION.        294      SUPPORTING DOCUMENTATION.




ENTITY NOT ELIGIBLE/NOT APPROVED
FOR DATES OF SERVICE.




ENTITY NOT ELIGIBLE.

AWAITING ELIGIBILITY DETERMINATION.


ENTITY NOT ELIGIBLE FOR BENEFITS FOR
SUBMITTED DATES OF SERVICE.
DATE(S) OF SERVICE.




ENTITY NOT ELIGIBLE/NOT APPROVED
FOR DATES OF SERVICE.

NON-COVERED DAY(S).




ENTITY'S ID NUMBER.

OTHER PAYER'S EXPLANATION OF
BENEFITS/PAYMENT INFORMATION.




                                                                                           Effective 10/22/10
                                                                        EOB TO 277 & 835



                                       277
                                       CLAIM
277 CLAIM STATUS CODE DESCRIPTION      STATUS   277 CLAIM STATUS CODE DESCRIPTION
ENTITY NOT ELIGIBLE FOR BENEFITS FOR
SUBMITTED DATES OF SERVICE.




INTERNAL REVIEW/AUDIT.


ENTITY SIGNATURE DATE.


ENTITY NOT ELIGIBLE FOR BENEFITS FOR
SUBMITTED DATES OF SERVICE.
MISSING OR INVALID INFORMATION.        294      SUPPORTING DOCUMENTATION.


SERVICE NOT AUTHORIZED.


CLAIM/SUBMISSION FORMAT IS INVALID.


ENTITY NOT ELIGIBLE/NOT APPROVED
FOR DATES OF SERVICE.

ENTITY NOT ELIGIBLE/NOT APPROVED
FOR DATES OF SERVICE.




CLAIM/LINE HAS BEEN PAID.




ENTITY NOT ELIGIBLE/NOT APPROVED
FOR DATES OF SERVICE.


SERVICE NOT AUTHORIZED.


CLAIM WAS PROCESSED AS ADJUSTMENT
TO PREVIOUS CLAIM.




                                                                                           Effective 10/22/10
                                                                         EOB TO 277 & 835



                                        277
                                        CLAIM
277 CLAIM STATUS CODE DESCRIPTION       STATUS   277 CLAIM STATUS CODE DESCRIPTION
OTHER INSURANCE COVERAGE
INFORMATION (HEALTH, LIABILITY, AUTO,
ETC).
MISSING OR INVALID INFORMATION.         4        THIS IS A SUBSEQUENT REQUEST FOR
                                                 INFORMATION FROM THE ORIGINAL
                                                 REQUEST.




CLAIM SUBMITTED TO INCORRECT PAYER.




SERVICE NOT AUTHORIZED.

CLAIM SUBMITTED TO INCORRECT PAYER.


LENGTH OF TIME FOR SERVICES
RENDERED.

DIAGNOSIS CODE.




CLAIM WAS PROCESSED AS ADJUSTMENT
TO PREVIOUS CLAIM.

CLAIM SUBMITTED TO INCORRECT PAYER.




MISSING OR INVALID INFORMATION.         187      DATE(S) OF SERVICE.




ENTITY NOT ELIGIBLE.




                                                                                            Effective 10/22/10
                                                                      EOB TO 277 & 835



                                     277
                                     CLAIM
277 CLAIM STATUS CODE DESCRIPTION    STATUS   277 CLAIM STATUS CODE DESCRIPTION
MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.

SERVICE NOT AUTHORIZED.

PROCEDURE CODE NOT VALID FOR
PATIENT AGE.
ENTITY NOT APPROVED AS AN
ELECTRONIC SUBMITTER.


NO PAYMENT WILL BE MADE FOR THIS
CLAIM.

SERVICE NOT AUTHORIZED.




DIAGNOSIS CODE(S) FOR THE SERVICES
RENDERED.

LINE INFORMATION.


SERVICE NOT AUTHORIZED.


CLAIM/LINE HAS BEEN PAID.

CLAIM WAS PROCESSED AS ADJUSTMENT
TO PREVIOUS CLAIM.




CLAIM WAS PROCESSED AS ADJUSTMENT
TO PREVIOUS CLAIM.




                                                                                         Effective 10/22/10
                                                                         EOB TO 277 & 835



                                        277
                                        CLAIM
277 CLAIM STATUS CODE DESCRIPTION       STATUS   277 CLAIM STATUS CODE DESCRIPTION
CLAIM WAS PROCESSED AS ADJUSTMENT
TO PREVIOUS CLAIM.


OTHER INSURANCE COVERAGE
INFORMATION (HEALTH, LIABILITY, AUTO,
ETC).




CLAIM WAS PROCESSED AS ADJUSTMENT
TO PREVIOUS CLAIM.
PROCEDURE CODE FOR SERVICES
RENDERED.




CLAIM IS OUT OF BALANCE.


ENTITY NOT ELIGIBLE FOR BENEFITS FOR
SUBMITTED DATES OF SERVICE.

CLAIM WAS PROCESSED AS ADJUSTMENT
TO PREVIOUS CLAIM.




COVERED DAY(S).


MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.




MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.

X-RAYS.




                                                                                            Effective 10/22/10
                                                                     EOB TO 277 & 835



                                    277
                                    CLAIM
277 CLAIM STATUS CODE DESCRIPTION   STATUS   277 CLAIM STATUS CODE DESCRIPTION
CLAIM IS OUT OF BALANCE.




ONE OR MORE ORIGINALLY SUBMITTED
PROCEDURE CODES HAVE BEEN
MODIFIED.


PAYMENT REFLECTS USUAL AND
CUSTOMARY CHARGES.


ENTITY'S ID NUMBER.


MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.

PROCEDURE CODE FOR SERVICES
RENDERED.
PROCEDURE CODE FOR SERVICES
RENDERED.


PROCEDURE CODE FOR SERVICES
RENDERED.




PROCEDURE CODE FOR SERVICES
RENDERED.
PROCEDURE CODE FOR SERVICES
RENDERED.




FACILITY DISCHARGE DATE.

CLAIM WAS PROCESSED AS ADJUSTMENT
TO PREVIOUS CLAIM.




                                                                                        Effective 10/22/10
                                                                     EOB TO 277 & 835



                                    277
                                    CLAIM
277 CLAIM STATUS CODE DESCRIPTION   STATUS   277 CLAIM STATUS CODE DESCRIPTION
CLAIM/LINE HAS BEEN PAID.




CLAIM/LINE HAS BEEN PAID.




CLAIM WAS PROCESSED AS ADJUSTMENT
TO PREVIOUS CLAIM.

CLAIM/LINE HAS BEEN PAID.




CLAIM/LINE HAS BEEN PAID.

CLAIM WAS PROCESSED AS ADJUSTMENT
TO PREVIOUS CLAIM.

MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.


SUPPORTING DOCUMENTATION.


CLAIM WAS PROCESSED AS ADJUSTMENT
TO PREVIOUS CLAIM.

COVERED DAY(S).


COVERED DAY(S).




SUPPORTING DOCUMENTATION.




                                                                                        Effective 10/22/10
                                                                        EOB TO 277 & 835



                                     277
                                     CLAIM
277 CLAIM STATUS CODE DESCRIPTION    STATUS   277 CLAIM STATUS CODE DESCRIPTION
PROCESSED ACCORDING TO
CONTRACT/PLAN PROVISIONS.




PROCESSED ACCORDING TO
CONTRACT/PLAN PROVISIONS.
PAYMENT MADE IN FULL.
DATE(S) OF SERVICE.


PROCESSED ACCORDING TO
CONTRACT/PLAN PROVISIONS.
PROCESSED ACCORDING TO
CONTRACT/PLAN PROVISIONS.




SERVICE NOT AUTHORIZED.

HOSPITAL'S SEMI-PRIVATE ROOM RATE.

MISSING OR INVALID INFORMATION.      56       AWAITING ELIGIBILITY DETERMINATION.




NDC NUMBER.


MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.


DRUG DISPENSING UNITS AND AVERAGE
WHOLESALE PRICE (AWP).

DIAGNOSIS CODE(S) FOR THE SERVICES
RENDERED.
REVENUE CODE FOR SERVICES
RENDERED.




                                                                                           Effective 10/22/10
                                                                     EOB TO 277 & 835



                                    277
                                    CLAIM
277 CLAIM STATUS CODE DESCRIPTION   STATUS   277 CLAIM STATUS CODE DESCRIPTION
NO PAYMENT WILL BE MADE FOR THIS
CLAIM.

CLAIM WAS PROCESSED AS ADJUSTMENT
TO PREVIOUS CLAIM.

CLAIM WAS PROCESSED AS ADJUSTMENT
TO PREVIOUS CLAIM.


CLAIM WAS PROCESSED AS ADJUSTMENT
TO PREVIOUS CLAIM.


CLAIM WAS PROCESSED AS ADJUSTMENT
TO PREVIOUS CLAIM.




ALLOWABLE/PAID FROM PRIMARY
COVERAGE.

DATE(S) OF SERVICE.




CLAIM/LINE HAS BEEN PAID.




ALLOWABLE/PAID FROM PRIMARY
COVERAGE.




ALLOWABLE/PAID FROM PRIMARY
COVERAGE.

CLAIM/LINE HAS BEEN PAID.




                                                                                        Effective 10/22/10
                                                                       EOB TO 277 & 835



                                      277
                                      CLAIM
277 CLAIM STATUS CODE DESCRIPTION     STATUS   277 CLAIM STATUS CODE DESCRIPTION
ALLOWABLE/PAID FROM PRIMARY
COVERAGE.




MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.


SERVICE NOT AUTHORIZED.


LINE INFORMATION.

MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.

ALLOWABLE/PAID FROM PRIMARY
COVERAGE.
ALLOWABLE/PAID FROM PRIMARY
COVERAGE.

CHARGES FOR PREGNANCY DEFERRED
UNTIL DELIVERY.




CLAIM WAS PROCESSED AS ADJUSTMENT
TO PREVIOUS CLAIM.


MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.

NO PAYMENT WILL BE MADE FOR THIS
CLAIM.




CLAIM COMBINED WITH OTHER CLAIM(S).




                                                                                          Effective 10/22/10
                                                                       EOB TO 277 & 835



                                      277
                                      CLAIM
277 CLAIM STATUS CODE DESCRIPTION     STATUS   277 CLAIM STATUS CODE DESCRIPTION
CLAIM COMBINED WITH OTHER CLAIM(S).




ALLOWABLE/PAID FROM PRIMARY
COVERAGE.




CLAIM WAS PROCESSED AS ADJUSTMENT
TO PREVIOUS CLAIM.


CLAIM WAS PROCESSED AS ADJUSTMENT
TO PREVIOUS CLAIM.




CLAIM WAS PROCESSED AS ADJUSTMENT
TO PREVIOUS CLAIM.

CLAIM WAS PROCESSED AS ADJUSTMENT
TO PREVIOUS CLAIM.

CLAIM WAS PROCESSED AS ADJUSTMENT
TO PREVIOUS CLAIM.

CLAIM WAS PROCESSED AS ADJUSTMENT
TO PREVIOUS CLAIM.

AUTHORIZATION/CERTIFICATION NUMBER.




MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.


AUTHORIZATION/CERTIFICATION NUMBER.




                                                                                          Effective 10/22/10
                                                                       EOB TO 277 & 835



                                      277
                                      CLAIM
277 CLAIM STATUS CODE DESCRIPTION     STATUS   277 CLAIM STATUS CODE DESCRIPTION
AUTHORIZATION/CERTIFICATION NUMBER.




SERVICE LINE NUMBER GREATER THAN
MAXIMUM ALLOWABLE FOR PAYER.


AUTHORIZATION/CERTIFICATION NUMBER.




AUTHORIZATION/CERTIFICATION NUMBER.


AUTHORIZATION/CERTIFICATION NUMBER.




SERVICE NOT AUTHORIZED.

AUTHORIZATION/CERTIFICATION NUMBER.


AUTHORIZATION/CERTIFICATION NUMBER.


AUTHORIZATION/CERTIFICATION NUMBER.


AUTHORIZATION/CERTIFICATION NUMBER.

NO PAYMENT WILL BE MADE FOR THIS
CLAIM.




PROCESSED ACCORDING TO
CONTRACT/PLAN PROVISIONS.




                                                                                          Effective 10/22/10
                                                                     EOB TO 277 & 835



                                    277
                                    CLAIM
277 CLAIM STATUS CODE DESCRIPTION   STATUS   277 CLAIM STATUS CODE DESCRIPTION
NO PAYMENT WILL BE MADE FOR THIS
CLAIM.




CLAIM/LINE HAS BEEN PAID.




DUPLICATE OF A PREVIOUSLY
PROCESSED CLAIM/LINE.

ENTITY'S LICENSE/CERTIFICATION
NUMBER.

MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.


MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.




MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.




MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.

MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.

MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.


MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.




                                                                                        Effective 10/22/10
                                                                     EOB TO 277 & 835



                                    277
                                    CLAIM
277 CLAIM STATUS CODE DESCRIPTION   STATUS   277 CLAIM STATUS CODE DESCRIPTION
MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.


MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.


MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.


MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.


MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.


MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.


CLAIM WAS PROCESSED AS ADJUSTMENT
TO PREVIOUS CLAIM.

CLAIM WAS PROCESSED AS ADJUSTMENT
TO PREVIOUS CLAIM.

CLAIM WAS PROCESSED AS ADJUSTMENT
TO PREVIOUS CLAIM.


CLAIM WAS PROCESSED AS ADJUSTMENT
TO PREVIOUS CLAIM.


MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.


MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.




                                                                                        Effective 10/22/10
                                                                     EOB TO 277 & 835



                                    277
                                    CLAIM
277 CLAIM STATUS CODE DESCRIPTION   STATUS   277 CLAIM STATUS CODE DESCRIPTION
PROCESSED ACCORDING TO
CONTRACT/PLAN PROVISIONS.




MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.

MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.




MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.


SERVICE NOT AUTHORIZED.

MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.


MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.

MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.

MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.


PROCESSED ACCORDING TO
CONTRACT/PLAN PROVISIONS.




MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.




                                                                                        Effective 10/22/10
                                                                        EOB TO 277 & 835



                                       277
                                       CLAIM
277 CLAIM STATUS CODE DESCRIPTION      STATUS   277 CLAIM STATUS CODE DESCRIPTION
MISSING OR INVALID UNITS OF SERVICE.




SERVICE NOT AUTHORIZED.


RETURNED TO ENTITY.




MISSING OR INVALID INFORMATION.        294      SUPPORTING DOCUMENTATION.




MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.


AWAITING RELATED CHARGES.


PROCESSED ACCORDING TO
CONTRACT/PLAN PROVISIONS.




LINE INFORMATION.




MISSING OR INVALID UNITS OF SERVICE.


PROCESSED ACCORDING TO
CONTRACT/PLAN PROVISIONS.




                                                                                           Effective 10/22/10
                                                                     EOB TO 277 & 835



                                    277
                                    CLAIM
277 CLAIM STATUS CODE DESCRIPTION   STATUS   277 CLAIM STATUS CODE DESCRIPTION
DIAGNOSIS CODE.


SUPPORTING DOCUMENTATION.


PROCESSED ACCORDING TO
CONTRACT/PLAN PROVISIONS.




MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.


MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.

PROCEDURE CODE FOR SERVICES
RENDERED.

PROCEDURE CODE FOR SERVICES
RENDERED.

MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.

MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.

MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.

MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.


SERVICE NOT AUTHORIZED.


MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.

MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.




                                                                                        Effective 10/22/10
                                                                        EOB TO 277 & 835



                                       277
                                       CLAIM
277 CLAIM STATUS CODE DESCRIPTION      STATUS   277 CLAIM STATUS CODE DESCRIPTION
PROCESSED ACCORDING TO
CONTRACT/PLAN PROVISIONS.


FACILITY ADMISSION DATE.


MISSING OR INVALID UNITS OF SERVICE.




ENTITY NOT ELIGIBLE/NOT APPROVED
FOR DATES OF SERVICE.




ENTITY NOT ELIGIBLE/NOT APPROVED
FOR DATES OF SERVICE.




SERVICE NOT AUTHORIZED.




DUPLICATE OF AN EXISTING CLAIM/LINE,
AWAITING PROCESSING.
DUPLICATE OF A PREVIOUSLY
PROCESSED CLAIM/LINE.
DUPLICATE OF AN EXISTING CLAIM/LINE,
AWAITING PROCESSING.
MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.
PROCESSED ACCORDING TO
CONTRACT/PLAN PROVISIONS.




PROCESSED ACCORDING TO
CONTRACT/PLAN PROVISIONS.




                                                                                           Effective 10/22/10
                                                                     EOB TO 277 & 835



                                    277
                                    CLAIM
277 CLAIM STATUS CODE DESCRIPTION   STATUS   277 CLAIM STATUS CODE DESCRIPTION
INDIVIDUAL TEST(S) COMPRISING THE
PANEL AND THE CHARGES FOR EACH
TEST.




INDIVIDUAL TEST(S) COMPRISING THE
PANEL AND THE CHARGES FOR EACH
TEST.




INDIVIDUAL TEST(S) COMPRISING THE
PANEL AND THE CHARGES FOR EACH
TEST.




PROCESSED ACCORDING TO
CONTRACT/PLAN PROVISIONS.


PROCESSED ACCORDING TO
CONTRACT/PLAN PROVISIONS.




PAPER CLAIM.




SERVICE NOT AUTHORIZED.


FACILITY ADMISSION DATE.




                                                                                        Effective 10/22/10
                                                                       EOB TO 277 & 835



                                      277
                                      CLAIM
277 CLAIM STATUS CODE DESCRIPTION     STATUS   277 CLAIM STATUS CODE DESCRIPTION
PROCESSED ACCORDING TO
CONTRACT/PLAN PROVISIONS.




CLAIM/LINE HAS BEEN PAID.




MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.

PROCESSED ACCORDING TO
CONTRACT/PLAN PROVISIONS.




PROCESSED ACCORDING TO
CONTRACT/PLAN PROVISIONS.




PROCESSED ACCORDING TO
CONTRACT/PLAN PROVISIONS.




PROCESSED ACCORDING TO
CONTRACT/PLAN PROVISIONS.


CLAIM/SUBMISSION FORMAT IS INVALID.




PROCESSED ACCORDING TO
CONTRACT/PLAN PROVISIONS.




                                                                                          Effective 10/22/10
                                                                     EOB TO 277 & 835



                                    277
                                    CLAIM
277 CLAIM STATUS CODE DESCRIPTION   STATUS   277 CLAIM STATUS CODE DESCRIPTION
PROCESSED ACCORDING TO
CONTRACT/PLAN PROVISIONS.




PROCESSED ACCORDING TO
CONTRACT/PLAN PROVISIONS.




PROCESSED ACCORDING TO
CONTRACT/PLAN PROVISIONS.




MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.

DUPLICATE OF A PREVIOUSLY
PROCESSED CLAIM/LINE.




PROCESSED ACCORDING TO
CONTRACT/PLAN PROVISIONS.




PROCESSED ACCORDING TO
CONTRACT/PLAN PROVISIONS.




PROCESSED ACCORDING TO
CONTRACT/PLAN PROVISIONS.




                                                                                        Effective 10/22/10
                                                                       EOB TO 277 & 835



                                      277
                                      CLAIM
277 CLAIM STATUS CODE DESCRIPTION     STATUS   277 CLAIM STATUS CODE DESCRIPTION
CLAIM/SUBMISSION FORMAT IS INVALID.




SUPPORTING DOCUMENTATION.


LENGTH OF TIME FOR SERVICES
RENDERED.




INDIVIDUAL TEST(S) COMPRISING THE
PANEL AND THE CHARGES FOR EACH
TEST.
MISSING OR INVALID LAB INDICATOR.

HISTORY AND PHYSICAL.


DETAILED DESCRIPTION OF SERVICE.


PATHOLOGY NOTES/REPORTS.

OPERATIVE REPORT.

TYPE OF SURGERY/SERVICE FOR WHICH
ANESTHESIA WAS ADMINISTERED.

DISCHARGE SUMMARY.

NEED FOR MORE THAN ONE PHYSICIAN TO
TREAT PATIENT.
MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.

NO PAYMENT WILL BE MADE FOR THIS
CLAIM.




                                                                                          Effective 10/22/10
                                                                     EOB TO 277 & 835



                                    277
                                    CLAIM
277 CLAIM STATUS CODE DESCRIPTION   STATUS   277 CLAIM STATUS CODE DESCRIPTION
PROCEDURE CODE FOR SERVICES
RENDERED.
PROCEDURE CODE FOR SERVICES
RENDERED.


DETAILED DESCRIPTION OF SERVICE.

MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.




SUPPORTING DOCUMENTATION.


DRUG NAME, STRENGTH AND DOSAGE
FORM.

SUPPORTING DOCUMENTATION.




PATHOLOGY NOTES/REPORTS.




SUPPORTING DOCUMENTATION.




SUPPORTING DOCUMENTATION.




                                                                                        Effective 10/22/10
                                                                       EOB TO 277 & 835



                                    277
                                    CLAIM
277 CLAIM STATUS CODE DESCRIPTION   STATUS   277 CLAIM STATUS CODE DESCRIPTION
MISSING OR INVALID INFORMATION.     481      CLAIM/SUBMISSION FORMAT IS INVALID.


ENTITIES ORIGINAL SIGNATURE.


ENTITY SIGNATURE DATE.


MISSING OR INVALID INFORMATION.     481      CLAIM/SUBMISSION FORMAT IS INVALID.




ENTITY SIGNATURE DATE.


ENTITIES ORIGINAL SIGNATURE.


ENTITY SIGNATURE DATE.




ENTITY'S DATE OF BIRTH.


SERVICE NOT AUTHORIZED.




ENTITY SIGNATURE DATE.




ENTITY SIGNATURE DATE.




DIAGNOSIS CODE.


MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.




                                                                                          Effective 10/22/10
                                                                       EOB TO 277 & 835



                                    277
                                    CLAIM
277 CLAIM STATUS CODE DESCRIPTION   STATUS   277 CLAIM STATUS CODE DESCRIPTION
MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.


MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.

MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.


PROCEDURE CODE FOR SERVICES
RENDERED.
ONE OR MORE ORIGINALLY SUBMITTED
PROCEDURE CODES HAVE BEEN
COMBINED.
ENTITY NOT APPROVED.




MISSING OR INVALID INFORMATION.     481      CLAIM/SUBMISSION FORMAT IS INVALID.




PROCESSED ACCORDING TO
CONTRACT/PLAN PROVISIONS.




PROCESSED ACCORDING TO
CONTRACT/PLAN PROVISIONS.




ENTITY NOT ELIGIBLE.




                                                                                          Effective 10/22/10
                                                                     EOB TO 277 & 835



                                    277
                                    CLAIM
277 CLAIM STATUS CODE DESCRIPTION   STATUS   277 CLAIM STATUS CODE DESCRIPTION
PROCESSED ACCORDING TO
CONTRACT/PLAN PROVISIONS.




PROCESSED ACCORDING TO
CONTRACT/PLAN PROVISIONS.




PROCESSED ACCORDING TO
CONTRACT/PLAN PROVISIONS.




MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.




MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.

MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.

MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.

MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.

MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.

MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.

MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.




                                                                                        Effective 10/22/10
                                                                     EOB TO 277 & 835



                                    277
                                    CLAIM
277 CLAIM STATUS CODE DESCRIPTION   STATUS   277 CLAIM STATUS CODE DESCRIPTION
MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.

PROCESSED ACCORDING TO
CONTRACT/PLAN PROVISIONS.


MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.

MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.

MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.

PROCESSED ACCORDING TO
CONTRACT/PLAN PROVISIONS.




PROCESSED ACCORDING TO
CONTRACT/PLAN PROVISIONS.




DUPLICATE OF A PREVIOUSLY
PROCESSED CLAIM/LINE.

ONE OR MORE ORIGINALLY SUBMITTED
PROCEDURE CODES HAVE BEEN
MODIFIED.


