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					                      DEAN HEALTH PLAN CLAIM ADJUSTMENT REASON CODES - 10/27/10

                      Paper
        Hold
                      Claim
        code                                                                         835 Claim Adj.    835 Description of ANSI code                      Group   835 Line Level
                       Adj.               Paper Description
       (Paper                                                                         Reason code        (note will not print on 835)                    Codes    Adjustment
                     Reason
        only)
                      code
                              Deductible amount                                                       Deductible amount

            DD         1                                                                   1                                                              PR        Deductible


                              Coinsurance Amount.                                                     Coinsurance Amount.


            MI         2                                                                   2                                                              PR        Coinsurance



                              Copayment amount.                                                       Copayment amount.


            WW         3                                                                   3                                                              PR          Copay



                              Copayment amount.                                                       Copayment amount.
        CJ (Used
       only for CU
                       3                                                                   3                                                              PR       Non - Covered
        hold code
         process)
                              The procedure code is inconsistent w/modifier                           The procedure code is inconsistent with the
                              used or req. modifier is misiing. MA does not allow                     modifier used or required modifier is misiing.
            PV         4      svc.                                                         4                                                              OA       Non - Covered


                              The procedure code is inconsistent w/modifier                           The procedure code is inconsistent with the
                              used or req. modifier missing.                                          modifier used or a required modifier is missing.


            XM         4                                                                   4                                                              OA       Non - Covered




                              The procedure code/bill type is inconsistent with                       The procedure code/bill type is inconsistent
                              the place of service.                                                   with the place of service.
            ZJ         5                                                                   5                                                              OA       Non - Covered



                              The procedure/revenue code is inconsistent with                         The procedure/revenue code is inconsistent
                              the patient's age                                                       with the patient's age
            XL         6                                                                   6                                                              OA       Non - Covered


                              The procedure/revenue code is inconsistent with                         The procedure/revenue code is inconsistent
                              the patient's gender                                                    with the patient's gender
            XT         7                                                                   7                                                              OA       Non - Covered


                              The procedure code is inconsistent with the prov.                       The procedure code is inconsistent with the
                              type/specialty (taxonomy).                                              provider type/specialty(taxonomy).
            PY         8                                                                   8                                                              OA       Non - Covered


                              The diagnosis is inconsistent with the patient's age                    The diagnosis is inconsistent with the patient's
                                                                                                      age
            XV         9                                                                   9                                                              OA       Non - Covered


                              The diagnosis is inconsistent with the patient's                        The diagnosis is inconsistent with the patient's
                              gender.                                                                 gender.
            XY         10                                                                  10                                                             OA       Non - Covered




8/26/2012                                                                           01577e13-3c76-4734-a04d-aa2d9594a637.xls                                                       1
                  DEAN HEALTH PLAN CLAIM ADJUSTMENT REASON CODES - 10/27/10

                  Paper
        Hold
                  Claim
        code                                                                       835 Claim Adj.    835 Description of ANSI code                     Group   835 Line Level
                   Adj.                Paper Description
       (Paper                                                                       Reason code        (note will not print on 835)                   Codes    Adjustment
                 Reason
        only)
                  code
                          The diagnosis is inconsistent with the procedure                          The diagnosis is inconsistent with the
                                                                                                    procedure
            DH     11                                                                    11                                                            OA       Non-Covered


                          The diagnosis is inconsistent with the provider type                      The diagnosis is inconsistent with the provider
                                                                                                    type
            DK     12                                                                    12                                                            OA       Non-Covered


                          The date of death precedes the date of service                            The date of death precedes the date of service

            DL     13                                                                    13                                                            OA       Non-Covered


                          The date of birth follows the date of service                             The date of birth follows the date of service

            DQ     14                                                                    14                                                            OA       Non-Covered