SERVICE NOT AUTHORIZED.




OTHER PROCEDURE CODE FOR
SERVICE(S) RENDERED.

HOSPITAL INFORMATION.




                                                                                        Effective 10/22/10
                                                                       EOB TO 277 & 835



                                      277
                                      CLAIM
277 CLAIM STATUS CODE DESCRIPTION     STATUS   277 CLAIM STATUS CODE DESCRIPTION
CLAIM/LINE IS CAPITATED.


MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.


MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.

MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.

SERVICE NOT AUTHORIZED.




MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.

MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.


MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.


MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.

MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.

AUTHORIZATION/CERTIFICATION NUMBER.




ENTITY'S SPECIALTY/TAXONOMY CODE.




ENTITY'S SPECIALTY/TAXONOMY CODE.




                                                                                          Effective 10/22/10
                                                                       EOB TO 277 & 835



                                      277
                                      CLAIM
277 CLAIM STATUS CODE DESCRIPTION     STATUS   277 CLAIM STATUS CODE DESCRIPTION
SERVICE NOT AUTHORIZED.




MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.

MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.

ENTITY NOT ELIGIBLE/NOT APPROVED
FOR DATES OF SERVICE.

MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.


SERVICE NOT AUTHORIZED.




CLAIM/SUBMISSION FORMAT IS INVALID.




ENTITY NOT ELIGIBLE/NOT APPROVED
FOR DATES OF SERVICE.

MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.


MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.

MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.

MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.

MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.




                                                                                          Effective 10/22/10
                                                                         EOB TO 277 & 835



                                        277
                                        CLAIM
277 CLAIM STATUS CODE DESCRIPTION       STATUS   277 CLAIM STATUS CODE DESCRIPTION
DUPLICATE OF A PREVIOUSLY
PROCESSED CLAIM/LINE.
MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.




ONE OR MORE ORIGINALLY SUBMITTED
PROCEDURE CODES HAVE BEEN
COMBINED.




ONE OR MORE ORIGINALLY SUBMITTED
PROCEDURE CODES HAVE BEEN
MODIFIED.
MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.

MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.

MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.

MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.

ENTITY'S SPECIALTY/TAXONOMY CODE.


MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.




OTHER INSURANCE COVERAGE
INFORMATION (HEALTH, LIABILITY, AUTO,
ETC).
MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.

MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.




                                                                                            Effective 10/22/10
                                                                       EOB TO 277 & 835



                                      277
                                      CLAIM
277 CLAIM STATUS CODE DESCRIPTION     STATUS   277 CLAIM STATUS CODE DESCRIPTION
MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.

MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.

MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.


MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.

MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.


MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.


MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.




MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.

MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.

MEDICAL NECESSITY FOR SERVICE.




PROCEDURE CODE FOR SERVICES
RENDERED.

SERVICE NOT AUTHORIZED.

AUTHORIZATION/CERTIFICATION NUMBER.




                                                                                          Effective 10/22/10
                                                                     EOB TO 277 & 835



                                    277
                                    CLAIM
277 CLAIM STATUS CODE DESCRIPTION   STATUS   277 CLAIM STATUS CODE DESCRIPTION
MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.

PROCEDURE CODE NOT VALID FOR
PATIENT AGE.

MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.

CLAIM/LINE HAS BEEN PAID.




MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.

PROCEDURE CODE AND PATIENT GENDER
MISMATCH.

MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.




                                                                                        Effective 10/22/10
                                                                       EOB TO 277 & 835



                                      277
                                      CLAIM
277 CLAIM STATUS CODE DESCRIPTION     STATUS   277 CLAIM STATUS CODE DESCRIPTION
PROCESSED ACCORDING TO
CONTRACT/PLAN PROVISIONS.




AUTHORIZATION/CERTIFICATION NUMBER.


SERVICE NOT AUTHORIZED.

MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.

MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.

MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.

TOOTH NUMBER OR LETTER.




MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.

MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.


MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.

PROCESSED ACCORDING TO
CONTRACT/PLAN PROVISIONS.




MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.




                                                                                          Effective 10/22/10
                                                                     EOB TO 277 & 835



                                    277
                                    CLAIM
277 CLAIM STATUS CODE DESCRIPTION   STATUS   277 CLAIM STATUS CODE DESCRIPTION
PROCESSED ACCORDING TO
CONTRACT/PLAN PROVISIONS.




MEDICAL NECESSITY FOR SERVICE.


SERVICE NOT AUTHORIZED.

PROCESSED ACCORDING TO
CONTRACT/PLAN PROVISIONS.

MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.




MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.

MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.

MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.

LENGTH OF TIME FOR SERVICES
RENDERED.




TYPE OF SURGERY/SERVICE FOR WHICH
ANESTHESIA WAS ADMINISTERED.




PROCESSED ACCORDING TO
CONTRACT/PLAN PROVISIONS.




                                                                                        Effective 10/22/10
                                                                     EOB TO 277 & 835



                                    277
                                    CLAIM
277 CLAIM STATUS CODE DESCRIPTION   STATUS   277 CLAIM STATUS CODE DESCRIPTION
MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.

MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.

MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.

MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.

MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.

PROCESSED ACCORDING TO
CONTRACT/PLAN PROVISIONS.




INDIVIDUAL TEST(S) COMPRISING THE
PANEL AND THE CHARGES FOR EACH
TEST.

OTHER PROCEDURE CODE FOR
SERVICE(S) RENDERED.


MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.




PROCEDURE CODE FOR SERVICES
RENDERED.




PROCESSED ACCORDING TO
CONTRACT/PLAN PROVISIONS.




MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.




                                                                                        Effective 10/22/10
                                                                     EOB TO 277 & 835



                                    277
                                    CLAIM
277 CLAIM STATUS CODE DESCRIPTION   STATUS   277 CLAIM STATUS CODE DESCRIPTION
PROCESSED ACCORDING TO
CONTRACT/PLAN PROVISIONS.




MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.

PROCESSED ACCORDING TO
CONTRACT/PLAN PROVISIONS.




MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.


MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.


MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.

MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.


SUPPORTING DOCUMENTATION.




MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.

ONE OR MORE ORIGINALLY SUBMITTED
PROCEDURE CODES HAVE BEEN
MODIFIED.




MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.




                                                                                        Effective 10/22/10
                                                                     EOB TO 277 & 835



                                    277
                                    CLAIM
277 CLAIM STATUS CODE DESCRIPTION   STATUS   277 CLAIM STATUS CODE DESCRIPTION
MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.


MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.

MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.




SERVICE NOT AUTHORIZED.


TYPE OF BILL FOR UB CLAIM.




CLAIM/LINE HAS BEEN PAID.




MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.

MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.

MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.

MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.

MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.




MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.




                                                                                        Effective 10/22/10
                                                                        EOB TO 277 & 835



                                       277
                                       CLAIM
277 CLAIM STATUS CODE DESCRIPTION      STATUS   277 CLAIM STATUS CODE DESCRIPTION
MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.


MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.

MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.


MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.

MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.

MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.

SERVICE NOT AUTHORIZED.


MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.

SUPPORTING DOCUMENTATION.


MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.

ENTITY NOT ELIGIBLE FOR BENEFITS FOR
SUBMITTED DATES OF SERVICE.




MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.




                                                                                           Effective 10/22/10
                                                                     EOB TO 277 & 835



                                    277
                                    CLAIM
277 CLAIM STATUS CODE DESCRIPTION   STATUS   277 CLAIM STATUS CODE DESCRIPTION
MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.




MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.

MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.


PROCEDURE CODE FOR SERVICES
RENDERED.

MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.

MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.

MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.

SERVICE NOT AUTHORIZED.




ENTITY NOT ELIGIBLE.




MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.

MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.

MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.




                                                                                        Effective 10/22/10
                                                                     EOB TO 277 & 835



                                    277
                                    CLAIM
277 CLAIM STATUS CODE DESCRIPTION   STATUS   277 CLAIM STATUS CODE DESCRIPTION
MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.




PROCESSED ACCORDING TO
CONTRACT/PLAN PROVISIONS.


MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.

SERVICE NOT AUTHORIZED.




MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.

MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.

MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.

MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.

SERVICE NOT AUTHORIZED.




MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.

MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.


MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.




                                                                                        Effective 10/22/10
                                                                     EOB TO 277 & 835



                                    277
                                    CLAIM
277 CLAIM STATUS CODE DESCRIPTION   STATUS   277 CLAIM STATUS CODE DESCRIPTION
MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.


MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.


MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.

MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.


MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.




MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.

ENTITY NOT ELIGIBLE.




MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.

MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.

MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.

MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.

SERVICE NOT AUTHORIZED.

ENTITY NOT PRIMARY.




                                                                                        Effective 10/22/10
                                                                     EOB TO 277 & 835



                                    277
                                    CLAIM
277 CLAIM STATUS CODE DESCRIPTION   STATUS   277 CLAIM STATUS CODE DESCRIPTION
MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.


CLAIM/LINE HAS BEEN PAID.


COVERED DAY(S).




MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.

CLAIM WAS PROCESSED AS ADJUSTMENT
TO PREVIOUS CLAIM.

CLAIM WAS PROCESSED AS ADJUSTMENT
TO PREVIOUS CLAIM.

CLAIM WAS PROCESSED AS ADJUSTMENT
TO PREVIOUS CLAIM.

MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.

INDIVIDUAL TEST(S) COMPRISING THE
PANEL AND THE CHARGES FOR EACH
TEST.


CLAIM WAS PROCESSED AS ADJUSTMENT
TO PREVIOUS CLAIM.


CLAIM WAS PROCESSED AS ADJUSTMENT
TO PREVIOUS CLAIM.

MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.

CLAIM WAS PROCESSED AS ADJUSTMENT
TO PREVIOUS CLAIM.




                                                                                        Effective 10/22/10
                                                                         EOB TO 277 & 835



                                        277
                                        CLAIM
277 CLAIM STATUS CODE DESCRIPTION       STATUS   277 CLAIM STATUS CODE DESCRIPTION
SERVICE NOT AUTHORIZED.


PROCESSED ACCORDING TO
CONTRACT/PLAN PROVISIONS.




SERVICE NOT AUTHORIZED.


MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.

OTHER INSURANCE COVERAGE
INFORMATION (HEALTH, LIABILITY, AUTO,
ETC).
MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.

PROCESSED ACCORDING TO
CONTRACT/PLAN PROVISIONS.




MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.

MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.

MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.

MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.

MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.

MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.

MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.




                                                                                            Effective 10/22/10
                                                                     EOB TO 277 & 835



                                    277
                                    CLAIM
277 CLAIM STATUS CODE DESCRIPTION   STATUS   277 CLAIM STATUS CODE DESCRIPTION
MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.

MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.

MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.




MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.




MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.


MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.


ONE OR MORE ORIGINALLY SUBMITTED
PROCEDURE CODES HAVE BEEN
COMBINED.


ONE OR MORE ORIGINALLY SUBMITTED
PROCEDURE CODES HAVE BEEN
COMBINED.


MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.

ONE OR MORE ORIGINALLY SUBMITTED
PROCEDURE CODES HAVE BEEN
MODIFIED.

MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.




                                                                                        Effective 10/22/10
                                                                        EOB TO 277 & 835



                                       277
                                       CLAIM
277 CLAIM STATUS CODE DESCRIPTION      STATUS   277 CLAIM STATUS CODE DESCRIPTION
MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.


MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.

CLAIM WAS PROCESSED AS ADJUSTMENT
TO PREVIOUS CLAIM.




PROCESSED ACCORDING TO
CONTRACT/PLAN PROVISIONS.

MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.

MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.

ENTITY NOT ELIGIBLE FOR BENEFITS FOR
SUBMITTED DATES OF SERVICE.


MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.

MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.

PROCESSED ACCORDING TO
CONTRACT/PLAN PROVISIONS.




MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.

PROCESSED ACCORDING TO
CONTRACT/PLAN PROVISIONS.




                                                                                           Effective 10/22/10
                                                                     EOB TO 277 & 835



                                    277
                                    CLAIM
277 CLAIM STATUS CODE DESCRIPTION   STATUS   277 CLAIM STATUS CODE DESCRIPTION
PROCESSED ACCORDING TO
CONTRACT/PLAN PROVISIONS.




PROCESSED ACCORDING TO
CONTRACT/PLAN PROVISIONS.


PROCESSED ACCORDING TO
CONTRACT/PLAN PROVISIONS.


PROCESSED ACCORDING TO
CONTRACT/PLAN PROVISIONS.


PROCESSED ACCORDING TO
CONTRACT/PLAN PROVISIONS.


PROCESSED ACCORDING TO
CONTRACT/PLAN PROVISIONS.


PROCESSED ACCORDING TO
CONTRACT/PLAN PROVISIONS.


PROCESSED ACCORDING TO
CONTRACT/PLAN PROVISIONS.


MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.

PROCESSED ACCORDING TO
CONTRACT/PLAN PROVISIONS.

SUPPORTING DOCUMENTATION.




PROCESSED ACCORDING TO
CONTRACT/PLAN PROVISIONS.




                                                                                        Effective 10/22/10
                                                                        EOB TO 277 & 835



                                       277
                                       CLAIM
277 CLAIM STATUS CODE DESCRIPTION      STATUS   277 CLAIM STATUS CODE DESCRIPTION
PROCESSED ACCORDING TO
CONTRACT/PLAN PROVISIONS.

MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.

MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.

PROCESSED ACCORDING TO
CONTRACT/PLAN PROVISIONS.




PROCESSED ACCORDING TO
CONTRACT/PLAN PROVISIONS.


PROCESSED ACCORDING TO
CONTRACT/PLAN PROVISIONS.

PROCESSED ACCORDING TO
CONTRACT/PLAN PROVISIONS.

CLAIM/LINE HAS BEEN PAID.




PARTIAL PAYMENT MADE FOR THIS CLAIM.




PROCESSED ACCORDING TO
CONTRACT/PLAN PROVISIONS.




PROCESSED ACCORDING TO
CONTRACT/PLAN PROVISIONS.




                                                                                           Effective 10/22/10
                                                                         EOB TO 277 & 835



                                        277
                                        CLAIM
277 CLAIM STATUS CODE DESCRIPTION       STATUS   277 CLAIM STATUS CODE DESCRIPTION
PROCESSED ACCORDING TO
CONTRACT/PLAN PROVISIONS.




DATE(S) OF SERVICE.




ENTITY'S LICENSE/CERTIFICATION
NUMBER.
ENTITY'S LICENSE/CERTIFICATION
NUMBER.
PROCESSED ACCORDING TO
CONTRACT/PLAN PROVISIONS.




PROCESSED ACCORDING TO
CONTRACT/PLAN PROVISIONS.




MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.

SUBSCRIBER AND POLICYHOLDER NAME
MISMATCHED.


PROCESSED ACCORDING TO
CONTRACT/PLAN PROVISIONS.




OTHER INSURANCE COVERAGE
INFORMATION (HEALTH, LIABILITY, AUTO,
ETC).




                                                                                            Effective 10/22/10
                                                                        EOB TO 277 & 835



                                       277
                                       CLAIM
277 CLAIM STATUS CODE DESCRIPTION      STATUS   277 CLAIM STATUS CODE DESCRIPTION
PROCESSED ACCORDING TO
CONTRACT/PLAN PROVISIONS.




MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.

PROCESSED ACCORDING TO
CONTRACT/PLAN PROVISIONS.




PROCESSED ACCORDING TO
CONTRACT/PLAN PROVISIONS.




DATE ENTITY SIGNED
CERTIFICATION/RECERTIFICATION

PROCESSED ACCORDING TO
CONTRACT/PLAN PROVISIONS.




PAPER CLAIM.




PARTIAL PAYMENT MADE FOR THIS CLAIM.




PROCESSED ACCORDING TO
CONTRACT/PLAN PROVISIONS.




                                                                                           Effective 10/22/10
                                                                     EOB TO 277 & 835



                                    277
                                    CLAIM
277 CLAIM STATUS CODE DESCRIPTION   STATUS   277 CLAIM STATUS CODE DESCRIPTION
PROCESSED ACCORDING TO
CONTRACT/PLAN PROVISIONS.




PROCESSED ACCORDING TO
CONTRACT/PLAN PROVISIONS.


MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.

PROCESSED ACCORDING TO
CONTRACT/PLAN PROVISIONS.


PROCESSED ACCORDING TO
CONTRACT/PLAN PROVISIONS.




PROCESSED ACCORDING TO
CONTRACT/PLAN PROVISIONS.

PROCESSED ACCORDING TO
CONTRACT/PLAN PROVISIONS.




MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.


PROCESSED ACCORDING TO
CONTRACT/PLAN PROVISIONS.




PROCESSED ACCORDING TO
CONTRACT/PLAN PROVISIONS.




                                                                                        Effective 10/22/10
                                                                     EOB TO 277 & 835



                                    277
                                    CLAIM
277 CLAIM STATUS CODE DESCRIPTION   STATUS   277 CLAIM STATUS CODE DESCRIPTION
PROCESSED ACCORDING TO
CONTRACT/PLAN PROVISIONS.




PROCESSED ACCORDING TO
CONTRACT/PLAN PROVISIONS.


PROCESSED ACCORDING TO
CONTRACT/PLAN PROVISIONS.


PROCESSED ACCORDING TO
CONTRACT/PLAN PROVISIONS.




PROCESSED ACCORDING TO
CONTRACT/PLAN PROVISIONS.




PROCESSED ACCORDING TO
CONTRACT/PLAN PROVISIONS.




PROCESSED ACCORDING TO
CONTRACT/PLAN PROVISIONS.




PROCESSED ACCORDING TO
CONTRACT/PLAN PROVISIONS.




PROCESSED ACCORDING TO
CONTRACT/PLAN PROVISIONS.




                                                                                        Effective 10/22/10
                                                                     EOB TO 277 & 835



                                    277
                                    CLAIM
277 CLAIM STATUS CODE DESCRIPTION   STATUS   277 CLAIM STATUS CODE DESCRIPTION
PROCESSED ACCORDING TO
CONTRACT/PLAN PROVISIONS.




SERVICE NOT AUTHORIZED.

MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.


PROCESSED ACCORDING TO
CONTRACT/PLAN PROVISIONS.

PROCESSED ACCORDING TO
CONTRACT/PLAN PROVISIONS.


MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.

PROCESSED ACCORDING TO
CONTRACT/PLAN PROVISIONS.




PROCESSED ACCORDING TO
CONTRACT/PLAN PROVISIONS.

MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.

MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.


PROCESSED ACCORDING TO
CONTRACT/PLAN PROVISIONS.

INTERNAL REVIEW/AUDIT.


MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.




                                                                                        Effective 10/22/10
                                                                     EOB TO 277 & 835



                                    277
                                    CLAIM
277 CLAIM STATUS CODE DESCRIPTION   STATUS   277 CLAIM STATUS CODE DESCRIPTION
MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.




PLACE OF SERVICE.




PROCESSED ACCORDING TO
CONTRACT/PLAN PROVISIONS.

PROCEDURE CODE FOR SERVICES
RENDERED.




PROCESSED ACCORDING TO
CONTRACT/PLAN PROVISIONS.


PROCESSED ACCORDING TO
CONTRACT/PLAN PROVISIONS.

PROCESSED ACCORDING TO
CONTRACT/PLAN PROVISIONS.




PROCESSED ACCORDING TO
CONTRACT/PLAN PROVISIONS.




PROCESSED ACCORDING TO
CONTRACT/PLAN PROVISIONS.




                                                                                        Effective 10/22/10
                                                                         EOB TO 277 & 835



                                        277
                                        CLAIM
277 CLAIM STATUS CODE DESCRIPTION       STATUS   277 CLAIM STATUS CODE DESCRIPTION
MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.


PROCESSED ACCORDING TO
CONTRACT/PLAN PROVISIONS.

CLAIM/LINE HAS BEEN PAID.


MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.


MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.


PROCESSED ACCORDING TO
CONTRACT/PLAN PROVISIONS.




PROCESSED ACCORDING TO
CONTRACT/PLAN PROVISIONS.




PROCESSED ACCORDING TO
CONTRACT/PLAN PROVISIONS.




PROCESSED ACCORDING TO
CONTRACT/PLAN PROVISIONS.
PROCESSED ACCORDING TO
CONTRACT/PLAN PROVISIONS.




OTHER INSURANCE COVERAGE
INFORMATION (HEALTH, LIABILITY, AUTO,
ETC).




                                                                                            Effective 10/22/10
                                                                         EOB TO 277 & 835



                                        277
                                        CLAIM
277 CLAIM STATUS CODE DESCRIPTION       STATUS   277 CLAIM STATUS CODE DESCRIPTION
PROCESSED ACCORDING TO
CONTRACT/PLAN PROVISIONS.




DRUG INFORMATION.


DRUG INFORMATION.


PROCESSED ACCORDING TO
CONTRACT/PLAN PROVISIONS.




MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.

MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.

MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.

MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.

MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.


OTHER INSURANCE COVERAGE
INFORMATION (HEALTH, LIABILITY, AUTO,
ETC).




MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.




                                                                                            Effective 10/22/10
                                                                         EOB TO 277 & 835



                                        277
                                        CLAIM
277 CLAIM STATUS CODE DESCRIPTION       STATUS   277 CLAIM STATUS CODE DESCRIPTION
OTHER INSURANCE COVERAGE
INFORMATION (HEALTH, LIABILITY, AUTO,
ETC).


MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.




MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.




OTHER INSURANCE COVERAGE
INFORMATION (HEALTH, LIABILITY, AUTO,
ETC).




MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.


PROCESSED ACCORDING TO
CONTRACT/PLAN PROVISIONS.


PROCESSED ACCORDING TO
CONTRACT/PLAN PROVISIONS.




MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.

PROCESSED ACCORDING TO
CONTRACT/PLAN PROVISIONS.




                                                                                            Effective 10/22/10
                                                                        EOB TO 277 & 835



                                       277
                                       CLAIM
277 CLAIM STATUS CODE DESCRIPTION      STATUS   277 CLAIM STATUS CODE DESCRIPTION
PROCESSED ACCORDING TO
CONTRACT/PLAN PROVISIONS.




DRUG INFORMATION.




DRUG DAYS SUPPLY AND DOSAGE.


PROCESSED ACCORDING TO
CONTRACT/PLAN PROVISIONS.


MISSING OR INVALID UNITS OF SERVICE.




NDC NUMBER.


INTERNAL REVIEW/AUDIT.


ENTITY'S ID NUMBER.

MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.

DRUG INFORMATION.


NDC NUMBER.


DRUG INFORMATION.


DRUG INFORMATION.




                                                                                           Effective 10/22/10
                                                                        EOB TO 277 & 835



                                       277
                                       CLAIM
277 CLAIM STATUS CODE DESCRIPTION      STATUS   277 CLAIM STATUS CODE DESCRIPTION
PRESCRIPTION NUMBER.


NDC NUMBER.




NDC NUMBER.


NDC NUMBER.


ENTITY NOT ELIGIBLE/NOT APPROVED
FOR DATES OF SERVICE.




ENTITY NOT ELIGIBLE FOR BENEFITS FOR
SUBMITTED DATES OF SERVICE.


ENTITY NOT ELIGIBLE FOR BENEFITS FOR
SUBMITTED DATES OF SERVICE.


MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.

DRUG INFORMATION.




CLAIM/SUBMISSION FORMAT IS INVALID.

MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.

NDC NUMBER.


NDC NUMBER.




                                                                                           Effective 10/22/10
                                                                     EOB TO 277 & 835



                                    277
                                    CLAIM
277 CLAIM STATUS CODE DESCRIPTION   STATUS   277 CLAIM STATUS CODE DESCRIPTION
NDC NUMBER.


NDC NUMBER.


SERVICE NOT AUTHORIZED.




MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.

NDC NUMBER.


MEDICAL NECESSITY FOR SERVICE.


CLAIM/LINE HAS BEEN PAID.




MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.


PROCESSED ACCORDING TO
CONTRACT/PLAN PROVISIONS.

MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.

PROCEDURE CODE MODIFIER(S) FOR
SERVICE(S) RENDERED.


MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.

MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.




                                                                                        Effective 10/22/10
                                                                        EOB TO 277 & 835



                                       277
                                       CLAIM
277 CLAIM STATUS CODE DESCRIPTION      STATUS   277 CLAIM STATUS CODE DESCRIPTION
PROCESSED ACCORDING TO
CONTRACT/PLAN PROVISIONS.

ENTITY NOT ELIGIBLE FOR BENEFITS FOR
SUBMITTED DATES OF SERVICE.

MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.

DIAGNOSIS CODE.

ENTITY NOT ELIGIBLE FOR BENEFITS FOR
SUBMITTED DATES OF SERVICE.
MISSING OR INVALID UNITS OF SERVICE.


ENTITY'S LICENSE/CERTIFICATION
NUMBER.


ENTITY NOT ELIGIBLE.


MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.

MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.

PROCESSED ACCORDING TO
CONTRACT/PLAN PROVISIONS.


MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.




DATE(S) OF SERVICE.




ENTITY NOT REFERRED BY SELECTED
PRIMARY CARE PROVIDER.




                                                                                           Effective 10/22/10
                                                                        EOB TO 277 & 835



                                       277
                                       CLAIM
277 CLAIM STATUS CODE DESCRIPTION      STATUS   277 CLAIM STATUS CODE DESCRIPTION
MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.

PROCESSED ACCORDING TO
CONTRACT/PLAN PROVISIONS.


INDIVIDUAL TEST(S) COMPRISING THE
PANEL AND THE CHARGES FOR EACH
TEST.


AWAITING RELATED CHARGES.




INDIVIDUAL TEST(S) COMPRISING THE
PANEL AND THE CHARGES FOR EACH
TEST.


MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.


MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.

ENTITY NOT ELIGIBLE FOR BENEFITS FOR
SUBMITTED DATES OF SERVICE.


ENTITY NOT ELIGIBLE FOR BENEFITS FOR
SUBMITTED DATES OF SERVICE.

INDIVIDUAL TEST(S) COMPRISING THE
PANEL AND THE CHARGES FOR EACH
TEST.


PROCESSED ACCORDING TO
CONTRACT/PLAN PROVISIONS.




                                                                                           Effective 10/22/10
                                                                        EOB TO 277 & 835



                                       277
                                       CLAIM
277 CLAIM STATUS CODE DESCRIPTION      STATUS   277 CLAIM STATUS CODE DESCRIPTION
CLAIM/SUBMISSION FORMAT IS INVALID.




ENTITY NOT ELIGIBLE FOR BENEFITS FOR
SUBMITTED DATES OF SERVICE.


MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.

MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.

CLAIM/SUBMISSION FORMAT IS INVALID.




REVENUE CODE FOR SERVICES
RENDERED.


DATE(S) OF SERVICE.




PROCESSED ACCORDING TO
CONTRACT/PLAN PROVISIONS.




MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.


MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.

MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.

MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.




                                                                                           Effective 10/22/10
                                                                     EOB TO 277 & 835



                                    277
                                    CLAIM
277 CLAIM STATUS CODE DESCRIPTION   STATUS   277 CLAIM STATUS CODE DESCRIPTION
MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.


MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.

ENTITY'S SPECIALTY/TAXONOMY CODE.




SUPPORTING DOCUMENTATION.


SUPPORTING DOCUMENTATION.


SUPPORTING DOCUMENTATION.


SUPPORTING DOCUMENTATION.


SUPPORTING DOCUMENTATION.


PROCESSED ACCORDING TO
CONTRACT/PLAN PROVISIONS.

PROCESSED ACCORDING TO
CONTRACT/PLAN PROVISIONS.

DATE(S) OF SERVICE.


MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.

SERVICE NOT AUTHORIZED.




SERVICE NOT AUTHORIZED.




                                                                                        Effective 10/22/10
                                                                        EOB TO 277 & 835



                                       277
                                       CLAIM
277 CLAIM STATUS CODE DESCRIPTION      STATUS   277 CLAIM STATUS CODE DESCRIPTION
REVENUE CODE FOR SERVICES
RENDERED.


HOSPITAL ADMISSION TYPE.

ENTITY NOT ELIGIBLE FOR BENEFITS FOR
SUBMITTED DATES OF SERVICE.

REVENUE CODE FOR SERVICES
RENDERED.




CLAIM/LINE HAS BEEN PAID.




PARTIAL PAYMENT MADE FOR THIS CLAIM.


CLAIM/LINE HAS BEEN PAID.


ENTITY NOT ELIGIBLE.


MAXIMUM COVERAGE AMOUNT MET OR
EXCEEDED FOR BENEFIT PERIOD.

ACCEPTED FOR PROCESSING.




                                                                                           Effective 10/22/10
                                                             ESC TO 277




                           ESC to 277                                                       Arkansas Medicaid Revised 03/16/12
                                                                                   277
                    PLAN                                                           CLAIM
 EDIT/AUDIT   TXN   CODE   EDIT/AUDIT DESCRIPTION                                  STATUS   CLAIM STATUS CODE
                           Z1704-RESPITE CARE PROVIDED MORE THAN 14 CONSECUTIVE             MAXIMUM COVERAGE AMOUNT MET OR
     A00            ZZZ    DAYS                                                    483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                            MAXIMUM COVERAGE AMOUNT MET OR
     A03            ZZZ    DRUG PAYMENT EXCEEDS 3 PERSCRIPTIONS PER MONTH          483      EXCEEDED FOR BENEFIT PERIOD.
                           WAIVER SERVICES ON OVERLAPPING DOS AS INSTITUTIONAL              ENTITY NOT ELIGIBLE FOR BENEFITS FOR
     A04            ZZZ    CLAIM                                                   88       SUBMITTED DATES OF SERVICE.
                                                                                            MAXIMUM COVERAGE AMOUNT MET OR
     A05            ZZZ    OUTPATIENT/PODIATRY LAB AND X-RAY LTD TO $500 PER SFY   483      EXCEEDED FOR BENEFIT PERIOD.
                           OUTPATIENT FAMILY PLANNING SVC NON PAY SAME DOS OTHER            PROCESSED ACCORDING TO PLAN
     A06            ZZZ    FEE                                                     104      PROVISIONS.
                           OUTPATIENT NORPLANT INSERTION PAYABLE TWICE PER FIVE             MAXIMUM COVERAGE AMOUNT MET OR
     A07            ZZZ    YEAR PERIOD                                             483      EXCEEDED FOR BENEFIT PERIOD.
                           OUTPATIENT NORPLANT REMOVAL PAYABLE ONCE PER FIVE                MAXIMUM COVERAGE AMOUNT MET OR
     A08            ZZZ    YEAR PERIOD                                             483      EXCEEDED FOR BENEFIT PERIOD.
                           OUTPATIENT FACILITY FEE NON PAY SAME DOS AS OUTP FAM             PROCESSED ACCORDING TO PLAN
     A09            ZZZ    PLAN                                                    104      PROVISIONS.
                           LAB PROCEDURE NOT PERFORMED WITHIN 7 DAYS OF                     PROCESSED ACCORDING TO PLAN
     A10            ZZZ    SCREENING                                               104      PROVISIONS.
                                                                                            MAXIMUM COVERAGE AMOUNT MET OR
     A11            ZZZ    REMOVAL OF CERVIX TISSUE ALLOWED ONCE IN A LIFETIME     483      EXCEEDED FOR BENEFIT PERIOD.
                           NEUROBEHAVIOR STATUS EXAM LIMITED TO ONE HOUR PER                MAXIMUM COVERAGE AMOUNT MET OR
     A13            DDS    STATE FISCAL YEAR                                       483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                            MAXIMUM COVERAGE AMOUNT MET OR
     A13            ZZZ    NEUROBEHAVIOR STATUS EXAM LIMITED TO ONE HOUR PER SFY 483        EXCEEDED FOR BENEFIT PERIOD.
                                                                                            PROCESSED ACCORDING TO PLAN
     A14            ZZZ    FAIL IF RELATED PROC BILLED SAME DOS/ATTENDING PROVIDER 104      PROVISIONS.
                                                                                            PROCESSED ACCORDING TO PLAN
     A15            ZZZ    FAIL IF RELATED PROC BILLED SAME DOS/ATTENDING PROVIDER 104      PROVISIONS.
                           NEW BIRTH STANDBY NON-PAYABLE SAME DOS AS PHYSICIAN              PROCESSED ACCORDING TO PLAN
     A16            ZZZ    STANDBY SERV                                            104      PROVISIONS.
                           PHYSICIAN STANDBY SERV NON-PAYABLE SAME DOS AS NEW               PROCESSED ACCORDING TO PLAN
     A17            ZZZ    BIRTH STANDBY                                           104      PROVISIONS.
                                                                                            MAXIMUM COVERAGE AMOUNT MET OR
     A20            DDS    Z0473 LIMITED TO TWO UNITS PER STATE FISCAL YEAR        483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                            MAXIMUM COVERAGE AMOUNT MET OR
     A21            DDS    Z2267 LIMITED TO ONE UNIT PER MONTH                   483        EXCEEDED FOR BENEFIT PERIOD.
                           RENTAL WHEELCHAIR NON-PAYABLE W/IN 5 YRS OF PURCHASED            PROCESSED ACCORDING TO
     A22            ZZZ    WHEELCHAIR                                            107        CONTRACT/PLAN PROVISIONS.




5/16/2012                                                     Page 309
                                                              ESC TO 277


                                                                                     277
                    PLAN                                                             CLAIM
 EDIT/AUDIT   TXN   CODE   EDIT/AUDIT DESCRIPTION                                    STATUS   CLAIM STATUS CODE
                           PURCHASED WHEELCHAIR NON-PAYABLE W/IN 5 YRS OF RENTAL              PROCESSED ACCORDING TO
     A23            ZZZ    WHEELCHAIR                                              107        CONTRACT/PLAN PROVISIONS.
                           12 OUTPATIENT HOSPITAL VISITS EXCEEDED FOR STATE FISCAL            MAXIMUM COVERAGE AMOUNT MET OR
     A24            ZZZ    YEAR                                                    483        EXCEEDED FOR BENEFIT PERIOD.
                                                                                              MAXIMUM COVERAGE AMOUNT MET OR
     C00            DDS    Z1582 LIMITED TO 832 UNITS PER SFY FOR AGES 21 AND OVER   483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                              MAXIMUM COVERAGE AMOUNT MET OR
     C01            DDS    Z1919 LIMITED TO $7500.00 PER STATE FISCAL YEAR           483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                              MAXIMUM COVERAGE AMOUNT MET OR
     C02            DDS    Z2336 LIMITED TO 48 UNITS PER STATE FISCAL YEAR           483      EXCEEDED FOR BENEFIT PERIOD.
                           LIGATION OR TRANSECTION OF FALLOPIAN TUBES ONCE IN                 MAXIMUM COVERAGE AMOUNT MET OR
     C03            ZZZ    LIFETIME                                                  483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                              MAXIMUM COVERAGE AMOUNT MET OR
     C05            ZZZ    TWO ULTRASOUNDS PER PREGNANCY                             483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                              MAXIMUM COVERAGE AMOUNT MET OR
     C06            ZZZ    FIVE FETAL NON-STRESS TESTS PER PREGNANCY                 483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                              MAXIMUM COVERAGE AMOUNT MET OR
     C07            ZZZ    PELVIC EXENTERATION ALLOWED ONCE IN A LIFETIME            483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                              MAXIMUM COVERAGE AMOUNT MET OR
     C08            ZZZ    VAGINECTOMY ALLOWED TWICE IN A LIFETIME                   483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                              MAXIMUM COVERAGE AMOUNT MET OR
     C09            ZZZ    SMALL INTESTINE REMOVAL ALLOWED ONCE IN A LIFETIME        483      EXCEEDED FOR BENEFIT PERIOD.
                           EXCEEDS LIMIT OF 12 OUTPATIENT VISITS PER STATE FISCAL             MAXIMUM COVERAGE AMOUNT MET OR
     E02            ZZZ    YEAR                                                      483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                              MAXIMUM COVERAGE AMOUNT MET OR
     E05            ZZZ    PURCHASE OF THIS DME LIMITED TO ONE PER YEAR              483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                              MAXIMUM COVERAGE AMOUNT MET OR
     E06            ZZZ    PURCHASE OF THIS DME LIMITED TO ONCE EVERY TWO YEARS      483      EXCEEDED FOR BENEFIT PERIOD.
                           PURCHASE OF THIS DURABLE MED EQUIP LIMITED TO ONCE IN A            MAXIMUM COVERAGE AMOUNT MET OR
     E07            ZZZ    LIFETIME                                                  483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                              MAXIMUM COVERAGE AMOUNT MET OR
     E08            ZZZ    PURCHASE OF THIS DME LIMITED TO ONCE EVERY 6 MONTHS       483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                              MAXIMUM COVERAGE AMOUNT MET OR
     E09            ZZZ    EXCEEDS LIMIT OF 455 UNITS FOR THE PURCHASE OF THIS DME   483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                              MAXIMUM COVERAGE AMOUNT MET OR
     E10            ZZZ    DME TOS I PROCEDURE CODE PAYABLE ONCE PER SFY             483      EXCEEDED FOR BENEFIT PERIOD.
                           TWO EPSDT AGE APPROPRIATE HEARING SCREENS PER YEAR                 MAXIMUM COVERAGE AMOUNT MET OR
     E11            ZZZ    AGE 5                                                     483      EXCEEDED FOR BENEFIT PERIOD.
                           TWO EPSDT AGE APPROPRIATE HEARING SCREENS 16 THRU 17               MAXIMUM COVERAGE AMOUNT MET OR
     E12            ZZZ    YEARS                                                     483      EXCEEDED FOR BENEFIT PERIOD.




5/16/2012                                                       Page 310
                                                             ESC TO 277


                                                                                   277
                    PLAN                                                           CLAIM
 EDIT/AUDIT   TXN   CODE   EDIT/AUDIT DESCRIPTION                                  STATUS   CLAIM STATUS CODE
                           TWO EPSDT HEARING SCREENS APPROPRIATE AGES 18 THRU 20            MAXIMUM COVERAGE AMOUNT MET OR
     E13            ZZZ    YEARS                                                   483      EXCEEDED FOR BENEFIT PERIOD.
                           TWO EPSDT HEARING SCREENS APPROPRIATE AGES 12 THRU 15            MAXIMUM COVERAGE AMOUNT MET OR
     E14            ZZZ    YEARS                                                   483      EXCEEDED FOR BENEFIT PERIOD.
                           TWO EPSDT VISION SCREENS APPROPRIATE FROM 6 THRU 9               MAXIMUM COVERAGE AMOUNT MET OR
     E15            ZZZ    YEARS                                                   483      EXCEEDED FOR BENEFIT PERIOD.
                           TWO EPSDT VISION SCREENS APPROPRIATE FROM 10 THRU 11             MAXIMUM COVERAGE AMOUNT MET OR
     E16            ZZZ    YEARS                                                   483      EXCEEDED FOR BENEFIT PERIOD.
                           TWO EPSDT AGE APPROPRIATE VISION SCREEN 12 THRU 15               MAXIMUM COVERAGE AMOUNT MET OR
     E17            ZZZ    YEARS                                                   483      EXCEEDED FOR BENEFIT PERIOD.
                           TWO EPSDT AGE APPROPRIATE VISION SCREEN 16 THRU 17               MAXIMUM COVERAGE AMOUNT MET OR
     E18            ZZZ    YEARS                                                   483      EXCEEDED FOR BENEFIT PERIOD.
                           TWO EPSDT AGE APPROPRIATE VISION SCREEN 18 THRU 20               MAXIMUM COVERAGE AMOUNT MET OR
     E19            ZZZ    YEARS                                                   483      EXCEEDED FOR BENEFIT PERIOD.
                           ONE PREVENTATIVE DENTAL SCREEN FROM NEWBORN TO 12                MAXIMUM COVERAGE AMOUNT MET OR
     E21            AR1    MONTHS                                                  483      EXCEEDED FOR BENEFIT PERIOD.
                           TWO EPSDT AGE APPROPRIATE VISION SCREENS FOR 5 YEARS             MAXIMUM COVERAGE AMOUNT MET OR
     E22            ZZZ    OF AGE                                                  483      EXCEEDED FOR BENEFIT PERIOD.
                           TWO EPSDT AGE APPROPRIATE VISION SCREENS FOR                     MAXIMUM COVERAGE AMOUNT MET OR
     E23            ZZZ    NEWBORN THRU 4 YRS                                      483      EXCEEDED FOR BENEFIT PERIOD.
                           TWO EPSDT AGE APPROPRIATE HEARING SCREENS FOR                    MAXIMUM COVERAGE AMOUNT MET OR
     E24            ZZZ    NEWBORN THRU 4 YRS                                      483      EXCEEDED FOR BENEFIT PERIOD.
                           TWO EPSDT AGE APPROPRIATE HEARING SCREENS FOR AGE 8              MAXIMUM COVERAGE AMOUNT MET OR
     E25            ZZZ    THRU 11 YRS                                             483      EXCEEDED FOR BENEFIT PERIOD.
                           VENIPUNCTURE NON-PAYABLE SAME DOS AS LAB TEST, SAME              PROCESSED ACCORDING TO PLAN
     E26            ZZZ    PROVIDER                                                104      PROVISIONS.
                           LAB TEST NON-PAYABLE SAME DOS AS VENIPUNCTURE, SAME              PROCESSED ACCORDING TO PLAN
     E27            ZZZ    PROVIDER                                                104      PROVISIONS.
                                                                                            MAXIMUM COVERAGE AMOUNT MET OR
     E28            ZZZ    Z0560 EXCEEDS LIMIT OF ONE PER STATE FISCAL YEAR        483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                            MAXIMUM COVERAGE AMOUNT MET OR
     E31            ZZZ    Z0564 EXCEEDS LIMIT OF ONE PER STATE FISCAL YEAR        483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                            MAXIMUM COVERAGE AMOUNT MET OR
     E32            ZZZ    Z0574 EXCEEDS LIMIT OF SIX UNITS PER WEEK               483      EXCEEDED FOR BENEFIT PERIOD.
                           ONE PAIR EYE GLASSES EVERY 12 MONTHS FOR RECIPIENTS              MAXIMUM COVERAGE AMOUNT MET OR
     E33            ZZZ    AGE 21/OLDER                                            483      EXCEEDED FOR BENEFIT PERIOD.
                           DIAPERS AND UNDERPADS EXCEEDS $130.00 PER CALENDAR               MAXIMUM COVERAGE AMOUNT MET OR
     E34            ZZZ    MONTH                                                   483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                            MAXIMUM COVERAGE AMOUNT MET OR
     E37            ZZZ    EYE EXAMINE EXCEEDS ONE PER 12 MONTH PERIOD             483      EXCEEDED FOR BENEFIT PERIOD.




5/16/2012                                                     Page 311
                                                                   ESC TO 277


                                                                                         277
                         PLAN                                                            CLAIM
      EDIT/AUDIT   TXN   CODE   EDIT/AUDIT DESCRIPTION                                   STATUS   CLAIM STATUS CODE
                                                                                                  MAXIMUM COVERAGE AMOUNT MET OR
         E38             ZZZ    NORPLANT SYSTEM PAYABLE TWICE PER 5 YEAR PERIOD          483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                                  MAXIMUM COVERAGE AMOUNT MET OR
         E39             ZZZ    NORPLANT INSERTION PAYABLE TWICE PER FIVE YEAR PERIOD    483      EXCEEDED FOR BENEFIT PERIOD.
                                TWO EPSDT AGE APPROPRIATE HEARING SCREENS PER YEAR                MAXIMUM COVERAGE AMOUNT MET OR
         E44             ZZZ    AGE 6                                                    483      EXCEEDED FOR BENEFIT PERIOD.
                                TWO EPSDT AGE APPROPRIATE HEARING SCREENS PER YEAR                MAXIMUM COVERAGE AMOUNT MET OR
         E45             ZZZ    AGE 7                                                    483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                                  MAXIMUM COVERAGE AMOUNT MET OR
         E66             ZZZ    TCM SERVICES EXCEED LIMIT OF 832 UNITS PER SFY           483      EXCEEDED FOR BENEFIT PERIOD.
                                TCM SERVICES NOT ALLOWED ON SAME DOS BY DIFFERENT                 PROCESSED ACCORDING TO PLAN
         E67             ZZZ    PROVIDERS                                                104      PROVISIONS.
                                                                                                  MAXIMUM COVERAGE AMOUNT MET OR
         E68             ZZZ    Z1885 EXCEEDS LIMIT OF 600 UNITS PER SFY                 483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                                  MAXIMUM COVERAGE AMOUNT MET OR
         E69             ZZZ    12 NURSE PRACTITIONER/CERT NURSE MIDWIFE VISTS PER SFY   483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                                  MAXIMUM COVERAGE AMOUNT MET OR
         E74             ZZZ    Z1888/WHEELCHAIR VAN/PAYABLE ONLY ONCE PER DOS           483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                                  MAXIMUM COVERAGE AMOUNT MET OR
         E75             ZZZ    Z1889 EXCEEDS LIMIT OF 15 MILES PER DOS                  483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                                  MAXIMUM COVERAGE AMOUNT MET OR
E76                      ZZZ    Z1890 EXCEEDS LIMIT OF 30 MILES PER DOS                  483      EXCEEDED FOR BENEFIT PERIOD.
                                TRANSPORTATION SERV LIMITED TO 50 MILES PER DATE OF               MAXIMUM COVERAGE AMOUNT MET OR
         E77             ZZZ    SERVICE                                                  483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                                  MAXIMUM COVERAGE AMOUNT MET OR
         E78             ZZZ    Z1904/PAYABLE ONLY ONCE PER DATE OF SERVICE              483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                                  MAXIMUM COVERAGE AMOUNT MET OR
         E79             ZZZ    Z1905/PAYABLE ONLY ONCE PER DATE OF SERVICE              483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                                  MAXIMUM COVERAGE AMOUNT MET OR
         E84             ZZZ    TRANSPORTATION SERVICES IN EXCESS OF 300 MILES PER DOS   483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                                  PROCESSED ACCORDING TO PLAN
         E85             ZZZ    TRANSPORTATION CODE NOT PAYABLE AS BILLED                104      PROVISIONS.
                                                                                                  MAXIMUM COVERAGE AMOUNT MET OR
         E87             ZZZ    P CARE TRANSPORTATION LIMIT 30 UNITS PER DOS/RECIP       483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                                  MAXIMUM COVERAGE AMOUNT MET OR
         E88             ZZZ    SYMPATHECTOMY ALLOWED TWICE IN A LIFETIME                483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                                  MAXIMUM COVERAGE AMOUNT MET OR
         E89             ZZZ    SYMPATHECTOMY ALLOWED TWICE IN A LIFETIME                483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                                  MAXIMUM COVERAGE AMOUNT MET OR
         E90             ZZZ    SYMPATHECTOMY ALLOWED TWICE IN A LIFETIME                483      EXCEEDED FOR BENEFIT PERIOD.