                          Clm/svc lacks info needed for adjudication. Refile                        Claim/service lacks information which is
                          w/ correct prov / vend#                                                   needed for adjudication. At least one Remark
            ZT    16W                                                                    16         Code must be provided (may be comprised of         OA       Non - Covered
                                                                                                    either the Remittance Advice Remark Code or
                                                                                                    NCPDP Reject Reason Code).
                          clm/svc lacks info for adjudication - refile with more                    Claim/service lacks information which is
                          appropriate CPT/ HCPC's code                                              needed for adjudication. At least one Remark
            YI     16V                                                                   16         Code must be provided (may be comprised of         OA       Non - Covered
                                                                                                    either the Remittance Advice Remark Code or
                                                                                                    NCPDP Reject Reason Code).
                          Claim/svc lacks info for adjudication. Submit                             Claim/service lacks information which is
                          Provider Name & Specialty                                                 needed for adjudication. At least one Remark
            ZS     16Q                                                                   16         Code must be provided (may be comprised of         OA       Non - Covered
                                                                                                    either the Remittance Advice Remark Code or
                                                                                                    NCPDP Reject Reason Code).
                          Claim/svc lacks info for adjudication - refile with                       Claim/service lacks information which is
                          itemzation sorted by days                                                 needed for adjudication. At least one Remark
            ZF     16K                                                                   16         Code must be provided (may be comprised of         OA       Non - Covered
                                                                                                    either the Remittance Advice Remark Code or
                                                                                                    NCPDP Reject Reason Code).
                          Claim/svc lacks info for adjudication. Submit                             Claim/service lacks information which is
                          description of procedure.                                                 needed for adjudication. At least one Remark
            X1     16X                                                                   16         Code must be provided (may be comprised of         OA       Non - Covered
                                                                                                    either the Remittance Advice Remark Code or
                                                                                                    NCPDP Reject Reason Code).
                          Clm/svc lacks info.needed for adjudication.                               Claim/service lacks information which is
                          Consent form does not meet age requirements.                              needed for adjudication. At least one Remark
            CF     16Z                                                                   16         Code must be provided (may be comprised of         OA        Non-Covered
                                                                                                    either the Remittance Advice Remark Code or
                                                                                                    NCPDP Reject Reason Code).
                          Clm /svc lacks info for adjudication. Submit                              Claim/service lacks information which is
                          Medicaid Consent Form.                                                    needed for adjudication. At least one Remark
            GF     16J                                                                   16         Code must be provided (may be comprised of         OA        Non-Covered
                                                                                                    either the Remittance Advice Remark Code or
                                                                                                    NCPDP Reject Reason Code).
                          Duplicate claim/service.                                                  Duplicate claim/service.


            XD     18                                                                    18                                                            OA       Non - Covered


8/26/2012                                                                       01577e13-3c76-4734-a04d-aa2d9594a637.xls                                                        2
                  DEAN HEALTH PLAN CLAIM ADJUSTMENT REASON CODES - 10/27/10

                  Paper
        Hold
                  Claim
        code                                                                    835 Claim Adj.    835 Description of ANSI code                       Group          835 Line Level
                   Adj.                Paper Description
       (Paper                                                                    Reason code        (note will not print on 835)                     Codes           Adjustment
                 Reason
        only)
                  code
                          This is a work-related injury/illness and thus the                     This is a work-related injury/illness and thus
                          liability of the worker's compensation carrier.                        the liability of the worker's compensation
            S1     19                                                                 19         carrier.                                               OA            Non - Covered


                          This care may be covered by another payer                              This care may be covered by another payer
                          (Medicare)                                                             per coordination of benefits.
            MP     22B                                                                22                                                                OA            Non- Covered



                          This care may be covered by another payer.                             This care may be covered by another payer
                                                                                                 per coordination of benefits.
            OI     22                                                                 22                                                                OA            Non - Covered


                          The impact of prior payer adj. Including payments                      The impact of prior payer(s) adjudication
                          and/ or adjustments.                                                   including payments and / or adjustments.
            S5     23                                                                 23                                                                OA            COB Savings


                          Expenses incurred prior to coverage.                                   Expenses incurred prior to coverage.

            CV     26                                                                 26                                                                PR             Non-Covered


                          Expenses incurred after coverage terminated.                           Expenses incurred after coverage terminated.