 5/16/2012                                                          Page 312
                                                             ESC TO 277


                                                                                     277
                    PLAN                                                             CLAIM
 EDIT/AUDIT   TXN   CODE   EDIT/AUDIT DESCRIPTION                                    STATUS   CLAIM STATUS CODE
                                                                                              MAXIMUM COVERAGE AMOUNT MET OR
     E95            ZZZ    MEDICAL EVALUATION LIMITED TO FOUR UNITS PER SFY          483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                              MAXIMUM COVERAGE AMOUNT MET OR
     E96            ZZZ    PHYSICAL EVALUATION LIMITED TO FOUR UNITS PER SFY         483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                              MAXIMUM COVERAGE AMOUNT MET OR
     E97            ZZZ    OCCUPATIONAL EVALUATION LIMITED TO FOUR UNITS PER SFY     483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                              MAXIMUM COVERAGE AMOUNT MET OR
     E98            ZZZ    PELVIC LYMPHADENECTOMY ALLOWED TWICE IN A LIFETIME        483      EXCEEDED FOR BENEFIT PERIOD.
                           INGUINOFEMORAL LYMPHADENECTOMY ALLOWED TWICE IN A                  MAXIMUM COVERAGE AMOUNT MET OR
     F00            ZZZ    LIFETIME                                                  483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                              MAXIMUM COVERAGE AMOUNT MET OR
     F02            ZZZ    ORCHIECTOMY ALLOWED TWICE IN A LIFETIME                   483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                              MAXIMUM COVERAGE AMOUNT MET OR
     F04            ZZZ    VESICULECTOMY ALLOWED TWICE IN A LIFETIME              483         EXCEEDED FOR BENEFIT PERIOD.
                           TRANSECTION/AVULSION OBTURATOR, EXTRAPELVIC TWICE IN A             MAXIMUM COVERAGE AMOUNT MET OR
     F06            ZZZ    LIFETIME                                               483         EXCEEDED FOR BENEFIT PERIOD.
                                                                                              MAXIMUM COVERAGE AMOUNT MET OR
     F07            ZZZ    TRANSECTION/AVULSION PUDENDAL NERVE TWICE IN A LIFETIME   483      EXCEEDED FOR BENEFIT PERIOD.
                           NEPHRECTOMY & RENAL HOMOTRANSPLANT ALLOWED ONCE IN                 MAXIMUM COVERAGE AMOUNT MET OR
     F11            ZZZ    A LIFETIME                                                483      EXCEEDED FOR BENEFIT PERIOD.
                           TRANSECTION/AVULSION OBTURATOR, INTRAPELVIC TWICE IN A             MAXIMUM COVERAGE AMOUNT MET OR
     F12            ZZZ    LIFETIME                                                  483      EXCEEDED FOR BENEFIT PERIOD.
                           ANESTHESIOLOGY PROCEDURE CODE 01996 ALLOWED ONCE                   MAXIMUM COVERAGE AMOUNT MET OR
     F17            ZZZ    PER SAME DOS                                              483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                              MAXIMUM COVERAGE AMOUNT MET OR
     F19            ZZZ    EXCEEDS 2 TELEMEDICINE CONSULTATION PER SFY               483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                              DUPLICATE OF A PREVIOUSLY PROCESSED
     F21            ZZZ    DETAIL DENIED. DUPLICATE SERVICES                         54       CLAIM/LINE.
                           PA REQUIRED FOR ARKIDS EXCEEDING $500 LMT PER SFY                  MAXIMUM COVERAGE AMOUNT MET OR
     F26            AR1    MENTAL HLTH                                               483      EXCEEDED FOR BENEFIT PERIOD.
                           ARKIDS EXCEEDED $2500 LMT PER SFY FOR MENTAL HEALTH                MAXIMUM COVERAGE AMOUNT MET OR
     F27            AR1    SERVICES                                                  483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                              MAXIMUM COVERAGE AMOUNT MET OR
     F28            ZZZ    CHMS IND PSYCHOTHERAPY 20-30 MIN LIMITED TO TWO PER SFY 483        EXCEEDED FOR BENEFIT PERIOD.
                                                                                              MAXIMUM COVERAGE AMOUNT MET OR
     F29            ZZZ    CHMS IND PSYCHOTHERAPY 45-50 MIN LIMITED TO TWO PER SFY 483        EXCEEDED FOR BENEFIT PERIOD.
                                                                                              MAXIMUM COVERAGE AMOUNT MET OR
     F30            ZZZ    LIMIT OF 3 UNITS PER DAY WITHOUT A BENEFIT EXTENSION      483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                              MAXIMUM COVERAGE AMOUNT MET OR
     F31            ZZZ    TWO EPSDT DENTAL SCREENS ALLOWED PER 150 DAYS             483      EXCEEDED FOR BENEFIT PERIOD.




5/16/2012                                                      Page 313
                                                              ESC TO 277


                                                                                      277
                    PLAN                                                              CLAIM
 EDIT/AUDIT   TXN   CODE   EDIT/AUDIT DESCRIPTION                                     STATUS   CLAIM STATUS CODE
                                                                                               MAXIMUM COVERAGE AMOUNT MET OR
     F32            ZZZ    CHMS SCREENING TEST LIMITED TO TWO PER SFY                 483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                               MAXIMUM COVERAGE AMOUNT MET OR
     F33            ZZZ    CHMS PURE TONE AUDIOMETRY; AIR LIMITED TO TWO PER SFY  483          EXCEEDED FOR BENEFIT PERIOD.
                           CHMS PURE TONE AUDIOMETRY; AIR/BONE LIMITED TO TWO PER              MAXIMUM COVERAGE AMOUNT MET OR
     F34            ZZZ    SFY                                                    483          EXCEEDED FOR BENEFIT PERIOD.
                           CHMS SPEECH AUDIOMETRY THRESHOLD LIMITED TO TWO PER                 MAXIMUM COVERAGE AMOUNT MET OR
     F35            ZZZ    SFY                                                    483          EXCEEDED FOR BENEFIT PERIOD.
                                                                                               MAXIMUM COVERAGE AMOUNT MET OR
     F36            ZZZ    CHMS COMPREHENSIVE AUDIOMETRY LIMITED TO TWO PER SFY 483            EXCEEDED FOR BENEFIT PERIOD.
                                                                                               MAXIMUM COVERAGE AMOUNT MET OR
     F37            ZZZ    CHMS TYMPANOMETRY LIMITED TO TWO PER SFY                   483      EXCEEDED FOR BENEFIT PERIOD.
                           CHMS CONDITIONING PLAY AUDIOMETRY LIMITED TO TWO PER                MAXIMUM COVERAGE AMOUNT MET OR
     F38            ZZZ    SFY                                                        483      EXCEEDED FOR BENEFIT PERIOD.
                           CHMS AUDITORY EVOKED POTENTIAL/RESPONSE LIMITED TO                  MAXIMUM COVERAGE AMOUNT MET OR
     F39            ZZZ    TWO PER SFY                                                483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                               MAXIMUM COVERAGE AMOUNT MET OR
     H00            ZZZ    VISUAL OFFICE MEDICAL SERVICES LTD TO 2 PER SFY            483      EXCEEDED FOR BENEFIT PERIOD.
                           CHMS EVOKED OTOACOUSTIC EMISSIONS LIMITED TO TWO PER                MAXIMUM COVERAGE AMOUNT MET OR
     H14            ZZZ    SFY                                                        483      EXCEEDED FOR BENEFIT PERIOD.
                           CHMS EVOKED OTOACOUSTIC EMISSIONS;COMPREHENSIVE LTD                 MAXIMUM COVERAGE AMOUNT MET OR
     H15            ZZZ    TWO PER SFY                                                483      EXCEEDED FOR BENEFIT PERIOD.
                           CHMS OTORHINOLAYRNGOLOGICAL PROCEDURE LIMITED TO                    MAXIMUM COVERAGE AMOUNT MET OR
     H16            ZZZ    TWO PER SFY                                                483      EXCEEDED FOR BENEFIT PERIOD.
                           WHEELCHAIR PURCHASE LIMITED TO ONE PER TWO YEAR                     MAXIMUM COVERAGE AMOUNT MET OR
     H17            ZZZ    PERIOD                                                     483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                               MAXIMUM COVERAGE AMOUNT MET OR
     H18            ZZZ    CHMS ASSESSMENT OF APHASIA LIMITED TO TWO PER SFY          483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                               MAXIMUM COVERAGE AMOUNT MET OR
     H19            ZZZ    CHMS DEVELOPMENTAL TESTING LIMITED TO TWO PER SFY          483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                               MAXIMUM COVERAGE AMOUNT MET OR
     H20            ZZZ    MATERNAL MMR INJECTION LIMITED TO TWO PER LIFETIME         483      EXCEEDED FOR BENEFIT PERIOD.
                           CHMS NEUROPSYCHOLOGICAL TESTING LIMITED TO EIGHT PER                MAXIMUM COVERAGE AMOUNT MET OR
     H21            ZZZ    SFY                                                        483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                               MAXIMUM COVERAGE AMOUNT MET OR
     H22            ZZZ    CHMS OFFICE VISIT FOR EVAL 10 MIN LIMITED TO TWO PER SFY   483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                               MAXIMUM COVERAGE AMOUNT MET OR
     H23            ZZZ    CHMS OFFICE VISIT FOR EVAL 20 MIN LIMITED TO TWO PER SFY   483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                               MAXIMUM COVERAGE AMOUNT MET OR
     H24            ZZZ    CHMS OFFICE VISIT FOR EVAL 30 MIN LIMITED TO TWO PER SFY   483      EXCEEDED FOR BENEFIT PERIOD.




5/16/2012                                                      Page 314
                                                               ESC TO 277


                                                                                      277
                    PLAN                                                              CLAIM
 EDIT/AUDIT   TXN   CODE   EDIT/AUDIT DESCRIPTION                                     STATUS   CLAIM STATUS CODE
                                                                                               MAXIMUM COVERAGE AMOUNT MET OR
     H25            ZZZ    CHMS OFFICE VISIT FOR EVAL 45 MIN LIMITED TO TWO PER SFY   483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                               MAXIMUM COVERAGE AMOUNT MET OR
     H26            ZZZ    CHMS OFFICE VISIT FOR EVAL 60 MIN LIMITED TO TWO PER SFY   483      EXCEEDED FOR BENEFIT PERIOD.
                           CHMS DIAGNOSTIC EVAL/REVIEW RECORDS LIMITED TO SIX PER              MAXIMUM COVERAGE AMOUNT MET OR
     H27            ZZZ    SFY                                                        483      EXCEEDED FOR BENEFIT PERIOD.
                           CHMS PSYCHOLOGICAL TESTING BATTERY LIMITED TO EIGHT                 MAXIMUM COVERAGE AMOUNT MET OR
     H28            ZZZ    PER SFY                                                    483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                               MAXIMUM COVERAGE AMOUNT MET OR
     H29            ZZZ    CHMS INTERPRETATION OF DIAGNOSIS LIMITED TO SIX PER SFY    483      EXCEEDED FOR BENEFIT PERIOD.
                           PA REQUIRED FOR BENEFIT ARKANSAS OUTPATIENT SERVICES                MAXIMUM COVERAGE AMOUNT MET OR
     H30                   OVER TEN                                                   483      EXCEEDED FOR BENEFIT PERIOD.
                           PA REQUIRED FOR BENEFIT ARKANSAS OUTPATIENT SERVICES                MAXIMUM COVERAGE AMOUNT MET OR
     H31                   OVER FIVE                                                  483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                               MAXIMUM COVERAGE AMOUNT MET OR
     H32            ZZZ    CHMS NUTRITION SCREENING LIMITED TO TWO PER SFY            483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                               MAXIMUM COVERAGE AMOUNT MET OR
     H33            ZZZ    CHMS NUTRITION ASSESSMENT LIMITED TO TWO PER SFY           483      EXCEEDED FOR BENEFIT PERIOD.
                           CHMS COMPREHENSIVE NUTRITION ASSESSMENT LTD TO FOUR                 MAXIMUM COVERAGE AMOUNT MET OR
     H34            ZZZ    PER SFY                                                    483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                               MAXIMUM COVERAGE AMOUNT MET OR
     H35            ZZZ    BRIEF CONSULTATION VISIT LIMITED TO FOUR PER SFY           483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                               MAXIMUM COVERAGE AMOUNT MET OR
     H36            ZZZ    COLLATERAL SERVICES LIMITED TO FOUR PER SFY                483      EXCEEDED FOR BENEFIT PERIOD.
                           PA REQUIRED FOR BENEFIT ARKANSAS OUTPATIENT SERVICES                MAXIMUM COVERAGE AMOUNT MET OR
     H37                   OVER FOUR                                                  483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                               MAXIMUM COVERAGE AMOUNT MET OR
     H38            ZZZ    LIMIT TWO ULTRASOUNDS PER NINE MONTH PERIOD                483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                               MAXIMUM COVERAGE AMOUNT MET OR
     I00            ZZZ    PERSONAL CARE TRANSPORTATION LIMIT 50 MILES PER DOS        483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                               MAXIMUM COVERAGE AMOUNT MET OR
     I01            AR1    EXCEEDS HOME HEALTH VISITS PER SFY                         483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                               MAXIMUM COVERAGE AMOUNT MET OR
     I01            ZZZ    EXCEEDS HOME HEALTH VISITS PER SFY                         483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                               MAXIMUM COVERAGE AMOUNT MET OR
     I03            ZZZ    Z1918 LIMITED TO 32 UNITS PER DOS                          483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                               MAXIMUM COVERAGE AMOUNT MET OR
     I04            DDS    92506 EXCEEDS LIMIT OF FOUR UNITS PER SFY                  483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                               MAXIMUM COVERAGE AMOUNT MET OR
     IO4            ZZZ    92506 DDTCS SPEECH THERAPY EVAL EXCEED 4 UNITS SFY         483      EXCEEDED FOR BENEFIT PERIOD.




5/16/2012                                                       Page 315
                                                                 ESC TO 277


                                                                                   277
                    PLAN                                                           CLAIM
 EDIT/AUDIT   TXN   CODE   EDIT/AUDIT DESCRIPTION                                  STATUS   CLAIM STATUS CODE
                                                                                            MAXIMUM COVERAGE AMOUNT MET OR
     I05            ZZZ    Z1919 LIMITED TO $7500.00 PER LIFETIME                  483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                            MAXIMUM COVERAGE AMOUNT MET OR
     I06            DDS    Z1920 LIMITED TO $300.00 PER CALENDAR MONTH             483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                            MAXIMUM COVERAGE AMOUNT MET OR
     I06            ZZZ    T1920 LIMITED TO $300.00 PER CALENDAR MONTH             483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                            MAXIMUM COVERAGE AMOUNT MET OR
     I07            DDS    Z1921 LIMITED TO ONCE PER CALENDER MONTH                483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                            MAXIMUM COVERAGE AMOUNT MET OR
     I07            ZZZ    Z1921 LIMITED TO ONCE PER CALENDER MONTH                483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                            MAXIMUM COVERAGE AMOUNT MET OR
     I08            ZZZ    Z1917 LIMITED TO $102.00 PER DOS                        483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                            MAXIMUM COVERAGE AMOUNT MET OR
     I09            ZZZ    Z0481 LIMITED TO 40 UNITS PER MONTH                     483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                            MAXIMUM COVERAGE AMOUNT MET OR
     I12            ZZZ    HOME -DELIVERED MEALS LIMITED TO 31 PER MONTH           483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                            MAXIMUM COVERAGE AMOUNT MET OR
     I13            ZZZ    Z2282 EXCEEDS LIMIT OF FOUR MEALS PER SFY               483      EXCEEDED FOR BENEFIT PERIOD.
                           Z2283-PERS ONE INSTALLATION PER LIFETIME OR PERIOD OF            MAXIMUM COVERAGE AMOUNT MET OR
     I14            ZZZ    ELIGIBILITY                                             483      EXCEEDED FOR BENEFIT PERIOD.
                           DDS LEVEL IV CASE MANAGEMENT LIMITED TO ONCE PER 12 MO.          MAXIMUM COVERAGE AMOUNT MET OR
     I15            ZZZ    PERIOD                                                  483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                            MAXIMUM COVERAGE AMOUNT MET OR
     I16            ZZZ    ONLY ONE DDS CASE MANAGEMENT SERVICE PER MONTH          483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                            MAXIMUM COVERAGE AMOUNT MET OR
     I17            ZZZ    ONLY ONE DDS CASE MANAGEMENT SERVICE PER MONTH          483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                            MAXIMUM COVERAGE AMOUNT MET OR
     I18            ZZZ    CHMS IND PSYCHOTHERAPY 75-80 MIN LIMITED TO TWO PER SFY 483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                            MAXIMUM COVERAGE AMOUNT MET OR
     I19            AR1    ONLY ONE ARKIDS PREVENTIVE HEALTH SCREEN FOR AGE 10     483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                            MAXIMUM COVERAGE AMOUNT MET OR
     I19            ZZZ    ONLY ONE EPSDT MEDICAL SCREEN FOR AGE 10                483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                            MAXIMUM COVERAGE AMOUNT MET OR
     I20            AR1    ONLY ONE ARKIDS PREVENTIVE HEALTH SCREEN FOR AGE 11     483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                            MAXIMUM COVERAGE AMOUNT MET OR
     I20            ZZZ    ONLY ONE EPSDT MEDICAL SCREEN FOR AGE 11                483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                            MAXIMUM COVERAGE AMOUNT MET OR
     I21            AR1    ONLY ONE ARKIDS PREVENTIVE HEALTH SCREEN FOR AGE 12     483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                            MAXIMUM COVERAGE AMOUNT MET OR
     I21            ZZZ    ONLY ONE EPSDT MEDICAL SCREEN FOR AGE 12                483      EXCEEDED FOR BENEFIT PERIOD.




5/16/2012                                                           Page 316
                                                             ESC TO 277


                                                                                    277
                    PLAN                                                            CLAIM
 EDIT/AUDIT   TXN   CODE   EDIT/AUDIT DESCRIPTION                                   STATUS   CLAIM STATUS CODE
                                                                                             MAXIMUM COVERAGE AMOUNT MET OR
     I22            AR1    ONLY ONE ARKIDS PREVENTIVE HEALTH SCREEN FOR AGE 13      483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                             MAXIMUM COVERAGE AMOUNT MET OR
     I22            ZZZ    ONLY ONE EPSDT MEDICAL SCREEN FOR AGE 13                 483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                             MAXIMUM COVERAGE AMOUNT MET OR
     I23            AR1    ONLY ONE ARKIDS PREVENTIVE HEALTH SCREEN FOR AGE 14      483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                             MAXIMUM COVERAGE AMOUNT MET OR
     I23            ZZZ    ONLY ONE EPSDT MEDICAL SCREEN FOR AGE 14                 483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                             MAXIMUM COVERAGE AMOUNT MET OR
     I24            AR1    ONLY ONE ARKIDS PREVENTIVE HEALTH SCREEN FOR AGE 15      483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                             MAXIMUM COVERAGE AMOUNT MET OR
     I24            ZZZ    ONLY ONE EPSDT MEDICAL SCREEN FOR AGE 15                 483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                             MAXIMUM COVERAGE AMOUNT MET OR
     I25            AR1    ONLY ONE ARKIDS PREVENTIVE HEALTH SCREEN FOR AGE 16      483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                             MAXIMUM COVERAGE AMOUNT MET OR
     I25            ZZZ    ONLY ONE EPSDT MEDICAL SCREEN FOR AGE 16                 483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                             MAXIMUM COVERAGE AMOUNT MET OR
     I26            AR1    ONLY ONE ARKIDS PREVENTIVE HEALTH SCREEN FOR AGE 17      483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                             MAXIMUM COVERAGE AMOUNT MET OR
     I26            ZZZ    ONLY ONE EPSDT MEDICAL SCREEN FOR AGE 17                 483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                             MAXIMUM COVERAGE AMOUNT MET OR
     I27            AR1    ONLY ONE ARKIDS PREVENTIVE HEALTH SCREEN FOR AGE 18      483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                             MAXIMUM COVERAGE AMOUNT MET OR
     I27            ZZZ    ONLY ONE EPSDT MEDICAL SCREEN FOR AGE 18                 483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                             MAXIMUM COVERAGE AMOUNT MET OR
     I28            ZZZ    ONLY ONE EPSDT MEDICAL SCREEN FOR AGE 19                 483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                             MAXIMUM COVERAGE AMOUNT MET OR
     I29            ZZZ    ONLY ONE EPSDT MEDICAL SCREEN FOR AGE 20                 483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                             MAXIMUM COVERAGE AMOUNT MET OR
     J00            ZZZ    E0570 EXCEEDS TOTAL REIMBURSEMENT OF $140.00 FOR TOS U   483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                             MAXIMUM COVERAGE AMOUNT MET OR
     J01            ZZZ    E0570 EXCEEDS TOTAL REIMBURSEMENT OF $175.00             483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                             MAXIMUM COVERAGE AMOUNT MET OR
     J03            ZZZ    TWO PODIATRY VISITS ALLOWED PER STATE FISCAL YEAR        483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                             MAXIMUM COVERAGE AMOUNT MET OR
     J05            ZZZ    MEDICAL SUPPLIES EXCEED $250.00 PER CALENDAR MONTH       483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                             MAXIMUM COVERAGE AMOUNT MET OR
     J06            ZZZ    MEDICAL SUPPLIES EXCEED $80.00 PER CALENDAR MONTH        483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                             MAXIMUM COVERAGE AMOUNT MET OR
     J08            ZZZ    92506 EXCEEDS LIMIT TO FOUR UNITS PER SFY                483      EXCEEDED FOR BENEFIT PERIOD.




5/16/2012                                                      Page 317
                                                              ESC TO 277


                                                                                        277
                    PLAN                                                                CLAIM
 EDIT/AUDIT   TXN   CODE   EDIT/AUDIT DESCRIPTION                                       STATUS   CLAIM STATUS CODE
                                                                                                 MAXIMUM COVERAGE AMOUNT MET OR
     J10            ZZZ    95882 EXCEEDS LIMIT OF ONE PER SFY                       483          EXCEEDED FOR BENEFIT PERIOD.
                           EXCEEDS LIMIT OF 30 RSPD (PT=26, PS=RH) DAYS PER CURRENT              MAXIMUM COVERAGE AMOUNT MET OR
     J13            ZZZ    SFY                                                      483          EXCEEDED FOR BENEFIT PERIOD.
                           AUGMENTATIVE COMMUNICATIVE DEVICES EXCEED $7500                       MAXIMUM COVERAGE AMOUNT MET OR
     J14            ZZZ    LIFETIME BENEFIT                                         483          EXCEEDED FOR BENEFIT PERIOD.
                                                                                                 MAXIMUM COVERAGE AMOUNT MET OR
     J15            ZZZ    EXCEEDS 12 FQHC VISITS PER SFY                               483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                                 MAXIMUM COVERAGE AMOUNT MET OR
     J16            ZZZ    EXCEEDS LIMIT OF 30 RSPD (PT=26, PS=RH) DAYS PER PRIOR SFY   483      EXCEEDED FOR BENEFIT PERIOD.
                           OCCUPATIONAL THERAPY CODE Z1929 LIMITED TO 4 UNITS PER                MAXIMUM COVERAGE AMOUNT MET OR
     J17            ZZZ    DOS                                                          483      EXCEEDED FOR BENEFIT PERIOD.
                           PUBLIC TRANSPORTATION Z1989 LTD TO 30 UNITS PER DATE OF               MAXIMUM COVERAGE AMOUNT MET OR
     J60            ZZZ    SERVICE                                                      483      EXCEEDED FOR BENEFIT PERIOD.
                           FETAL ULTRASOUND LTD TO TWO PER NINE MO PERIOD                        MAXIMUM COVERAGE AMOUNT MET OR
     J61            ZZZ    COMPLETE/PROF                                                483      EXCEEDED FOR BENEFIT PERIOD.
                           FETAL ULTRASOUND LTD TO TWO PER NINE MO PERIOD                        MAXIMUM COVERAGE AMOUNT MET OR
     J62            ZZZ    COMPLETE/TECH                                                483      EXCEEDED FOR BENEFIT PERIOD.
                           PROSTHETICS DEVICES LIMITED TO $20,000 PER STATE FISCAL               MAXIMUM COVERAGE AMOUNT MET OR
     J63            ZZZ    YEAR                                                         483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                                 MAXIMUM COVERAGE AMOUNT MET OR
     J64            ZZZ    PROSTHETICS DEVICES LIMITED TO ONE IN FIVE YEARS             483      EXCEEDED FOR BENEFIT PERIOD.
                           ORTHOTIC APPLIANCE LIMITED TO $3,000 PER STATE FISCAL                 MAXIMUM COVERAGE AMOUNT MET OR
     J65            ZZZ    YEAR                                                         483      EXCEEDED FOR BENEFIT PERIOD.
                           ORTHOTIC APPLIANCE REPLACEMENT LIMITED TO ONE PER 12                  MAXIMUM COVERAGE AMOUNT MET OR
     J66            ZZZ    MONTHS                                                       483      EXCEEDED FOR BENEFIT PERIOD.
                           POST STERILIZATION VISIT LIMITED TO ONE PER STATE FISCAL              MAXIMUM COVERAGE AMOUNT MET OR
     J67            ZZZ    YEAR                                                         483      EXCEEDED FOR BENEFIT PERIOD.
                           PROSTHETICS DEVICES LIMITED TO ONE IN FIVE YEARS                      MAXIMUM COVERAGE AMOUNT MET OR
     J68            ZZZ    (BILATERAL)                                                  483      EXCEEDED FOR BENEFIT PERIOD.
                           ORTHOTIC APPL REPLACEMENT LIMITED TO ONE PER 12 MO                    MAXIMUM COVERAGE AMOUNT MET OR
     J69            ZZZ    (BILATERAL)                                                  483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                                 MAXIMUM COVERAGE AMOUNT MET OR
     J70            DDS    OCCUPATIONAL THERAPY EVAL LIMITED TO 4 PER SFY               483      EXCEEDED FOR BENEFIT PERIOD.
                           FAMILY SUPPORT SERVICES LIMITED TO $5,000 PER STATE                   MAXIMUM COVERAGE AMOUNT MET OR
     J71            DDS    FISCAL YR                                                    483      EXCEEDED FOR BENEFIT PERIOD.
                           PA REQUIRED FOR ARKIDS EXCEEDING $500 LMT PER SFY                     MAXIMUM COVERAGE AMOUNT MET OR
     J72            AR1    MENTAL HLTH                                                  483      EXCEEDED FOR BENEFIT PERIOD.
                           ARKIDS EXCEEDED $2500 LMT PER SFY FOR MENTAL HEALTH                   MAXIMUM COVERAGE AMOUNT MET OR
     J73            AR1    SERVICES                                                     483      EXCEEDED FOR BENEFIT PERIOD.




5/16/2012                                                      Page 318
                                                             ESC TO 277


                                                                                   277
                    PLAN                                                           CLAIM
 EDIT/AUDIT   TXN   CODE   EDIT/AUDIT DESCRIPTION                                  STATUS   CLAIM STATUS CODE
                           TWO FETAL NON-STRESS TESTS ALLOWED PER NINE-MONTH                MAXIMUM COVERAGE AMOUNT MET OR
     J74            ZZZ    PERIOD                                                  483      EXCEEDED FOR BENEFIT PERIOD.

     J75            ZZZ    FORMULAS NOT PAYABLE WITH SAME TOS IN SAME MONTH        9        NO PAYMENT WILL BE MADE FOR THIS CLAIM.

     J76            ZZZ    FORMULAS NOT PAYABLE WITH SAME TOS IN SAME MONTH        9        NO PAYMENT WILL BE MADE FOR THIS CLAIM.
                           DME TOS I PCODE NOT PAYABLE SAME DOS AS DME PCODE TOS            PROCESSED ACCORDING TO PLAN
     N00            ZZZ    169HUI                                                  104      PROVISIONS.
                           DME TOS 169H OR U PCODE NOT PAY SAME OR O/LAP DOS AS             PROCESSED ACCORDING TO PLAN
     N01            ZZZ    PCODE I                                                 104      PROVISIONS.
                                                                                            MAXIMUM COVERAGE AMOUNT MET OR
     N02            DDS    PHYSICAL THERAPY EVAL LIMITED TO 4 PER SFY              483      EXCEEDED FOR BENEFIT PERIOD.
                           FULL AND INTERPERIODIC MEDICAL SCREENS NOT PAYABLE ON            PROCESSED ACCORDING TO PLAN
     N03            ZZZ    SAME DOS                                                104      PROVISIONS.
                           INTERPERIODIC AND FULL MEDICAL SCREENS NOT PAYABLE ON            PROCESSED ACCORDING TO PLAN
     N04            ZZZ    SAME DOS                                                104      PROVISIONS.
                           PARTIAL EPSDT SCREEN NOPAY SAME DOS AS FULL EPSDT                PROCESSED ACCORDING TO PLAN
     N05            ZZZ    SCREEN                                                  104      PROVISIONS.
                           RECOUPE OR DENY PART/SCREENS WHEN BILLED SAME DOS AS             PROCESSED ACCORDING TO PLAN
     N06            ZZZ    FULL SCREEN                                             104      PROVISIONS.
                           INPATIENT HOSPICE CARE NONPAYABLE SAME DOS AS HOSPICE            PROCESSED ACCORDING TO PLAN
     N07            ZZZ    ROOM/BOARD                                              104      PROVISIONS.
                           HOSPICE ROOM /BOARD NONPAYABLE SAME DOS AS INPATIENT             PROCESSED ACCORDING TO PLAN
     N08            ZZZ    HOSPICE CARE                                            104      PROVISIONS.
                           ROUTINE HOME CARE NO/PAY SAME DOS AS                             PROCESSED ACCORDING TO PLAN
     N09            ZZZ    CONT/HOMECARE/RESP/CARE                                 104      PROVISIONS.
                           CONT/HOME CARE OR RESP/CARE NO/PAY SAME DOS AS                   PROCESSED ACCORDING TO PLAN
     N10            ZZZ    ROUTINE HOMECARE                                        104      PROVISIONS.
                           Z1714 NONPAYABLE IN CONJUNCTION WITH OTHER HOSPICE               PROCESSED ACCORDING TO PLAN
     N11            ZZZ    SERVICES                                                104      PROVISIONS.
                           HOSPICE SERV/NONPAYABLE ON SAME DOS AS PAID/PENDING              PROCESSED ACCORDING TO PLAN
     N12            ZZZ    CLAIM/Z1714                                             104      PROVISIONS.
                           INPATIENT HOSPICE CARE NOPAY/SAME DOS AS HOSPICE HOME            PROCESSED ACCORDING TO PLAN
     N13            ZZZ    CARE                                                    104      PROVISIONS.
                           HOSPICE HOME CARE NOPAY/SAME DOS AS INPATIENT HOSPICE            PROCESSED ACCORDING TO PLAN
     N14            ZZZ    CARE                                                    104      PROVISIONS.
                                                                                            MAXIMUM COVERAGE AMOUNT MET OR
     N17            ZZZ    NORPLANT REMOVAL ALLOWED ONCE PER FIVE YEAR PERIOD      483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                            PROCESSED ACCORDING TO PLAN
     N18            ZZZ    Z0561 NOT PAYABLE SAME DOS AS Z0562                     104      PROVISIONS.




5/16/2012                                                        Page 319
                                                             ESC TO 277


                                                                                  277
                    PLAN                                                          CLAIM
 EDIT/AUDIT   TXN   CODE   EDIT/AUDIT DESCRIPTION                                 STATUS   CLAIM STATUS CODE
                           ABSENCE OF ANESTHESIA PROCEDURE CODE PREVENTS                   PROCEDURE CODE FOR SERVICES
     N19            ZZZ    PAYMENT OF CLAIM                                       454      RENDERED.
                           93541 NOT ALLOW SAME DOS AS CERTAIN COMPANION                   PROCESSED ACCORDING TO PLAN
     N50            ZZZ    RADIOLOGICAL CODE                                      104      PROVISIONS.
                                                                                           PROCESSED ACCORDING TO PLAN
     N51            ZZZ    PROCEDURE IS INCLUDED IN 93541 FOR SAME DOS            104      PROVISIONS.
                           93542 NOT ALLOW SAME DOS AS CERTAIN COMPANION                   PROCESSED ACCORDING TO PLAN
     N52            ZZZ    RADIOLOGICAL CODE                                      104      PROVISIONS.
                                                                                           PROCESSED ACCORDING TO PLAN
     N53            ZZZ    PROCEDURE IS INCLUDED IN 93542 FOR SAME DOS            104      PROVISIONS.
                           93543/93546 NOT ALLOW SAME DOS AS COMPANION                     PROCESSED ACCORDING TO PLAN
     N54            ZZZ    RADIOLOGICAL CODE                                      104      PROVISIONS.
                                                                                           PROCESSED ACCORDING TO PLAN
     N55            ZZZ    PROCEDURE IS INCLUDED IN 93543/93546 FOR SAME DOS      104      PROVISIONS.
                           93544 NOT ALLOW SAME DOS AS CERTAIN COMPANION                   PROCESSED ACCORDING TO PLAN
     N56            ZZZ    RADIOLOGICAL CODE                                      104      PROVISIONS.
                                                                                           PROCESSED ACCORDING TO PLAN
     N57            ZZZ    PROCEDURE INCLUDED IN CODE 93544 FOR SAME DOS          104      PROVISIONS.
                           93545 NOT ALLOWED SAME DOS AS CERTAIN COMPANION                 PROCESSED ACCORDING TO PLAN
     N58            ZZZ    RADIOLOGICAL CODE                                      104      PROVISIONS.
                                                                                           PROCESSED ACCORDING TO PLAN
     N59            ZZZ    PROCEDURE INCLUDED IN CODE 93545 FOR SAME DOS          104      PROVISIONS.
                           93501-93529 NOT ALLOW SAME DOS AS CERTAIN COMPANION             PROCESSED ACCORDING TO PLAN
     N64            ZZZ    RADIO CODES                                            104      PROVISIONS.
                                                                                           PROCESSED ACCORDING TO PLAN
     N65            ZZZ    PROCEDURE INCLUDED IN CODES 93501-93529 FOR SAME DOS   104      PROVISIONS.
                           93551 NOT ALLOW SAME DOS AS CERTAIN COMPANION                   PROCESSED ACCORDING TO PLAN
     N68            ZZZ    RADIOLOGICAL CODES                                     104      PROVISIONS.
                                                                                           PROCESSED ACCORDING TO PLAN
     N69            ZZZ    PROCEDURE INCLUDED IN CODE 93551 FOR SAME DOS          104      PROVISIONS.
                           93552-93553 NOT ALLOW SAME DOS AS CERTAIN COMPANION             PROCESSED ACCORDING TO PLAN
     N70            ZZZ    RADIO CODES                                            104      PROVISIONS.
                                                                                           PROCESSED ACCORDING TO PLAN
     N71            ZZZ    PROCEDURE INCLUDED IN CODES 93552-93553 FOR SAME DOS   104      PROVISIONS.
                           SERVICE INCLUDED IN CRITICAL OR SUBSEQUENT HOSPITAL             PROCESSED ACCORDING TO PLAN
     N72            ZZZ    CARE CODE                                              104      PROVISIONS.
                           CRITICAL OR SUB HOSPITAL CARE NO PAY SAME DOS AS                PROCESSED ACCORDING TO PLAN
     N73            ZZZ    RELATED PROC                                           104      PROVISIONS.
                           93503 NOT PAYABLE IN CONJUNCTION WITH RELATED                   PROCESSED ACCORDING TO PLAN
     N74            ZZZ    PROCEDURE                                              104      PROVISIONS.




5/16/2012                                                     Page 320
                                                              ESC TO 277


                                                                                     277
                    PLAN                                                             CLAIM
 EDIT/AUDIT   TXN   CODE   EDIT/AUDIT DESCRIPTION                                    STATUS   CLAIM STATUS CODE
                                                                                              PROCESSED ACCORDING TO PLAN
     N75            ZZZ    SERVICE NOT PAYABLE SAME DOS AS 93503                     104      PROVISIONS.
                                                                                              PROCESSED ACCORDING TO PLAN
     N76            ZZZ    90704/90705/90706/90707 NOT ALLOWED ON SAME DOS           104      PROVISIONS.
                                                                                              PROCESSED ACCORDING TO PLAN
     N78            ZZZ    90704/90706/90709 NOT ALLOWED ON SAME DOS                 104      PROVISIONS.
                                                                                              PROCESSED ACCORDING TO PLAN
     N79            ZZZ    90705/90706/90708 NOT ALLOWED ON SAME DOS                 104      PROVISIONS.
                           VENIPUNCTURE/ANESTHESIOLOGY CODE DISALLOWED SAME                   PROCESSED ACCORDING TO PLAN
     N80            ZZZ    DOS 90780                                                 104      PROVISIONS.
                           90780 DISALLOWED IN CONJUNCTION WITH PAID                          PROCESSED ACCORDING TO PLAN
     N81            ZZZ    VENIPUNC/ANESTHESIA                                       104      PROVISIONS.
                           NEONATAL INTENSIVE CARE NOT PAID IN ADDITION TO RELATED            PROCESSED ACCORDING TO PLAN
     P00            ZZZ    PROC                                                      104      PROVISIONS.
                                                                                              PROCESSED ACCORDING TO PLAN
     P01            ZZZ    PROCEDURE INCLUDED IN CODES 99295-99297 FOR SAME DOS      104      PROVISIONS.
                           NEONATAL INTENSIVE CARE NOT PAID IN ADDITION TO RELATED            PROCESSED ACCORDING TO PLAN
     P02            ZZZ    SERVICE                                                   104      PROVISIONS.
                                                                                              PROCESSED ACCORDING TO PLAN
     P03            ZZZ    PROCEDURE INCLUDED IN CODES 99295-99297 FOR SAME DOS      104      PROVISIONS.
                           PAID PANEL 77419 PREENTS PAY OF RELATED PROCEDURE                  PROCESSED ACCORDING TO PLAN
     P14            ZZZ    SAME DOS                                                  104      PROVISIONS.
                           RADIOLOGY PROCEDURE 77419 NOT ALLOWED SAME DOS AS                  PROCESSED ACCORDING TO PLAN
     P15            ZZZ    77420-77431                                               104      PROVISIONS.
                                                                                              PROCESSED ACCORDING TO PLAN
     P16            ZZZ    ANESTHESIA NO PAY FOR HOSP VISIT W/01996 FOR SAME DOS     104      PROVISIONS.
                                                                                              PROCESSED ACCORDING TO PLAN
     P17            ZZZ    ANESTHESIA NO PAY FOR 01996 SAME DOS AS PAID HOSP VISIT   104      PROVISIONS.
                                                                                              PROCESSED ACCORDING TO PLAN
     P18            ZZZ    00857 OR 00955 NOT SAME DOS 62278 OR 62279                104      PROVISIONS.
                                                                                              PROCESSED ACCORDING TO PLAN
     P19            ZZZ    62278 OR 62279 NOT SAME DOS AS 00857 OR 00955             104      PROVISIONS.
                                                                                              PROCESSED ACCORDING TO PLAN
     P20            ZZZ    GMIS/INCIDENTAL PROCEDURE, SHOULD NOT BE REIMBURSED       104      PROVISIONS.
                                                                                              PROCESSED ACCORDING TO PLAN
     P21            ZZZ    GMIS/PROCEDURE REBUNDLED TO A GLOBAL COM CODE             104      PROVISIONS.
                                                                                              PROCESSED ACCORDING TO PLAN
     P22            ZZZ    GMIS/MED VISITS ARE CONTENT OF SRV ON SAME DOS            104      PROVISIONS.
                                                                                              PROCESSED ACCORDING TO PLAN
     P23            ZZZ    GMIS/GMIS/MUTUALLY EXCLUS CODE NOT CO-EXIST SAME DOS      104      PROVISIONS.




5/16/2012                                                      Page 321
                                                              ESC TO 277


                                                                                        277
                    PLAN                                                                CLAIM
 EDIT/AUDIT   TXN   CODE   EDIT/AUDIT DESCRIPTION                                       STATUS   CLAIM STATUS CODE
                                                                                                 PROCESSED ACCORDING TO PLAN
     P24            ZZZ    OUTPATIENT ER AND NON-ER SERVICES INCLUDE ASSESSMENT         104      PROVISIONS.
                                                                                                 PROCESSED ACCORDING TO PLAN
     P25            ZZZ    OUTPATIENT ER AND NON-ER SERVICES INCLUDE ASSESSMENT         104      PROVISIONS.
                                                                                                 PROCESSED ACCORDING TO PLAN
     P26            ZZZ    GMIS/PAID RELATED PROC PREVENTS PAYMENT OF THIS CODE         104      PROVISIONS.
                                                                                                 MAXIMUM COVERAGE AMOUNT MET OR
     P27            ZZZ    FLU VACCINE LIMITED TO ONE PER STATE FISCAL YEAR             483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                                 MAXIMUM COVERAGE AMOUNT MET OR
     P29            ZZZ    LIMIT Z2734/Z2735 RO $1000 PER DATE OF SERVICE               483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                                 MAXIMUM COVERAGE AMOUNT MET OR
     P30            ZZZ    APD ENVIRONMENT ADAPTATION LIMITED TO $7500 PER LIFETIME 483          EXCEEDED FOR BENEFIT PERIOD.
                                                                                                 MAXIMUM COVERAGE AMOUNT MET OR
     P31            ZZZ    PNEUMONIA VACCINE LIMITED TO ONE EVERY TEN YEARS             483      EXCEEDED FOR BENEFIT PERIOD.
                           ARKIDS EXCEEDED $2500 LMT PER SFY FOR MENTAL HEALTH                   MAXIMUM COVERAGE AMOUNT MET OR
     P36            AR1    SERVICE                                                      483      EXCEEDED FOR BENEFIT PERIOD.
                           ONE AEROCHAMBER DEVICE PER 365 DAYS FOR RECIPIENTS                    MAXIMUM COVERAGE AMOUNT MET OR
     P37            ZZZ    UNDER 21                                                     483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                                 MAXIMUM COVERAGE AMOUNT MET OR
     P38            ZZZ    ONE THIN PAP SMEAR ALLOWED PER SFY                           483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                                 MAXIMUM COVERAGE AMOUNT MET OR
     P39            ZZZ    INSERTS LIMITED TO THREE PAIR PER SHOE PER SFY (6 INSERTS)   483      EXCEEDED FOR BENEFIT PERIOD.
     Q00            ZZZ    HOSPICE INPATIENT RESPITE CARE 5 CONSECUTIVE DAYS            456      COVERED DAY(S).
     Q01            ZZZ    HOSPICE CONT'D HOME CARE NO PAY FOR UNITS <8 DOS             456      COVERED DAY(S).
                           DEVELOPMENTAL TESTING, EXT W/INTERPRETATION, N/P TO                   PROCESSED ACCORDING TO PLAN
     Q12            DDS    MULT PROV SAME DOS                                           104      PROVISIONS.
                           DEVELOPMENTAL TESTING, EXT W/INTERPRETATION, N/P TO                   PROCESSED ACCORDING TO PLAN
     Q12            ZZZ    MULT PROV SAME DOS                                           104      PROVISIONS.
                           DEVELOPMENTAL TESTING, EXT W/INTERPRETATION, N/P TO                   PROCESSED ACCORDING TO PLAN
     Q13            DDS    MULT PROV SAME DOS                                           104      PROVISIONS.
                           DEVELOPMENTAL TESTING, EXT W/INTERPRETATION, N/P TO                   PROCESSED ACCORDING TO PLAN
     Q13            ZZZ    MULT PROV SAME DOS                                           104      PROVISIONS.
                           THERAPEUTIC ACTIVITIES NON-PAYABLE TO MULT PROVIDERS                  PROCESSED ACCORDING TO PLAN
     Q14            DDS    ON SAME DOS                                                  104      PROVISIONS.
                           THERAPEUTIC ACTIVITIES NON-PAYABLE TO MULT PROVIDERS                  PROCESSED ACCORDING TO PLAN
     Q14            ZZZ    ON SAME DOS                                                  104      PROVISIONS.
                           THERAPEUTIC ACTIVITIES NON-PAYABLE TO MULT PROVIDERS                  PROCESSED ACCORDING TO PLAN
     Q15            DDS    ON SAME DOS                                                  104      PROVISIONS.
                           THERAPEUTIC ACTIVITIES NON-PAYABLE TO MULT PROVIDERS                  PROCESSED ACCORDING TO PLAN
     Q15            ZZZ    ON SAME DOS                                                  104      PROVISIONS.




5/16/2012                                                       Page 322
                                                              ESC TO 277


                                                                                     277
                    PLAN                                                             CLAIM
 EDIT/AUDIT   TXN   CODE   EDIT/AUDIT DESCRIPTION                                    STATUS   CLAIM STATUS CODE
                           ONE PAIR EYE GLASSES EVERY 24 MONTHS FOR REC 21 AND                MAXIMUM COVERAGE AMOUNT MET OR
     Q17            ZZZ    OLDER                                                     483      EXCEEDED FOR BENEFIT PERIOD.
                           ONE EYE EXAM EVERY 24 MONTHS FOR RECIPIENTS 21 AND                 MAXIMUM COVERAGE AMOUNT MET OR
     Q18            ZZZ    OLDER                                                     483      EXCEEDED FOR BENEFIT PERIOD.
                           POWER WHEELCHAIR ACCESSORIES, BATTERY/CHARGER,                     MAXIMUM COVERAGE AMOUNT MET OR
     Q19            ZZZ    LIMITED TO TWO PER SFY                                    483      EXCEEDED FOR BENEFIT PERIOD.
                           PERSONAL CARE SERV LTD TO 256 UNITS W/O EXT OF BENEFITS            MAXIMUM COVERAGE AMOUNT MET OR
     Q20            ZZZ    PA                                                        483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                              MAXIMUM COVERAGE AMOUNT MET OR
     Q24            ZZZ    SYMPATHECTOMY ALLOWED TWICE IN A LIFETIME                 483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                              MAXIMUM COVERAGE AMOUNT MET OR
     Q25            ZZZ    SYMPATHECTOMY ALLOWED TWICE IN A LIFETIME                 483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                              MAXIMUM COVERAGE AMOUNT MET OR
     Q26            ZZZ    SYMPATHECTOMY ALLOWED TWICE IN A LIFETIME                 483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                              PROCESSED ACCORDING TO PLAN
     Q27            ZZZ    SERVICES NOT PAYABLE TO POST-STERILIZED RECIPIENT         104      PROVISIONS.
                                                                                              PROCESSED ACCORDING TO PLAN
     Q28            ZZZ    SERVICES NOT PAYABLE TO POST-STERILIZED RECIPIENT         104      PROVISIONS.
                           OFFICE/OP VISITS W/TOS R PT26 NON-PAYABLE                          PROCESSED ACCORDING TO PLAN
     Q29            ZZZ    W/PSYCHOTHERAPY CODES                                     104      PROVISIONS.
                           PSYCHOTHERAPY CODE NONPAYABLE WITH                                 PROCESSED ACCORDING TO PLAN
     Q30            ZZZ    OFFICE/OUTPAT/HOSPITAL VISITS                             104      PROVISIONS.
                                                                                              MAXIMUM COVERAGE AMOUNT MET OR
     Q31            ZZZ    ONLY ONE PSYCHOTHERAPY VISIT ALLOWED PER DAY              483      EXCEEDED FOR BENEFIT PERIOD.
     Q32            ZZZ    ONE DISP FEE PER MONTH PER LTC RECIPIENT                  216      DRUG INFORMATION.
                           31 UNITS ASSISTED LIVING PHARMACIST CONSULTANT                     MAXIMUM COVERAGE AMOUNT MET OR
     Q35            ZZZ    SERVICES ALLOWED PER MO                                   483      EXCEEDED FOR BENEFIT PERIOD.
                           ONLY ONE CONSULT/OFFICE VISIT PER DOS PER PERFORMING               MAXIMUM COVERAGE AMOUNT MET OR
     Q36            ZZZ    PROVIDER                                                  483      EXCEEDED FOR BENEFIT PERIOD.
                           31 UNITS ASSISTED LIVING WAIVER SERVICES ALLOWED PER               MAXIMUM COVERAGE AMOUNT MET OR
     Q37            ZZZ    MONTH                                                     483      EXCEEDED FOR BENEFIT PERIOD.
                           X-RAYS LIMITED TO $52.00 PER 5 YEARS WITHOUT PRIOR                 MAXIMUM COVERAGE AMOUNT MET OR
     R05            ZZZ    AUTHORIZATION                                             483      EXCEEDED FOR BENEFIT PERIOD.
                           FILLING NOT ALLOWED ON TOOTH NUMBERS WITH CROWNS                   PROCESSED ACCORDING TO PLAN
     R06            ZZZ    WITHIN ONE YEAR                                           104      PROVISIONS.
                                                                                              MAXIMUM COVERAGE AMOUNT MET OR
     R08            ZZZ    PERIODIC FAMILY PLANNING VISITS LIMITED TO 3 PER SFY      483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                              MAXIMUM COVERAGE AMOUNT MET OR
     R09            ZZZ    PERIODIC FAMILY PLANNING VISITS LIMITED TO 3 PER SFY      483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                              MAXIMUM COVERAGE AMOUNT MET OR
     R10            ZZZ    ONLY ONE FAMILY PLANNING VISIT/SERVICE ALLOWED PER DOS    483      EXCEEDED FOR BENEFIT PERIOD.