            CX     27                                                                 27                                                                PR             Non-Covered


                          Time limit for filing has expired. Per review,                         Time limit for filing has expired.
                          service remains denied.
            YU     29B                                                                29                                                           (1) CO, (2) PR     Non - Covered


                          The time limit for filing has expired.                                 The time limit for filing has expired.

            TF     29                                                                 29                                                                PR            Non - Covered


                          The time limit for filing has expired.                                 The time limit for filing has expired.

            X6     29                                                                 29                                                           (1) CO, (2) PR     Non - Covered


                          Patient cannot be identified as our insured                            Patient cannot be identified as our insured

            FF     31                                                                 31                                                                PR            Non- Covered


                          Our records indicate that this dependent is not an                     Our records indicate that this dependent is not
                          eligible dependent as defined                                          an eligible dependent as defined
            CW     32                                                                 32                                                                PR            Non - Covered


                          Insured has no dependent coverage                                      Insured has no dependent coverage

            CZ     33                                                                 33                                                                PR            Non - Covered


                          Insured has no coverage for newborns.                                  Insured has no coverage for newborns.

            C2     34                                                                 34                                                                PR            Non - Covered




8/26/2012                                                                      01577e13-3c76-4734-a04d-aa2d9594a637.xls                                                               3
                  DEAN HEALTH PLAN CLAIM ADJUSTMENT REASON CODES - 10/27/10

                  Paper
        Hold
                  Claim
        code                                                                   835 Claim Adj.    835 Description of ANSI code                    Group                835 Line Level
                   Adj.               Paper Description
       (Paper                                                                   Reason code        (note will not print on 835)                  Codes                 Adjustment
                 Reason
        only)
                  code
                          Lifetime Benefit maximum has been reached                             Lifetime Benefit maximum has been reached

            BM     35                                                                35                                                             PR                    Non-Covered


                          Services not provided or authorized by designated                     Services not provided or authorized by
                          network/primary care prov.                                            designated (network/primary care) providers.
            NA     38                                                                38                                                             PR                   Non - Covered



                          Services denied at the time                                           Services denied at the time
                          authorization/precertification was req                                authorization/precertification was requested

            NZ     39                                                                39                                                             PR                   Non - Covered



                          Charges do not meet qualifications for                                Charges do not meet qualifications for
                          emergent/urgent care.                                                 emergent/urgent care.
            NE     40                                                                40                                                             PR                   Non - Covered


                          Charge exceeds fee schedule/maximum allowable.                        Charge exceeds fee schedule/maximum
                          Discount applied.                                                     allowable or contracted /legislated fee
                                                                                                arrangement.                                                     Difference between charged and
            50     45                                                                45                                                        (1.) CO, (2) PR
                                                                                                                                                                          allowed amount



                          Charge exceeds contracted fee arrangement. No                         Charge exceeds fee schedule/maximum
                          HPSA Incentive applied                                                allowable or contracted /legislated fee
                                                                                                arrangement.                                                     Difference between charged and
            SE     45A                                                               45                                                             CO
                                                                                                                                                                         allowed amount



                          Charge exceeds contracted fee arrangement.                            Charge exceeds fee schedule/maximum
                          HPSA Incentive applied                                                allowable or contracted /legislated fee
                                                                                                arrangement.                                                     Difference between charged and
            SB     45B                                                               45                                                             CO
                                                                                                                                                                         allowed amount



                          Charge exceeds contracted fee arrangement. No                         Charge exceeds fee schedule/maximum
                          Discount applied                                                      allowable or contracted /legislated fee
                                                                                                arrangement.                                                     Difference between charged and
            BE     45C                                                               45                                                             CO
                                                                                                                                                                         allowed amount



                          Charge exceeds contracted fee arrangement.                            Charge exceeds fee schedule/maximum
                          Reduced by Managed care.                                              allowable or contracted /legislated fee
                                                                                                arrangement.                                                     Difference between charged and
            BX     45D                                                               45                                                        (1) CO, (2) PR
                                                                                                                                                                         allowed amount