5/16/2012                                                      Page 323
                                                              ESC TO 277


                                                                                    277
                    PLAN                                                            CLAIM
 EDIT/AUDIT   TXN   CODE   EDIT/AUDIT DESCRIPTION                                   STATUS   CLAIM STATUS CODE
                                                                                             MAXIMUM COVERAGE AMOUNT MET OR
     R11            ZZZ    ONLY ONE FAMILY PLANNING VISIT/SERVICE ALLOWED PER DOS   483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                             MAXIMUM COVERAGE AMOUNT MET OR
     R12            ZZZ    ONE ANNUAL FAMILY PLANNING VISIT PER SFY                 483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                             MAXIMUM COVERAGE AMOUNT MET OR
     R13            ZZZ    ONE ANNUAL FAMILY PLANNING VISIT PER SFY                 483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                             MAXIMUM COVERAGE AMOUNT MET OR
     R14            ZZZ    NORPLANT REMOVAL PAYABLE ONCE PER 5 YEAR PERIOD          483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                             MAXIMUM COVERAGE AMOUNT MET OR
     R15            ZZZ    NORPLANT REMOVAL PAYABLE ONCE PER 5 YEAR PERIOD          483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                             MAXIMUM COVERAGE AMOUNT MET OR
     R18            ZZZ    NORPLANT INSERTION PAYABLE TWICE PER 5 YEAR PERIOD       483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                             MAXIMUM COVERAGE AMOUNT MET OR
     R19            ZZZ    NORPLANT INSERTION PAYABLE TWICE PER 5 YEAR PERIOD       483      EXCEEDED FOR BENEFIT PERIOD.
                           OFFICE/OP VISIT NOT PAYABLE SAME DOS AS COCHLEAR                  PROCESSED ACCORDING TO PLAN
     R20            ZZZ    IMPLANT ANL/RPR                                          104      PROVISIONS.
                           COCHLEAR IMPLANT ANAL/REPROG NOT PAYABLE SAME                     PROCESSED ACCORDING TO PLAN
     R21            ZZZ    DOS/PROV AS OFF/OP                                       104      PROVISIONS.
     R23            ZZZ    PRODUR EARLY REFILL                                      216      DRUG INFORMATION.
                           MULTIPLE PARTIALS ON SAME PRESCRIPTION NUMBER NOT                 CANNOT PROVIDE FURTHUR STATUS
     R24            ZZZ    ALLOWED                                                  0        ELECTRONICALLY.
                           COMPLETION REQUEST SHOULD HAVE ONLY ONE RELATED                   CANNOT PROVIDE FURTHUR STATUS
     R25            ZZZ    PARTIAL IN HISTORY                                       0        ELECTRONICALLY.
                           COMPLETION DOS SHOULD BE DIFFERENT FROM THE RELATED               CANNOT PROVIDE FURTHUR STATUS
     R26            ZZZ    PARTIAL IN HISTORY                                       0        ELECTRONICALLY.
                           INCOMING DOS ON COMPLETION MUST BE LESS THAN 31 DAYS              CANNOT PROVIDE FURTHUR STATUS
     R27            ZZZ    AFTER THE PARTIAL DATE OF SERVICE                        0        ELECTRONICALLY.
                                                                                             MAXIMUM COVERAGE AMOUNT MET OR
     R28            ZZZ    HOMEMAKER SERVICES LIMITED TO 172 UNITS PER MONTH        483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                             MAXIMUM COVERAGE AMOUNT MET OR
     R29            ZZZ    ADULT DAY CARE LIMITED TO 736 UNITS PER MONTH            483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                             MAXIMUM COVERAGE AMOUNT MET OR
     R30            ZZZ    ADULT DAY CARE LIMITED TO 736 UNITS PER MONTH            483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                             MAXIMUM COVERAGE AMOUNT MET OR
     R31            ZZZ    IN HOME RESPITE CARE LIMITED TO 2400 UNITS PER SFY       483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                             PROCESSED ACCORDING TO PLAN
     S00            ZZZ    IN-HOME RESPITE NOT ALLOWED WITH PAID ELDERCHOICES       104      PROVISIONS.
                                                                                             PROCESSED ACCORDING TO PLAN
     S01            ZZZ    ELDERCHOICE DISALLOWED WITH IN-HOME RESPITE CARE         104      PROVISIONS.
                                                                                             PROCESSED ACCORDING TO PLAN
     S02            ZZZ    PERS INSTALL NOT REQUIRED FOR CONNECTED PERS UNIT        104      PROVISIONS.



5/16/2012                                                      Page 324
                                                             ESC TO 277


                                                                                     277
                    PLAN                                                             CLAIM
 EDIT/AUDIT   TXN   CODE   EDIT/AUDIT DESCRIPTION                                    STATUS   CLAIM STATUS CODE
                                                                                              PROCESSED ACCORDING TO PLAN
     T02            ZZZ    BITEWING NOT ALLOWED WITHIN 30 DAYS FULL/PANO X-RAY       104      PROVISIONS.
                           FULL/PANO X-RAY NOT ALLOWED WITHIN 30 DAYS PAY OF                  PROCESSED ACCORDING TO PLAN
     T03            ZZZ    BITEWING                                                  104      PROVISIONS.
                           STANDARD WHEELCHAIR NO-PAY SAME DOS AS SPECIALIZED                 PROCESSED ACCORDING TO PLAN
     U00            ZZZ    WHEELCHAIR                                                104      PROVISIONS.
                           SPECIALIZED WHEELCHAIR NO-PAY SAME DOS AS STANDARD                 PROCESSED ACCORDING TO PLAN
     U01            ZZZ    WHEELCHAIR                                                104      PROVISIONS.
                           STANDARD WHEELCHAIR NOPAY N 2 YRS OF SPECIALIZED                   PROCESSED ACCORDING TO PLAN
     U02            ZZZ    WHEELCHAIR                                                104      PROVISIONS.
     400            ZZZ    SERVICE NOT PAYABLE TO STERILIZED RECIPIENT               109      ENTITY NOT ELIGIBLE.
                           INTER/PERIODIC SCREEN NON-PAY 7 DAYS BEF/AFT FULL                  PROCESSED ACCORDING TO PLAN
     402            ZZZ    MEDICAL SCREEN                                            104      PROVISIONS.
                           DUP EPSDT SCREENS NON-PAY 7 DAYS BEFORE/AFTER DATE OF              PROCESSED ACCORDING TO PLAN
     403            ZZZ    SERVICE                                                   104      PROVISIONS.
                           PERSONAL CARE AIDE IN PUBLIC SCHOOL LTD TO 3 HOURS PER             MAXIMUM COVERAGE AMOUNT MET OR
     404            ZZZ    DAY                                                       483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                              MAXIMUM COVERAGE AMOUNT MET OR
     405            ZZZ    ATTENDANT CARE SERVICES LIMITED TO 2 HOURS PER DAY        483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                              MAXIMUM COVERAGE AMOUNT MET OR
     406            ZZZ    PERSONAL CARE SERVICES LIMITED TO 64 HOURS PER MONTH      483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                              MAXIMUM COVERAGE AMOUNT MET OR
     407            AR1    ARKIDS 1ST PARTICIPANT EXCEEDS $500 LIMIT FOR DME         483      EXCEEDED FOR BENEFIT PERIOD.
                           MED SUPPLY LTD TO $125/CALENDAR MONTH FOR ARKIDS 1ST               MAXIMUM COVERAGE AMOUNT MET OR
     408            AR1    PARTICIPANT                                               483      EXCEEDED FOR BENEFIT PERIOD.
                           PRIOR APPROVAL REQUIRED FOR ARKIDS 1ST PARTICIPANT                 MAXIMUM COVERAGE AMOUNT MET OR
     409            AR1    EXCEED $500                                               483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                              MAXIMUM COVERAGE AMOUNT MET OR
     409            ZZZ    REHAB HOSP SVCS REQ PA IF NET BENE LIMIT OVER $           483      EXCEEDED FOR BENEFIT PERIOD.
                           PERSONAL CARE SERVICES WITH NET UNITS OVER 64 REQUIRE              MAXIMUM COVERAGE AMOUNT MET OR
     428            ZZZ    PA                                                        483      EXCEEDED FOR BENEFIT PERIOD.
                           ONLY ONE HEALTH SCREEN ALLOWED FOR AGES 18 YRS 1 DAY               MAXIMUM COVERAGE AMOUNT MET OR
     429            AR1    TO 19 YRS                                                 483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                              MAXIMUM COVERAGE AMOUNT MET OR
     433            ZZZ    ADULT WHEELCHAIR LIMITED TO ONE PER FIVE YEARS            483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                              MAXIMUM COVERAGE AMOUNT MET OR
     436            ZZZ    DME SERVICES LIMITED TO $1000.00 PER SFY WITHOUT PA       483      EXCEEDED FOR BENEFIT PERIOD.
     441            ZZZ    ANTI-ULCER ACUTE DOSAGE REQUIRES PA                       252      AUTHORIZATION/CERTIFICATION NUMBER.
     447            ZZZ    CLAIM DOS OVERLAPS SPENDDOWN BEGIN DATE                   187      DATE(S) OF SERVICE.

     449            ZZZ    DAIGNOSIS NO TON INSTITUTIONAL CRITERIA FILE FOR PAS DAYS 255      DIAGNOSIS CODE.




5/16/2012                                                      Page 325
                                                                 ESC TO 277


                                                                                     277
                    PLAN                                                             CLAIM
 EDIT/AUDIT   TXN   CODE   EDIT/AUDIT DESCRIPTION                                    STATUS   CLAIM STATUS CODE
     450             ZZZ   PAS DAYS ON INST CRIT FILE ARE ZERO                       456      COVERED DAY(S).
                                                                                              MAXIMUM COVERAGE AMOUNT MET OR
     451            ZZZ    MAX PAID INPATIENT HOSP DAYS PER PRIOR SFY FOR AGES 21-99 483      EXCEEDED FOR BENEFIT PERIOD.
     452            ZZZ    EXCESS OF 14 CONSECUTIVE HOME LEAVE DAYS                  457      NON-COVERED DAY(S).
                           MAX PAID INPAT HOSP DAYS 21-99 /SFY WHICH PRECEDES PRIOR           MAXIMUM COVERAGE AMOUNT MET OR
     453            ZZZ    SFY                                                       483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                              MAXIMUM COVERAGE AMOUNT MET OR
     457            ZZZ    DRUG PAYMENT EXCEEDS 4 PRESCRIPTIONS PER MONTH        483          EXCEEDED FOR BENEFIT PERIOD.
                           MAX TRANSPLANT REIMBURSE AMT EXCEED - TAKE WORKSHEET               MAXIMUM COVERAGE AMOUNT MET OR
     459            ZZZ    TO SYSTEMS                                            483          EXCEEDED FOR BENEFIT PERIOD.
                           MAX PAID INPATIENT HOSP DAYS PER CURRENT SFY FOR AGES              MAXIMUM COVERAGE AMOUNT MET OR
     460            ZZZ    21-99                                                 483          EXCEEDED FOR BENEFIT PERIOD.
                                                                                              MAXIMUM COVERAGE AMOUNT MET OR
     462            ZZZ    SEALANT ONCE IN A LIFETIME FOR TOOTH                      483      EXCEEDED FOR BENEFIT PERIOD.
     463            ZZZ    TANDEM/PRESCRIPTION IS ALL USED UP, NEW REQUIRED          219      PRESCRIPTION NUMBER.

     464            ZZZ    PAS ALLOWED DAYS USED, 96 HOURS READMISSION EXCEEDED      9        NO PAYMENT WILL BE MADE FOR THIS CLAIM.
                           INGUINOFERMORAL LYMPHADENECTOMY ALLOWED TWICE IN A                 MAXIMUM COVERAGE AMOUNT MET OR
     466            ZZZ    LIFETIME                                                  483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                              MAXIMUM COVERAGE AMOUNT MET OR
     467            ZZZ    DEDUCTIBLE LIMITED T OONCE PER 60 DAY BENEFIT PERIOD      483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                              DUPLICATE OF A PREVIOUSLY PROCESSED
     468            ZZZ    DUPE ICN OF CLAIM ON HISTORY/PROF AND INSTITUTION         54       CLAIM/LINE.
                                                                                              MAXIMUM COVERAGE AMOUNT MET OR
     469            ZZZ    TWO CHIROPREACTIC X-RAYS PER STATE FISCAL YEAR            483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                              MAXIMUM COVERAGE AMOUNT MET OR
     470            ZZZ    DENTAL ORAL EXAM LIMITED TO ONE PER STATE FISCAL YEAR     483      EXCEEDED FOR BENEFIT PERIOD.
                           PREVENTATIVE DENTAL SCREEN LIMITED TO ONE PER STATE                MAXIMUM COVERAGE AMOUNT MET OR
     472            AR1    FISCAL YEAR                                               483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                              DUPLICATE OF A PREVIOUSLY PROCESSED
     473            ZZZ    SUSPECT DUPE * OVERLAPPING DOS, RID                       54       CLAIM/LINE.
                           DUPE NUTRITIONAL FORMULA PROC NOT ALLED ON                         DUPLICATE OF A PREVIOUSLY PROCESSED
     474            ZZZ    SAME/OVERLAP DOS                                          54       CLAIM/LINE.
                                                                                              CANNOT PROVIDE FURTHUR STATUS
     477            ZZZ    NO LONGER IN USE                                          0        ELECTRONICALLY.
                           SUSPECT DUPE, DENTAL * PROCEDURE CODE, TOS, DOS, TOOTH             DUPLICATE OF A PREVIOUSLY PROCESSED
     478            ZZZ    SURFACE                                                   54       CLAIM/LINE.
                           SUSPECT DUPE, PROFESSIONAL * PROCEDURE CODE, TOS,                  DUPLICATE OF A PREVIOUSLY PROCESSED
     479            ZZZ    OVERLAP DOS                                               54       CLAIM/LINE.
                           LESS SEVERE DUPE, PHYSICIAN * PROVIDER, PROC, TOS,                 DUPLICATE OF A PREVIOUSLY PROCESSED
     480            ZZZ    OVERLAP DOS                                               54       CLAIM/LINE.




5/16/2012                                                         Page 326
                                                               ESC TO 277


                                                                                        277
                    PLAN                                                                CLAIM
 EDIT/AUDIT   TXN   CODE   EDIT/AUDIT DESCRIPTION                                       STATUS   CLAIM STATUS CODE
                                                                                                 DUPLICATE OF A PREVIOUSLY PROCESSED
     481            ZZZ    LESS SEVERE DUPE, PHARMACY * PROVIDER, NDC, DOS, RID         54       CLAIM/LINE.
                           LESS SEVERE DUPE, INSTITUTIONAL * PROVIDER, OVERLAPPING               DUPLICATE OF A PREVIOUSLY PROCESSED
     482            ZZZ    DOS, RID                                                     54       CLAIM/LINE.
                           LESS SEVERE DUPE, INSTITUTIONAL * PROVIDER, EXACT DOS,                DUPLICATE OF A PREVIOUSLY PROCESSED
     483            ZZZ    RID                                                          54       CLAIM/LINE.
                                                                                                 DUPLICATE OF A PREVIOUSLY PROCESSED
     484            ZZZ    LESS SEVERE DUPE * PROCEDURE, OVERLAPPING DOS, TOS, RID 54            CLAIM/LINE.
                           NO MORE THAN 1 INPATIENT HOSPITAL VISIT PER DAY PER                   MAXIMUM COVERAGE AMOUNT MET OR
     485            ZZZ    PROVIDER                                                483           EXCEEDED FOR BENEFIT PERIOD.
                                                                                                 CANNOT PROVIDE FURTHUR STATUS
     486            ZZZ    NO LONGER IN USE                                             0        ELECTRONICALLY.
                           LESS SEVERE DUPE, PHYSICIAN * PROV, 1ST 3 DGT OF PROC,                DUPLICATE OF A PREVIOUSLY PROCESSED
     487            ZZZ    TOS, O/DOS                                                   54       CLAIM/LINE.
                           LESS SEVERE DUPE, DENTAL * PROV, PROC, TOS, O/DOS, TOOTH              DUPLICATE OF A PREVIOUSLY PROCESSED
     488            ZZZ    SURFACE                                                      54       CLAIM/LINE.
                           MAX 35 INPATIENT REHAB HOSPITAL DAYS PER STATE FISCAL                 MAXIMUM COVERAGE AMOUNT MET OR
     490            ZZZ    YEAR                                                         483      EXCEEDED FOR BENEFIT PERIOD.
                           EXACT DUPE OF DRUG CLAIM * NDC, BILLED AMT, DOS, PROV,                DUPLICATE OF A PREVIOUSLY PROCESSED
     491            ZZZ    TOS, RID                                                     54       CLAIM/LINE.
                           EXACT DUPE, INSTITUTIONAL * PROV, BILLED AMT, DOS, PROC,              DUPLICATE OF A PREVIOUSLY PROCESSED
     492            ZZZ    TOS, RID                                                     54       CLAIM/LINE.
                                                                                                 DUPLICATE OF A PREVIOUSLY PROCESSED
     493            ZZZ    TANDEM/DUPLICATE RX CODE FOR SAME DATE OF SERVICE            54       CLAIM/LINE.
                                                                                                 MAXIMUM COVERAGE AMOUNT MET OR
     495            ZZZ    BITEWINGS LIMITED TO ONE PER STATE FISCAL YEAR               483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                                 DUPLICATE OF A PREVIOUSLY PROCESSED
     496            ZZZ    EXACT DUPE, CROSSOVER * RID, PROV, DOS, BILLED AMOUNT        54       CLAIM/LINE.
                           EXACT DUPE, PHYSICIAN * PROV, 1ST 3 DGT PROC,TOS, O/DOS,              DUPLICATE OF A PREVIOUSLY PROCESSED
     497            ZZZ    BILL AMT                                                     54       CLAIM/LINE.
                           EXACT DUPE, DENTAL * PROV, PROC, TOS, DOS, BILL AMT, TTH #            DUPLICATE OF A PREVIOUSLY PROCESSED
     498            ZZZ    & SURF                                                       54       CLAIM/LINE.
                           EXACT DUPE, PROFESSIONAL * PROV, PROC, TOS, DOS, BILLED               DUPLICATE OF A PREVIOUSLY PROCESSED
     499            ZZZ    AMOUNT                                                       54       CLAIM/LINE.
     500            ZZZ    EXCESS OF 5 CONSECUTIVE HOSPITAL LEAVE DAYS                  457      NON-COVERED DAY(S).
                                                                                                 MAXIMUM COVERAGE AMOUNT MET OR
     506            ZZZ    LIMIT FACILITY RESPITE CARE TO 600 UNITS PER SFY        483           EXCEEDED FOR BENEFIT PERIOD.
                           Z1700/MEALS NP RECIP RCVG 5 MORE HRS ADLT DAY CARE                    PROCESSED ACCORDING TO PLAN
     507            ZZZ    SAME DOS                                                104           PROVISIONS.
                           Z1700/MEALS NP RECIP RCVG 5 MORE HRS ADLT DAY HLTH CARE               PROCESSED ACCORDING TO PLAN
     508            ZZZ    SAME DOS                                                104           PROVISIONS.



5/16/2012                                                       Page 327
                                                              ESC TO 277


                                                                                     277
                    PLAN                                                             CLAIM
 EDIT/AUDIT   TXN   CODE   EDIT/AUDIT DESCRIPTION                                    STATUS   CLAIM STATUS CODE
                                                                                              MAXIMUM COVERAGE AMOUNT MET OR
     510            ZZZ    Z1709-CHORE SERVICES LIMITED TO 20 UNITS PER MONTH        483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                              MAXIMUM COVERAGE AMOUNT MET OR
     512            ZZZ    Z1689-HOMEMAKER SERVICES LIMITED TO 43 UNITS PER MONTH    483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                              MAXIMUM COVERAGE AMOUNT MET OR
     513            ZZZ    ADULT DAYCARE LIMITED TO 184 UNITS PER MONTH              483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                              MAXIMUM COVERAGE AMOUNT MET OR
     514            ZZZ    Z1710-PERS INSTALLATION LIMITED TO 1 PER SFY              483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                              MAXIMUM COVERAGE AMOUNT MET OR
     515            ZZZ    LIMIT Z1701-PERS TO 31 UNITS PER MONTH                    483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                              MAXIMUM COVERAGE AMOUNT MET OR
     516            ZZZ    LIMIT Z1688-ADULT FOSTER CARE TO 31 UNITS PER MONTH       483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                              MAXIMUM COVERAGE AMOUNT MET OR
     517            ZZZ    ONLY 12 NURSE PRACTITIONER VISITS PER SFY                 483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                              MAXIMUM COVERAGE AMOUNT MET OR
     518            ZZZ    CRISIS MANAGEMENT VISIT LIMITED TO 48 1/4 HR UNITS/SFY    483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                              MAXIMUM COVERAGE AMOUNT MET OR
     519            ZZZ    FAMILY THERAPY/MARITAL LIMITED TO SIX UNITS/WEEK          483      EXCEEDED FOR BENEFIT PERIOD.
                           INDIVIDUAL OUTPT-COLLATERAL SVCS LIMITED TO 12 UNITS/90            MAXIMUM COVERAGE AMOUNT MET OR
     520            ZZZ    DAYS                                                      483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                              MAXIMUM COVERAGE AMOUNT MET OR
     522            ZZZ    PRE-SCHOOL SERVICES LIMITED TO 155 UNITS PER MONTH        483      EXCEEDED FOR BENEFIT PERIOD.
                           EARLY INTERVENTION AND PRE-SCHOOLI SERVICES LIMITED TO             MAXIMUM COVERAGE AMOUNT MET OR
     531            ZZZ    1 UNIT/DOS                                                483      EXCEEDED FOR BENEFIT PERIOD.
                           ADD. THERAPEUTIC DAY TREATMENT LIMITED TO 32                       MAXIMUM COVERAGE AMOUNT MET OR
     537            ZZZ    UNTS/DOS/ATT PROV                                         483      EXCEEDED FOR BENEFIT PERIOD.
                           CRISIS MANAGEMENT LIMITED TO 4 UNITS PER DOS PER ATT               MAXIMUM COVERAGE AMOUNT MET OR
     541            ZZZ    PROV                                                      483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                              MAXIMUM COVERAGE AMOUNT MET OR
     547            ZZZ    OCCUPATIONAL INDIVIDUAL THERAPY LIMITED TO 3 UNITS/DOS    483      EXCEEDED FOR BENEFIT PERIOD.
                           INDIVIDUAL OUTPT-MED. ADMIN. LIMITED TO 2 UNITS/DOS/ATT            MAXIMUM COVERAGE AMOUNT MET OR
     548            ZZZ    PROV                                                      483      EXCEEDED FOR BENEFIT PERIOD.
                           DIAGNOSIS AND EVALUATION SERVICES LIMITED TO 1 PER 12              MAXIMUM COVERAGE AMOUNT MET OR
     553            ZZZ    MONTH PER                                                 483      EXCEEDED FOR BENEFIT PERIOD.
                           INDIVIDUAL OUTPT - THERAPY SESSION LIMITED TO 4                    MAXIMUM COVERAGE AMOUNT MET OR
     554            ZZZ    UNITS/WEEK                                                483      EXCEEDED FOR BENEFIT PERIOD.
                           PROCEDURE CODE Z1555 LIMITED TO 720 UNITS/12 MONTH                 MAXIMUM COVERAGE AMOUNT MET OR
     555            ZZZ    PERIOD                                                    483      EXCEEDED FOR BENEFIT PERIOD.
                           ANY COMBINATION OF WAIVER SERVICES LIMITED TO 720                  MAXIMUM COVERAGE AMOUNT MET OR
     563            ZZZ    UNITS/MONTH                                               483      EXCEEDED FOR BENEFIT PERIOD.




5/16/2012                                                       Page 328
                                                              ESC TO 277


                                                                                     277
                    PLAN                                                             CLAIM
 EDIT/AUDIT   TXN   CODE   EDIT/AUDIT DESCRIPTION                                    STATUS   CLAIM STATUS CODE
                                                                                              PROCESSED ACCORDING TO PLAN
     576            ZZZ    MEALS DISALLOWED SAME DOS AS ADC OR ADHC                  104      PROVISIONS.
                                                                                              MAXIMUM COVERAGE AMOUNT MET OR
     583            ZZZ    ONE PSYCHOTHERAPY PROCEDURE/DOS/RECIP                     483      EXCEEDED FOR BENEFIT PERIOD.

                           MANUAL REV OF MULT SURGERIES DONE SAME DAY - EX                    MEDICAL REVIEW
     584            ZZZ    SUBSEQ SURG                                               421      ATTACHMENT/INFORMATION FOR SERVICE(S).

                           MANUAL REV OF MULT SURGERIES DONE SAME DAY - EX                    MEDICAL REVIEW
     585            ZZZ    SUBSEQ SURG                                               421      ATTACHMENT/INFORMATION FOR SERVICE(S).
                                                                                              MAXIMUM COVERAGE AMOUNT MET OR
     586            ZZZ    ADULT SERVICES EXCEED 155 UNITS PER MONTH                 483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                              MAXIMUM COVERAGE AMOUNT MET OR
     587            ZZZ    THERAPEUTIC DAY TREATMENT, 224-1/4 HOUR UNIT/WEEK         483      EXCEEDED FOR BENEFIT PERIOD.
                           Z1685-APNEA MONITOR WITH SET-UP LIMITED TO ONCE IN A               MAXIMUM COVERAGE AMOUNT MET OR
     588            ZZZ    LIFETIME                                                  483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                              MAXIMUM COVERAGE AMOUNT MET OR
     590            ZZZ    E0608-APNEA MONITOR-1 UNIT PER DATE OF SERVICE            483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                              MAXIMUM COVERAGE AMOUNT MET OR
     592            ZZZ    CS. MGMT. SERVICE PLANNING LIMITED TO 6 UNITS/SFY         483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                              MAXIMUM COVERAGE AMOUNT MET OR
     593            ZZZ    CS. MGMT. SERVICE COORDINATION LIMITIED TO 60 UNITS/SFY   483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                              MAXIMUM COVERAGE AMOUNT MET OR
     594            ZZZ    CS. MGMT. ASSESSMENT SERVICE LIMITED TO 8 UNITS/SFY       483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                              MAXIMUM COVERAGE AMOUNT MET OR
     595            ZZZ    CS. MGMT. SERVICE MONITORING LIMITED TO 60 UNITS/SFY      483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                              MAXIMUM COVERAGE AMOUNT MET OR
     596            ZZZ    CS. MGMT. SERVICE PLAN UPDATING LIMITED TO 16 UNITS/SFY   483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                              MAXIMUM COVERAGE AMOUNT MET OR
     598            ZZZ    ADULT DAY HEALTH CARE LIMITED TO 184 UNITS PER MONTH      483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                              MAXIMUM COVERAGE AMOUNT MET OR
     599            AR1    NEWBORN CARE ALLOWED ONCE IN A LIFETIME                   483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                              MAXIMUM COVERAGE AMOUNT MET OR
     599            ZZZ    NEWBORN CARE ALLOWED ONCE IN A LIFETIME                   483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                              MAXIMUM COVERAGE AMOUNT MET OR
     600            ZZZ    EXTRACTIONS MAY BE PERFORMED ONCE IN A LIFETIME           483      EXCEEDED FOR BENEFIT PERIOD.
                           ONLY 6 PREVENTATIVE HEALTH SCREENS AGES BIRTH                      MAXIMUM COVERAGE AMOUNT MET OR
     601            AR1    THROUGH 12 MONTHS                                         483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                              MAXIMUM COVERAGE AMOUNT MET OR
     601            ZZZ    ONLY 6 EPSDT MED SCREENS FROM BIRTH TO 12 MONTHS          483      EXCEEDED FOR BENEFIT PERIOD.




5/16/2012                                                      Page 329
                                                            ESC TO 277


                                                                                   277
                    PLAN                                                           CLAIM
 EDIT/AUDIT   TXN   CODE   EDIT/AUDIT DESCRIPTION                                  STATUS   CLAIM STATUS CODE
                           ONLY 3 PREV HEALTH SCREENS FOR PARTICIPANTS 12 MO 1 DAY          MAXIMUM COVERAGE AMOUNT MET OR
     602            AR1    TO 2 YEARS                                              483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                            MAXIMUM COVERAGE AMOUNT MET OR
     602            ZZZ    ONLY 3 EPSDT MEDIC SCRNS FOR AGES 12 MOS 1 DAY-2YR      483      EXCEEDED FOR BENEFIT PERIOD.
                           ONLY 1 PREV HEALTH SCREENS FOR PARTICIPANTS 2 YEARS 1            MAXIMUM COVERAGE AMOUNT MET OR
     603            AR1    DAY TO 3 YEARS                                          483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                            MAXIMUM COVERAGE AMOUNT MET OR
     603            ZZZ    ONLY 1 EPSDT MEDIC SCRNS FOR AGES 2 YRS 1 DAY-3 YR      483      EXCEEDED FOR BENEFIT PERIOD.
                           ONLY 1 PREV HEALTH SCREENS FOR PARTICIPANTS 3 YEARS 1            MAXIMUM COVERAGE AMOUNT MET OR
     604            AR1    DAY TO 4 YEARS                                          483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                            MAXIMUM COVERAGE AMOUNT MET OR
     604            ZZZ    ONLY 1 EPSDT MEDIC SCRNS FOR AGES 3 YRS 1 DAY-4 YR      483      EXCEEDED FOR BENEFIT PERIOD.
                           ONLY 1 PREV HEALTH SCREENS FOR PARTICIPANTS 4 YEARS 1            MAXIMUM COVERAGE AMOUNT MET OR
     606            AR1    DAY TO 5 YEARS                                          483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                            MAXIMUM COVERAGE AMOUNT MET OR
     606            ZZZ    ONLY 1 EPSDT MEDIC SCRNS FOR AGES 4 YRS 1 DAY-5 YR      483      EXCEEDED FOR BENEFIT PERIOD.
                           ONLY 1 PREV HEALTH SCREENS FOR PARTICIPANTS 5 YEARS 1            MAXIMUM COVERAGE AMOUNT MET OR
     607            AR1    DAY TO 6 YEARS                                          483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                            MAXIMUM COVERAGE AMOUNT MET OR
     607            ZZZ    ONLY 1 EPSDT MEDIC SCRNS FOR AGES 5 YRS 1 DAY-6 YR      483      EXCEEDED FOR BENEFIT PERIOD.
                           ONLY 1 PREV HEALTH SCREENS FOR PARTICIPANTS 6 YEARS 1            MAXIMUM COVERAGE AMOUNT MET OR
     608            AR1    DAY TO 8 YEARS                                          483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                            MAXIMUM COVERAGE AMOUNT MET OR
     608            ZZZ    ONLY 1 EPSDT MEDIC SCRNS FOR AGES 6 YRS 1 DAY-8 YR      483      EXCEEDED FOR BENEFIT PERIOD.
                           ONLY 1 PREV HEALTH SCREENS FOR PARTICIPANTS 8 YEARS 1            MAXIMUM COVERAGE AMOUNT MET OR
     609            AR1    DAY TO 10 YEARS                                         483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                            MAXIMUM COVERAGE AMOUNT MET OR
     609            ZZZ    ONLY 1 EPSDT MEDIC SCRNS FOR AGES 8 YRS 1 DAY-10 YR     483      EXCEEDED FOR BENEFIT PERIOD.
                           MAXIMUM OF 12 CHIROPRACTIC VISITS ALLOWED PER STATE              MAXIMUM COVERAGE AMOUNT MET OR
     610            ZZZ    FISCAL YEAR                                             483      EXCEEDED FOR BENEFIT PERIOD.

                           1ST EXTRACTION 07110 EA ADD EXTRACTION 07120, 3                  ONE OR MORE ORIGINALLY SUBMITTED
     630            ZZZ    XTRACTIONS USE PA                                       15       PROCEDURE CODES HAVE BEEN MODIFIED.
                           HEARING AID - ONLY TWO APPLIANCES ALLOWED PER SIX                MAXIMUM COVERAGE AMOUNT MET OR
     643            ZZZ    MONTH PERIOD                                            483      EXCEEDED FOR BENEFIT PERIOD.
                           ONLY ONE PROCEDURE ALLOWED PER DOS PER ATTENDING                 MAXIMUM COVERAGE AMOUNT MET OR
     646            ZZZ    PROVIDER                                                483      EXCEEDED FOR BENEFIT PERIOD.

                                                                                            MEDICAL REVIEW
     649            ZZZ    MANUAL REVIEW OF MULTIPLE SURGERIES                     421      ATTACHMENT/INFORMATION FOR SERVICE(S).




5/16/2012                                                    Page 330
                                                               ESC TO 277


                                                                                    277
                    PLAN                                                            CLAIM
 EDIT/AUDIT   TXN   CODE   EDIT/AUDIT DESCRIPTION                                   STATUS   CLAIM STATUS CODE

                                                                                             MEDICAL REVIEW
     650            ZZZ    MANUAL REVIEW OF MULTIPLE SURGERIES                      421      ATTACHMENT/INFORMATION FOR SERVICE(S).
                                                                                             MAXIMUM COVERAGE AMOUNT MET OR
     653            ZZZ    DME * ONLY ONE OF THIS TYPE OF DME ALLOWED PER DOS       483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                             MAXIMUM COVERAGE AMOUNT MET OR
     654            ZZZ    ONLY ONE PROCEDURE ALLOWED PER DOS                       483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                             MAXIMUM COVERAGE AMOUNT MET OR
     655            ZZZ    ONLY ONE PROCEDURE ALLOWED PER DOS                       483      EXCEEDED FOR BENEFIT PERIOD.
                           ONE NEW PATIENT VISIT PER 3 YEARS SAME ATTENDING                  MAXIMUM COVERAGE AMOUNT MET OR
     658            ZZZ    PROVIDER                                                 483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                             MAXIMUM COVERAGE AMOUNT MET OR
     659            ZZZ    ONLY ONE DELIVERY IN A 9 MONTH PERIOD                    483      EXCEEDED FOR BENEFIT PERIOD.
                           FAIL IF 2 ADMITS BILLED ON SAME DAY (SAME OR DIFF                 PROCESSED ACCORDING TO PLAN
     660            ZZZ    ATTENDING PROV)                                          104      PROVISIONS.
                                                                                             MAXIMUM COVERAGE AMOUNT MET OR
     662            ZZZ    ONLY ONE DELIVERY IN A NINE MONTH PERIOD                 483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                             MAXIMUM COVERAGE AMOUNT MET OR
     663            ZZZ    ONLY ONE DELIVERY IN A NINE MONTH PERIOD                 483      EXCEEDED FOR BENEFIT PERIOD.

                                                                                             MEDICAL REVIEW
     664            ZZZ    MANUAL REVIEW OF MULTIPLE SURGERIES DONE SAME DAY        421      ATTACHMENT/INFORMATION FOR SERVICE(S).

                                                                                             MEDICAL REVIEW
     665            ZZZ    MANUAL REVIEW OF MULTIPLE SURGERIES DONE SAME DAY        421      ATTACHMENT/INFORMATION FOR SERVICE(S).
                                                                                             MAXIMUM COVERAGE AMOUNT MET OR
     667            ZZZ    ONLY ONE DELIVERY IN A 9 MONTH PERIOD                    483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                             MAXIMUM COVERAGE AMOUNT MET OR
     668            ZZZ    ONLY ONE DELIVERY IN A 9 MONTH PERIOD                    483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                             MAXIMUM COVERAGE AMOUNT MET OR
     671            ZZZ    LAPAROSCOPY ALLOWED ONCE IN A LIFETIME                   483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                             MAXIMUM COVERAGE AMOUNT MET OR
     674            ZZZ    VASECTOMY ALLOWED ONCE IN A LIFETIME                     483      EXCEEDED FOR BENEFIT PERIOD.
                           HYSTERECTOMY/BLADDER REPAIR ALLOWED ONCE IN A                     MAXIMUM COVERAGE AMOUNT MET OR
     675            ZZZ    LIFETIME                                                 483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                             MAXIMUM COVERAGE AMOUNT MET OR
     676            ZZZ    OOPHORECTOMY ALLOWED TWICE IN A LIFETIME                 483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                             MAXIMUM COVERAGE AMOUNT MET OR
     677            ZZZ    REMOVAL OF EAR ALLOWED TWICE IN A LIFETIME               483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                             MAXIMUM COVERAGE AMOUNT MET OR
     678            ZZZ    EXCISION SUBMAXILLARY GLAND ALLOWED ONCE IN A LIFETIME   483      EXCEEDED FOR BENEFIT PERIOD.




5/16/2012                                                       Page 331
                                                             ESC TO 277


                                                                                    277
                    PLAN                                                            CLAIM
 EDIT/AUDIT   TXN   CODE   EDIT/AUDIT DESCRIPTION                                   STATUS   CLAIM STATUS CODE
                                                                                             MAXIMUM COVERAGE AMOUNT MET OR
     679            ZZZ    EXCISION SUBLINGUAL GLAND ALLOWED ONCE IN A LIFETIME     483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                             MAXIMUM COVERAGE AMOUNT MET OR
     680            ZZZ    PROCEDURE MAY BE PERFORMED ONCE IN A LIFETIME            483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                             MAXIMUM COVERAGE AMOUNT MET OR
     681            ZZZ    REMOVAL OF TEAR GLAND ALLOWED TWICE IN A LIFETIME        483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                             MAXIMUM COVERAGE AMOUNT MET OR
     683            ZZZ    VAGINECTOMY ALLOWED ONCE IN A LIFETIME                   483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                             MAXIMUM COVERAGE AMOUNT MET OR
     684            ZZZ    ESOPHAGECTOMY ALLOWED ONCE IN A LIFETIME                 483      EXCEEDED FOR BENEFIT PERIOD.
                           RESECTION OF PHARYNGEAL WALL ALLOWED ONCE IN A                    MAXIMUM COVERAGE AMOUNT MET OR
     685            ZZZ    LIFETIME                                                 483      EXCEEDED FOR BENEFIT PERIOD.
                           COCCYGECTOMY; PRIMARY SUTURE ALLOWED ONCE IN A                    MAXIMUM COVERAGE AMOUNT MET OR
     686            ZZZ    LIFETIME                                                 483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                             MAXIMUM COVERAGE AMOUNT MET OR
     688            ZZZ    REMOVAL OF NOSE ALLOWED ONCE IN A LIFETIME               483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                             MAXIMUM COVERAGE AMOUNT MET OR
     689            ZZZ    REMOVAL OF LARYNX ALLOWED ONCE IN A LIFETIME             483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                             MAXIMUM COVERAGE AMOUNT MET OR
     691            ZZZ    REMOVAL OF EPIGLOTTIS ALLOWED ONCE IN A LIFETIME         483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                             MAXIMUM COVERAGE AMOUNT MET OR
     692            ZZZ    REMOVAL OF SPLEEN ALLOWED ONCE IN A LIFETIME             483      EXCEEDED FOR BENEFIT PERIOD.
                           REMOVAL OF SUPRAHYOID LYMPH NODES ALLOWED TWICE IN A              MAXIMUM COVERAGE AMOUNT MET OR
     693            ZZZ    LIFETIME                                                 483      EXCEEDED FOR BENEFIT PERIOD.
                           REMOVAL OF CERVICAL LYMPH NODES ALLOWED TWICE IN A                MAXIMUM COVERAGE AMOUNT MET OR
     694            ZZZ    LIFETIME                                                 483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                             MAXIMUM COVERAGE AMOUNT MET OR
     697            ZZZ    EXCISE LIP OR CHEEK FOLD ALLOWED ONCE IN A LIFETIME      483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                             MAXIMUM COVERAGE AMOUNT MET OR
     698            ZZZ    GLOSSECTOMY ALLOWED ONCE IN A LIFETIME                   483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                             MAXIMUM COVERAGE AMOUNT MET OR
     699            ZZZ    EXCISION OF UVULA ALLOWED ONCE IN A LIFETIME             483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                             MAXIMUM COVERAGE AMOUNT MET OR
     701            ZZZ    REMOVAL OF TONSILS/ADENOIDS ALLOWED ONCE IN A LIFETIME   483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                             MAXIMUM COVERAGE AMOUNT MET OR
     702            ZZZ    GASTRECTOMY ALLOWED ONCE IN A LIFETIME                   483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                             MAXIMUM COVERAGE AMOUNT MET OR
     703            ZZZ    COLECTOMY ALLOWED ONCE IN A LIFETIME                     483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                             MAXIMUM COVERAGE AMOUNT MET OR
     704            ZZZ    APPENDECTOMY ALLOWED ONCE IN A LIFETIME                  483      EXCEEDED FOR BENEFIT PERIOD.




5/16/2012                                                     Page 332
                                                              ESC TO 277


                                                                                     277
                    PLAN                                                             CLAIM
 EDIT/AUDIT   TXN   CODE   EDIT/AUDIT DESCRIPTION                                    STATUS   CLAIM STATUS CODE
                                                                                              MAXIMUM COVERAGE AMOUNT MET OR
     705            ZZZ    PROCTECTOMY ALLOWED ONCE IN A LIFETIME                    483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                              MAXIMUM COVERAGE AMOUNT MET OR
     707            ZZZ    CHOLECYSTECTOMY ALLOWED ONCE IN A LIFETIME                483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                              MAXIMUM COVERAGE AMOUNT MET OR
     708            ZZZ    PANCREATECTOMY ALLOWED ONCE IN A LIFETIME                 483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                              MAXIMUM COVERAGE AMOUNT MET OR
     709            ZZZ    UMBILLECTOMY ALLOWED ONCE IN A LIFETIME                   483      EXCEEDED FOR BENEFIT PERIOD.
                           REMOVAL OF PELVIC STRUCTURES ALLOWED ONCE IN A                     MAXIMUM COVERAGE AMOUNT MET OR
     712            ZZZ    LIFETIME                                                  483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                              MAXIMUM COVERAGE AMOUNT MET OR
     713            ZZZ    URETHRECTOMY ALLOWED ONCE IN A LIFETIME                   483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                              MAXIMUM COVERAGE AMOUNT MET OR
     714            ZZZ    AMPUTATION OF PENIS ALLOWED ONCE IN A LIFETIME            483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                              MAXIMUM COVERAGE AMOUNT MET OR
     719            ZZZ    PROSTATECTOMY ALLOWED ONCE IN A LIFETIME                  483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                              MAXIMUM COVERAGE AMOUNT MET OR
     720            ZZZ    VULVECTOMY ALLOWED ONCE IN A LIFETIME                     483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                              MAXIMUM COVERAGE AMOUNT MET OR
     722            ZZZ    TRACHELECTOMY ALLOWED ONCE IN A LIFETIME                  483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                              MAXIMUM COVERAGE AMOUNT MET OR
     723            ZZZ    HYSTERECTOMY ALLOWED ONCE IN A LIFETIME                   483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                              MAXIMUM COVERAGE AMOUNT MET OR
     726            ZZZ    THYROIDECTOMY ALLOWED ONCE IN A LIFETIME                  483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                              MAXIMUM COVERAGE AMOUNT MET OR
     727            ZZZ    THYMECTOMY ALLOWED ONCE IN A LIFETIME                     483      EXCEEDED FOR BENEFIT PERIOD.
                           CRISIS MANAGEMENT SERVICE LIMITED TO 48-1/4 HOUR UNIT              MAXIMUM COVERAGE AMOUNT MET OR
     731            ZZZ    PER SFY                                                   483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                              MAXIMUM COVERAGE AMOUNT MET OR
     732            ZZZ    MAXIMUM OF TWO CONSULTATIONS PER STATE FISCAL YEAR        483      EXCEEDED FOR BENEFIT PERIOD.
                           ONLY ONE CONSULTATION PER STATE FISCAL YEAR SAME                   MAXIMUM COVERAGE AMOUNT MET OR
     733            ZZZ    PROVIDER                                                  483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                              MAXIMUM COVERAGE AMOUNT MET OR
     736            ZZZ    PERODIC FAMILY PLANNING VISIT - 3 PER STATE FISCAL YEAR   483      EXCEEDED FOR BENEFIT PERIOD.
                           DENTURE ADJ/REALIGN NOT COVERED WITHIN 6 MTH OF                    PROCESSED ACCORDING TO PLAN
     740            ZZZ    APPLIANCE PLACEMT                                         104      PROVISIONS.
                           FAIL IF OVER 1 OCCURANCE IN 2 YRS SAME ATTENDING PROV              PROCESSED ACCORDING TO PLAN
     741            ZZZ    TOOTH NUM                                                 104      PROVISIONS.
                           FAIL IF SUBJECT PROC BILLED SAME DAY-TOOTH-ATTENDING               PROCESSED ACCORDING TO PLAN
     742            ZZZ    PROVIDER                                                  104      PROVISIONS.