                          Charge exceeds contracted fee arrangement. Svc                        Charge exceeds fee schedule/maximum
                          not on your fee sched.                                                allowable or contracted /legislated fee
                                                                                                arrangement.
            X7    45W                                                                45                                                             CO                   Non - Covered




8/26/2012                                                                     01577e13-3c76-4734-a04d-aa2d9594a637.xls                                                                            4
                  DEAN HEALTH PLAN CLAIM ADJUSTMENT REASON CODES - 10/27/10

                  Paper
        Hold
                  Claim
        code                                                                   835 Claim Adj.    835 Description of ANSI code                    Group        835 Line Level
                   Adj.               Paper Description
       (Paper                                                                   Reason code        (note will not print on 835)                  Codes         Adjustment
                 Reason
        only)
                  code
                          Charge exceeds contracted fee schedule. Submit                        Charge exceeds fee schedule/maximum
                          notes to rev for add'l $                                              allowable or contracted /legislated fee
                                                                                                arrangement.                                             Difference between charged and
            YQ     45X                                                               45                                                           CO
                                                                                                                                                                 allowed amount



                          Charge exceeds contracted fee arrangement.                            Charge exceeds fee schedule/maximum
                          Provider discount applied.                                            allowable or contracted /legislated fee
                                                                                                arrangement.
            DT     45Z                                                               45                                                           CO             Discount field



                          These are noncovered services because this is                         These are noncovered services because this
                          not deemed a "medical necessity"                                      is not deemed a "medical necessity" by the
                                                                                                payer
            MT     50                                                                50                                                           PR             Non - Covered



                          These are noncovered services because this is a                       These are noncovered services because this
                          preexisting condition                                                 is a preexisting condition

            DP     51                                                                51                                                           PR             Non- Covered



                          Services by an immediate relative or member of                        Services by an immediate relative or a
                          same household are not covered                                        member of the same household are not
                                                                                                covered
            N1     53                                                                53                                                           PR             Non - Covered



                          Multiple physicians/assistants are not covered in                     Multiple physicians/assistants are not covered
                          this case.                                                            in this case.

            X4     54                                                                54                                                           OA            Non - Covered



                          Procedure/treatment is deemed                                         Procedure/treatment is deemed
                          experimental/investigational by the payer                             experimental/investigational by the payer

            EV     55                                                                55                                                           PR             Non-Covered



                          Treatment deemed to have been rendered in                             Treatment was deemed by the payer to have
                          inappro. or invalid POS                                               been rendered in an inappropriate or invalid
                                                                                                place of service.
            ZX     58                                                                58                                                           OA             Non -covered



                          Processed based on mulitple or concurrent                             Processed based on mulitple or concurrent
                          procedure rules.                                                      procedure rules.
                                                                                                                                                         Difference between charged and
            2X     59                                                                59                                                           OA
                                                                                                                                                                 allowed amount



                          Noncovered days/room charge adjustment                                Noncovered days/room charge adjustment


            PN     78                                                                78                                                           PR              Non-covered




8/26/2012                                                                     01577e13-3c76-4734-a04d-aa2d9594a637.xls                                                                    5
                  DEAN HEALTH PLAN CLAIM ADJUSTMENT REASON CODES - 10/27/10

                  Paper
        Hold
                  Claim
        code                                                                     835 Claim Adj.    835 Description of ANSI code                     Group        835 Line Level
                   Adj.               Paper Description
       (Paper                                                                     Reason code        (note will not print on 835)                   Codes         Adjustment
                 Reason
        only)
                  code
                          Transfer Amount                                                         Transfer Amount


            C1     87                                                                  87                                                            PR                 Copay



                          Plan procedures not followed.                                           Plan procedures not followed.

            XP     95                                                                  95                                                            PR            Non - Covered


                          Plan procedures not followed.Penalty applied                            Plan procedures not followed.