5/16/2012                                                      Page 333
                                                             ESC TO 277


                                                                                    277
                    PLAN                                                            CLAIM
 EDIT/AUDIT   TXN   CODE   EDIT/AUDIT DESCRIPTION                                   STATUS   CLAIM STATUS CODE
                           FAIL IF SUBJECT PROCEDURE BILLED SAME DAY-ATTENDING               PROCESSED ACCORDING TO PLAN
     743            ZZZ    PROVIDER                                                 104      PROVISIONS.
                           FAIL IF SUBJECT PROC BILLED ANY DOS-SAME-TOOTH-PROV-              PROCESSED ACCORDING TO PLAN
     744            ZZZ    RECIPIENT                                                104      PROVISIONS.
                                                                                             MAXIMUM COVERAGE AMOUNT MET OR
     746            ZZZ    ONLY ONE PRE-NATAL LAB COVERED IN NINE MONTH SPAN        483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                             MAXIMUM COVERAGE AMOUNT MET OR
     748            AR1    ONLY ONE EYE EXAM PER 12 MONTHS UNDER 18 YEARS OLD       483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                             MAXIMUM COVERAGE AMOUNT MET OR
     748            ZZZ    ONLY ONE EXAM PER 12 MONTHS UNDER 21 YEARS OLD           483      EXCEEDED FOR BENEFIT PERIOD.
                           ONLY ONE PAIR OF GLASSES PER 12 MO FOR PARTICIPANTS               MAXIMUM COVERAGE AMOUNT MET OR
     749            AR1    UNDER 18 YR OLD                                          483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                             MAXIMUM COVERAGE AMOUNT MET OR
     749            ZZZ    ONE PAIR OF GLASSES PER 12 MONTHS/UNDER 21 YEARS         483      EXCEEDED FOR BENEFIT PERIOD.
                           ONLY ONE ANNUAL FAMILY PLANNING VISIT PER STATE FISCAL            MAXIMUM COVERAGE AMOUNT MET OR
     750            ZZZ    YEAR                                                     483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                             PROCESSED ACCORDING TO PLAN
     751            ZZZ    COMPONENT TESTS INCLUDED IN COMPLETE BLOOD COUNT         104      PROVISIONS.
                                                                                             MAXIMUM COVERAGE AMOUNT MET OR
     752            ZZZ    ONLY ONE DAY TREATMENT SERVICE ALLOWED PER DOS           483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                             MAXIMUM COVERAGE AMOUNT MET OR
     753            ZZZ    MENTAL HEALTH - ONLY ONE SERVICE ALLOWED PER DOS         483      EXCEEDED FOR BENEFIT PERIOD.
                           OP NON-ER ROOM CHARGE NOT ALLOWED                                 PROCESSED ACCORDING TO PLAN
     754            ZZZ    W/TREATMENT/THERAPY CODES                                104      PROVISIONS.
                                                                                             PROCESSED ACCORDING TO PLAN
     756            ZZZ    CHROME CROWN WITH BASE INCLUDES PULPOTOMY/PULP CAP       104      PROVISIONS.
                                                                                             MAXIMUM COVERAGE AMOUNT MET OR
     759            ZZZ    MENTAL HEALTH * ONLY ONE SERVICE ALLOWED PER DOS         483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                             MAXIMUM COVERAGE AMOUNT MET OR
     760            ZZZ    ONLY 1 OFFICE VISIT ALLOWED PER DOS/ATTEND PROV         483       EXCEEDED FOR BENEFIT PERIOD.
                           ONLY 1 HOSPITAL SERVICE VISIT ALLOWED PER DOS ATTENDING           MAXIMUM COVERAGE AMOUNT MET OR
     761            ZZZ    PROVIDER                                                483       EXCEEDED FOR BENEFIT PERIOD.
                                                                                             MAXIMUM COVERAGE AMOUNT MET OR
     762            ZZZ    1 CARE FACILITY VISIT ALLOWED PER DOS/ATTEND PROV        483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                             MAXIMUM COVERAGE AMOUNT MET OR
     763            ZZZ    DME * ONLY ONE OF THIS TYPE OF DME ALLOWED PER DOS       483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                             MAXIMUM COVERAGE AMOUNT MET OR
     764            ZZZ    ONLY ONE FAMILY PLANNING VISIT ALLOWED PER DOS           483      EXCEEDED FOR BENEFIT PERIOD.
                           ONLY ONE PROCEDURE CODE ALLOWED PER DOS PER                       MAXIMUM COVERAGE AMOUNT MET OR
     765            ZZZ    ATTENDING PROVIDER                                       483      EXCEEDED FOR BENEFIT PERIOD.




5/16/2012                                                     Page 334
                                                             ESC TO 277


                                                                                       277
                    PLAN                                                               CLAIM
 EDIT/AUDIT   TXN   CODE   EDIT/AUDIT DESCRIPTION                                      STATUS   CLAIM STATUS CODE
                                                                                                PROCESSED ACCORDING TO PLAN
     766            ZZZ    FAIL IF ADJ/REALIGN BILLED WITHIN SIX MONTHS OF PLACEMENT   104      PROVISIONS.
                           ONLY ONE PROCEDURE CODE ALLOWED PER DOS PER                          MAXIMUM COVERAGE AMOUNT MET OR
     767            ZZZ    ATTENDING PROVIDER                                          483      EXCEEDED FOR BENEFIT PERIOD.
                           ONLY ONE EVALUATION PROCEDURE ALLOWED PER DOS PER                    MAXIMUM COVERAGE AMOUNT MET OR
     768            ZZZ    ATTEND PROV                                                 483      EXCEEDED FOR BENEFIT PERIOD.
                           ONLY ONE PROCEDURE ALLOWED PER DOS PER ATTENDING                     MAXIMUM COVERAGE AMOUNT MET OR
     769            ZZZ    PROVIDER                                                    483      EXCEEDED FOR BENEFIT PERIOD.
                           ONLY ONE PURE TONE AUDIOMETRY PROC ALLOWED/DOS PER                   MAXIMUM COVERAGE AMOUNT MET OR
     770            ZZZ    ATTEND PROV                                                 483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                                MAXIMUM COVERAGE AMOUNT MET OR
     771            ZZZ    ONE HEARING TEST ALLOWED PER DOS PER ATTEND PROV            483      EXCEEDED FOR BENEFIT PERIOD.
                           ONLY ONE PROCEDURE ALLOWED PER DOS PER ATTENDING                     MAXIMUM COVERAGE AMOUNT MET OR
     772            ZZZ    PROVIDER                                                    483      EXCEEDED FOR BENEFIT PERIOD.
                           ONLY ONE HEARING AID EXAM PROCEDURE ALLOWED/DOS PER                  MAXIMUM COVERAGE AMOUNT MET OR
     773            ZZZ    ATTEND PROV                                                 483      EXCEEDED FOR BENEFIT PERIOD.
                           ONLY 1 ELECTROACOUSTIC EVAL PROC ALLOWED/DOS PER                     MAXIMUM COVERAGE AMOUNT MET OR
     774            ZZZ    ATTEND PROV                                                 483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                                MAXIMUM COVERAGE AMOUNT MET OR
     775            ZZZ    DDTCS-ONE PRESCHOOL VISIT/DOS PER ATTEND PROVIDER           483      EXCEEDED FOR BENEFIT PERIOD.
                           ONLY ONE PROCEDURE ALLOWED PER DOS PER ATTENDING                     MAXIMUM COVERAGE AMOUNT MET OR
     777            ZZZ    PROVIDER                                                    483      EXCEEDED FOR BENEFIT PERIOD.
                           ONLY ONE PROCEDURE ALLOWED PER DOS PER ATTENDING                     MAXIMUM COVERAGE AMOUNT MET OR
     778            ZZZ    PROVIDER                                                    483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                                PROCESSED ACCORDING TO PLAN
     779            ZZZ    IV INSERTION INCLUDED IN CHEMOTHERAPY ADMINISTRATION        104      PROVISIONS.
                                                                                                PROCESSED ACCORDING TO PLAN
     780            ZZZ    IV INSERTION INCLUDED IN CHEMOTHERAPY ADMINISTRATION        104      PROVISIONS.
                           ONLY ONE OFFICE VISIT ALLOWED PER DOS PER ATTENDING                  MAXIMUM COVERAGE AMOUNT MET OR
     781            ZZZ    PROVIDER                                                    483      EXCEEDED FOR BENEFIT PERIOD.
                           ONLY ONE HOSPITAL VISIT ALLOWED PER DOS PER ATTENDING                MAXIMUM COVERAGE AMOUNT MET OR
     782            ZZZ    PROVIDER                                                    483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                                MAXIMUM COVERAGE AMOUNT MET OR
     785            ZZZ    MENTAL HEALTH - ONLY ONE SERVICE ALLOWED PER DOS            483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                                MAXIMUM COVERAGE AMOUNT MET OR
     786            ZZZ    1 CARE FACILITY VISIT ALLOWED PER DOS/ATTEND PROV           483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                                MAXIMUM COVERAGE AMOUNT MET OR
     787            ZZZ    DME - ONLY ONE OF THIS TYPE OF DME ALLOWED PER DOS          483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                                MAXIMUM COVERAGE AMOUNT MET OR
     788            ZZZ    ONLY ONE FAMILY PLANNING VISIT SERVICE ALLOWED PER DOS      483      EXCEEDED FOR BENEFIT PERIOD.




5/16/2012                                                      Page 335
                                                             ESC TO 277


                                                                                     277
                    PLAN                                                             CLAIM
 EDIT/AUDIT   TXN   CODE   EDIT/AUDIT DESCRIPTION                                    STATUS   CLAIM STATUS CODE
                                                                                              PROCESSED ACCORDING TO PLAN
     789            ZZZ    FAIL IF ADJ/REALIGN BILLED WITHIN 6 MONTHS OF PLACEMENT   104      PROVISIONS.
                           ONLY ONE EVALUATION PROCEDURE ALLOWED PER DOS PER                  MAXIMUM COVERAGE AMOUNT MET OR
     790            ZZZ    ATTEND PROV                                               483      EXCEEDED FOR BENEFIT PERIOD.
                           OP NON-ER ROOM CHARGE NOT ALLOWED                                  PROCESSED ACCORDING TO PLAN
     791            ZZZ    W/TREATMENT/THERAPY CODES                                 104      PROVISIONS.
                           10 DAYS POST-OP CARE INCLUDE IN PAY FOR SURGICAL                   PROCESSED ACCORDING TO PLAN
     792            ZZZ    PROCEDURE                                                 104      PROVISIONS.
                           10 DAYS POST-OP CARE INCLUDE IN PAY FOR SURGICAL                   PROCESSED ACCORDING TO PLAN
     793            ZZZ    PROCEDURE                                                 104      PROVISIONS.
                                                                                              MAXIMUM COVERAGE AMOUNT MET OR
     794            ZZZ    ONLY 1 HEARING TEST ALLOWED/DOS PER ATTEND PROV           483      EXCEEDED FOR BENEFIT PERIOD.
                           ONLY ONE HEARING AID EXAM PROCEDURE ALLOWED PER DOS                MAXIMUM COVERAGE AMOUNT MET OR
     795            ZZZ    PER ATT PROV                                              483      EXCEEDED FOR BENEFIT PERIOD.
                           ONLY 1 ELECTROACOUSTIC EVAL PROC ALLOWED/DOS PER                   MAXIMUM COVERAGE AMOUNT MET OR
     796            ZZZ    ATTEND PROV                                               483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                              MAXIMUM COVERAGE AMOUNT MET OR
     797            ZZZ    DDTCS - ONE PRESCHOOL VISIT/DOS PER ATTEND PROVIDER       483      EXCEEDED FOR BENEFIT PERIOD.
                           DDTCS-1 ADULT DEVELOPMENT VISIT ALLOWED/DOS PER                    MAXIMUM COVERAGE AMOUNT MET OR
     798            ZZZ    ATTEND PROV                                               483      EXCEEDED FOR BENEFIT PERIOD.
                           ONLY 1 PURE TONE AUDIOMETRY PROCEDURE ALLOWED/DOS                  MAXIMUM COVERAGE AMOUNT MET OR
     799            ZZZ    PER ATT PROV                                              483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                              PROCESSED ACCORDING TO PLAN
     800            ZZZ    SINGLE FILM NOT ALLOWED WITH FULL MOUTH SERIES            104      PROVISIONS.
                                                                                              PROCESSED ACCORDING TO PLAN
     801            ZZZ    SINGLE FILM NOT ALLOWED WITH FULL MOUTH SERIES            104      PROVISIONS.
                           OP NON-PHYSICIAN SVCS NOT ALLOWED WITH                             PROCESSED ACCORDING TO PLAN
     802            ZZZ    TREATMENT/THERAPY CODES                                   104      PROVISIONS.
                           OP NON-PHYSICIAN SVCS NOT ALLOWED WITH                             PROCESSED ACCORDING TO PLAN
     803            ZZZ    TREATMENT/THERAPY CODES                                   104      PROVISIONS.
                           OFFICE VST AND VISUAL ANALYSIS NOT ALLWD SAME DOS SAME             PROCESSED ACCORDING TO PLAN
     804            ZZZ    ATT PROV                                                  104      PROVISIONS.
                           OFFICE VST AND VISUAL ANALYSIS NOT ALLWD SAME DOS SAME             PROCESSED ACCORDING TO PLAN
     805            ZZZ    ATT PROV                                                  104      PROVISIONS.
                           GROUP OUTP/THERAPY SVCS N-PAY TO MENTAL HEALTH PROV                PROCESSED ACCORDING TO PLAN
     806            ZZZ    ON SAME DOS                                               104      PROVISIONS.
                           INDIV/COLLATERAL SVCS N-PAY TO MULTIPLE MH PROV ON                 PROCESSED ACCORDING TO PLAN
     808            ZZZ    SAME DOS                                                  104      PROVISIONS.
                           INDIV/COLLATERAL SVCS N-PAY TO MULTIPLE MH PROV ON                 PROCESSED ACCORDING TO PLAN
     809            ZZZ    SAME DOS                                                  104      PROVISIONS.




5/16/2012                                                      Page 336
                                                            ESC TO 277


                                                                                    277
                    PLAN                                                            CLAIM
 EDIT/AUDIT   TXN   CODE   EDIT/AUDIT DESCRIPTION                                   STATUS   CLAIM STATUS CODE
                           MARITAL/FAMILY THERAPY SVCS N-PAY TO MULTIPLE MH PROV             PROCESSED ACCORDING TO PLAN
     810            ZZZ    SAME DOS                                                 104      PROVISIONS.
                           INDIV OUTP/THERAPY SESSION N-PAY TO MULT MH PROV ON               PROCESSED ACCORDING TO PLAN
     812            ZZZ    SAME DOS                                                 104      PROVISIONS.
                                                                                             PROCESSED ACCORDING TO PLAN
     814            ZZZ    CRISIS MGMT SERV N-PAY TO MULTIPLE MH PROV ON SAME DOS   104      PROVISIONS.
                           INTERPRETATION OF DIAG SVC N-PAY TO MULTIPLE MH PROV              PROCESSED ACCORDING TO PLAN
     816            ZZZ    SAME DOS                                                 104      PROVISIONS.
                           DIAG/PSYCH TEST BATTERY SVC N-PAY PSYCH WHEN PAID                 PROCESSED ACCORDING TO PLAN
     818            ZZZ    RSPMI SAME DOS                                           104      PROVISIONS.
                           DIAGN/PSYCH TEST SVC N-PAY TO PSYCH WHEN PAID TO RSPMI            PROCESSED ACCORDING TO PLAN
     820            ZZZ    SAME DOS                                                 104      PROVISIONS.
                           DIAGNOSIS SVC N-PAY TO MULTIPLE MH PROVIDERS ON SAME              PROCESSED ACCORDING TO PLAN
     822            ZZZ    DOS                                                      104      PROVISIONS.
                           ONLY ONE PROCEDURE ALLOWED PER DOS PER ATTENDING                  MAXIMUM COVERAGE AMOUNT MET OR
     825            ZZZ    PROVIDER                                                 483      EXCEEDED FOR BENEFIT PERIOD.
                           ONLY ONE PROCEDURE ALLOWED PER DOS PER ATTENDING                  MAXIMUM COVERAGE AMOUNT MET OR
     826            ZZZ    PROVIDER                                                 483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                             PROCESSED ACCORDING TO PLAN
     829            ZZZ    ROUTINE NEWBORN CARE INCLUDES ROUTINE HOSPITAL CARE      104      PROVISIONS.
                                                                                             PROCESSED ACCORDING TO PLAN
     830            ZZZ    ROUTINE NEWBORN CARE INCLUDES ROUTINE HOSPITAL CARE      104      PROVISIONS.
                           PAYMENT FOR PHYSICAL MEDICINE INCLUDES FEE FOR OFFICE             PROCESSED ACCORDING TO PLAN
     832            ZZZ    VISIT                                                    104      PROVISIONS.
                           PAYMENT FOR PHYSICAL MEDICINE INCLUDES FEE FOR OFFICE             PROCESSED ACCORDING TO PLAN
     833            ZZZ    VISIT                                                    104      PROVISIONS.
                           HOSP ADM NOT ALLOWED SAME DAY                                     PROCESSED ACCORDING TO PLAN
     836            ZZZ    OFFICE,ER,NH,PSYCH,HOSP DISCHARGE                        104      PROVISIONS.
                                                                                             PROCESSED ACCORDING TO PLAN
     837            ZZZ    COMPONENT TEST INCLUDED IN COMPLETE BLOOD COUNT          104      PROVISIONS.
                           OFFICE,ER,NH,PSYCH,HOSP DISCHARGE NOT ALLOWED SAME                PROCESSED ACCORDING TO PLAN
     838            ZZZ    DAY HOSP ADM                                             104      PROVISIONS.
                           PROC CODE Z1555 NOT ALLOWED SAME DOS AS PROC CODE                 PROCESSED ACCORDING TO PLAN
     839            ZZZ    Z1556                                                    104      PROVISIONS.
                           PROC CODE Z1556 NOT ALLOWED SAME DOS AS PROC CODE                 PROCESSED ACCORDING TO PLAN
     840            ZZZ    Z1555                                                    104      PROVISIONS.
                                                                                             PROCESSED ACCORDING TO PLAN
     841            ZZZ    PROC CODE Z0481 NOT ALLOWED SAME DOS PROC CODE Z1564     104      PROVISIONS.
                                                                                             PROCESSED ACCORDING TO PLAN
     847            ZZZ    URINALYSIS INCLUDED IN PROCEDURE CODE-Z1635              104      PROVISIONS.




5/16/2012                                                    Page 337
                                                              ESC TO 277


                                                                                      277
                    PLAN                                                              CLAIM
 EDIT/AUDIT   TXN   CODE   EDIT/AUDIT DESCRIPTION                                     STATUS   CLAIM STATUS CODE
                                                                                               MAXIMUM COVERAGE AMOUNT MET OR
     848            ZZZ    ONLY ONE DAY TREATMENT SERVICE ALLOWED PER DOS             483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                               MAXIMUM COVERAGE AMOUNT MET OR
     849            ZZZ    ONLY ONE DAY TREATMENT SERVICE ALLOWED PER DOS             483      EXCEEDED FOR BENEFIT PERIOD.
                           OUTPA HOSPITAL DRUGS, INJEC AND SUPPLIES N-PAY IN N-EMER            PROCESSED ACCORDING TO PLAN
     851            ZZZ    ROOM                                                       104      PROVISIONS.
                           OUTPA HOSPITAL DRUGS, INJEC AND SUPPLIES N-PAY IN N-EMER            PROCESSED ACCORDING TO PLAN
     852            ZZZ    ROOM                                                       104      PROVISIONS.
                           Z1688-ADULT FOSTER CARE INCLUSIVE OF ALL ELDER CHOICES              PROCESSED ACCORDING TO PLAN
     853            ZZZ    WVER SVSC                                                  104      PROVISIONS.
                           ELDER CHOICE SERVICE NOPAY SAME DOS AS Z1704 LT FACILITY            PROCESSED ACCORDING TO PLAN
     854            ZZZ    RES CARE                                                   104      PROVISIONS.
                           RESPITE CARE SERVICE Z1704 NOT PAYABLE SAME DOS AS PD               PROCESSED ACCORDING TO PLAN
     855            ZZZ    ELDERCHOICE                                                104      PROVISIONS.
                           ELDER CHOICE WAIVER SERVICE NOT PAYABLE IN                          PROCESSED ACCORDING TO PLAN
     856            ZZZ    CONJUNCTION WITH Z1688                                     104      PROVISIONS.
                           ELDER CHOICE WAIVER SERVICES NOT PAYABLE SAME DOS AS                PROCESSED ACCORDING TO PLAN
     857            ZZZ    Z1687-PC/RCF                                               104      PROVISIONS.
                                                                                               MAXIMUM COVERAGE AMOUNT MET OR
     859            ZZZ    ONLY ONE ADC OR ADHC SERVICE ALLOWED PER DOS               483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                               MAXIMUM COVERAGE AMOUNT MET OR
     860            ZZZ    ONLY ONE ADC OR ADHC SERVICE ALLOWED PER DOS               483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                               MAXIMUM COVERAGE AMOUNT MET OR
     861            ZZZ    SCALING LIMITED TO ONE PER STATE FISCAL YEAR               483      EXCEEDED FOR BENEFIT PERIOD.
                                                                                               PROCESSED ACCORDING TO PLAN
     862            ZZZ    E0608 BILLED PRIOR TO 30 DAYS OF Z1685                     104      PROVISIONS.
                                                                                               MAXIMUM COVERAGE AMOUNT MET OR
     863            ZZZ    PROPHYS/FLOURIDE TREATMENT LIMITED TO ONE PER SFY          483      EXCEEDED FOR BENEFIT PERIOD.
                           ADC OR ADHC NOT PAYABLE SAME DOS AS PAID HOMEMAKER                  PROCESSED ACCORDING TO PLAN
     864            ZZZ    OR CHORE                                                   104      PROVISIONS.
                           HOMEMAKER OR CHORE NOT PAYABLE SAME DOS AS PAID ADC                 PROCESSED ACCORDING TO PLAN
     865            ZZZ    OR ADHC                                                    104      PROVISIONS.
                           REVIEW PD CLM Z1703-ADHC WHEN OCCURRING ON SAME DOS                 PROCESSED ACCORDING TO PLAN
     866            ZZZ    AS Z0005-HHPT                                              104      PROVISIONS.
                                                                                               PROCESSED ACCORDING TO PLAN
     867            ZZZ    SUSPEND Z1703-ADHC WHEN BILLED SAME DOS AS Z0005-HHPT      104      PROVISIONS.
                                                                                               MAXIMUM COVERAGE AMOUNT MET OR
     869            ZZZ    PERIAPRICAL X-RAYS LIMITED TO FOUR PER VISIT               483      EXCEEDED FOR BENEFIT PERIOD.
                           TANDEM/THERAPEUTIC CLASS DOSAGE MAX EXCEEDED FOR                    MAXIMUM COVERAGE AMOUNT MET OR
     871            ZZZ    MONTH                                                      483      EXCEEDED FOR BENEFIT PERIOD.




5/16/2012                                                       Page 338
                                                             ESC TO 277


                                                                                      277
                    PLAN                                                              CLAIM
 EDIT/AUDIT   TXN   CODE   EDIT/AUDIT DESCRIPTION                                     STATUS   CLAIM STATUS CODE
                                                                                               PROCESSED ACCORDING TO PLAN
     872            ZZZ    INCLUDED IN FLAT FEE FOR MAJOR PROCEDURE                   104      PROVISIONS.
                                                                                               PROCESSED ACCORDING TO PLAN
     875            ZZZ    CAST INCLUDED IN FEE FOR SURGICAL PROCEDURE                104      PROVISIONS.
                                                                                               PROCESSED ACCORDING TO PLAN
     876            ZZZ    INCLUDED IN FLAT FEE FOR MAJOR PROCEDURE                   104      PROVISIONS.
                                                                                               PROCESSED ACCORDING TO PLAN
     877            ZZZ    CAST INCLUDED IN FEE FOR SURGICAL PROCEDURE                104      PROVISIONS.
                                                                                               PROCESSED ACCORDING TO PLAN
     878            ZZZ    PROCEDURE INCLUDED IN OFFICE VISIT IF BILLED ON SAME DOS   104      PROVISIONS.
                                                                                               PROCESSED ACCORDING TO PLAN
     879            ZZZ    PROCEDURE INCLUDED IN OFFICE VISIT IF BILLED ON SAME DOS   104      PROVISIONS.
                           PROCEDURE INCLUDED IN PAYMENT FOR COMPREHENSIVE                     PROCESSED ACCORDING TO PLAN
     880            ZZZ    SERVICE                                                    104      PROVISIONS.
                           PROCEDURE INCLUDED IN PAYMENT FOR COMPREHENSIVE                     PROCESSED ACCORDING TO PLAN
     881            ZZZ    SERVICE                                                    104      PROVISIONS.
                           PROCEDURE INCLUDED IN PAYMENT FOR COMPREHENSIVE                     PROCESSED ACCORDING TO PLAN
     882            ZZZ    SERVICE                                                    104      PROVISIONS.
                                                                                               PROCESSED ACCORDING TO PLAN
     883            ZZZ    PROCEDURE INCLUDED IN GLOBAL OB CARE BY SAME PROVIDER 104           PROVISIONS.
                                                                                               PROCESSED ACCORDING TO PLAN
     884            ZZZ    PROCEDURE INCLUDED IN GLOBAL OB CARE BY SAME PROVIDER 104           PROVISIONS.