            P5     95E                                                                 95                                                            PR             Non - Covered



                          Plan procedures not followed. S/B enrolled w/                           Plan procedures not followed.
                          Medicare Part B
            RB     95C                                                                 95                                                            PR             Non- Covered



                          Noncovered charges. Noncovered per policy                               Noncovered charges


            NC     96                                                                  96                                                            PR             Non - Covered



                          Noncovered charges. Service covered at 50%.                             Noncovered charges.


            C5     96J                                                                 96                                                            PR              Non-covered



                          Payment included in the allowance for another                           Payment included in the allowance for another
                          service. Svc pd at DRG/PerDiem                                          service/procedure
                                                                                                                                                            Difference between charged and
            LO     97E                                                                 97                                                            CO
                                                                                                                                                                    allowed amount


                          Payment made to patient/insured/responsible party                       Payment made to patient/insured/responsible
                                                                                                  party
            PJ     100                                                                 100                                                           PR             Non - Covered



                          Managed care withholding ***note should only be                         Managed care withholding
                          on Provider EOP, not printed on Member EOB
            WH     104                                                                 104                                                           CO               With hold



                          The related claim/service was not identified on this                    The related or qualifying claim/service was not
                          claim.                                                                  identified on this claim
            N2     107                                                                 107                                                           OA             Non-Covered



                          Rent/purchase guidelines were not met                                   Rent/purchase guidelines were not met


            RT     108                                                                 108                                                           PR             Non -covered




8/26/2012                                                                    01577e13-3c76-4734-a04d-aa2d9594a637.xls                                                                        6
                  DEAN HEALTH PLAN CLAIM ADJUSTMENT REASON CODES - 10/27/10

                  Paper
        Hold
                  Claim
        code                                                                    835 Claim Adj.    835 Description of ANSI code                   Group   835 Line Level
                   Adj.               Paper Description
       (Paper                                                                    Reason code        (note will not print on 835)                 Codes    Adjustment
                 Reason
        only)
                  code
                          Claim not covered by this payer. You must send                         Claim not covered by this payer/contractor.
                          the clm to North Central Opthalmology.                                 You must send the claim to the correct
            Y1     109                                                                109        payor/contractor                                 OA       Non - Covered



                          Claim not covered by this payor. You must send                         Claim not covered by this payer/contractor.
                          the claim to contracted repricer.                                      You must send the claim to the correct
            RW     109                                                                109        payor/contractor                                 OA       Non - Covered



                          Claim not covered by this payor. You must send                         Claim not covered by this payer/contractor.
                          the claim to Interlink.                                                You must send the claim to the correct
            Z1     109                                                                109        payor/contractor                                 OA       Non-Covered



                          Claim not covered by this payor. You must send                         Claim not covered by this payer/contractor.
                          the claim to URN.                                                      You must send the claim to the correct
            Z2     109                                                                109        payor/contractor                                 OA       Non - Covered



                          Claim not covered by this payer. You must send                         Claim not covered by this payer/contracter.
                          the claim to the correct payer                                         You must send the claim to the correct
            TI     109                                                                109        payer/contracter                                 OA       Non - Covered


                          Billing date predates service date. Resubmit                           Billing date predates service date
                          w/correct DOS
            YF     110                                                                110                                                         OA       Non - Covered


                          Not covered unless the provider accepts                                Not covered unless the provider accepts
                          assignment                                                             assignment

            AA     111                                                                111                                                         OA       Non-Covered



                          Procedure postponed, cancelled or delayed                              Procedure postponed, cancelled or delayed


            C6     115                                                                115                                                         PR       Non-Covered



                          Transportation is only covered to the closest                          Transportation is only covered to the closest
                          facility.                                                              facility that can provide the necessary care
            TV     117                                                                117                                                         PR       Non-Covered


                          Benefit max for this period/occurrence is reached.                     Benefit maximum for this time period or
                           2 Yr Eyeglass benefit met.                                            occurrence has been reached

            EG     119                                                                119                                                         PR       Non- Covered




8/26/2012                                                                      01577e13-3c76-4734-a04d-aa2d9594a637.xls                                                    7
                  DEAN HEALTH PLAN CLAIM ADJUSTMENT REASON CODES - 10/27/10

                  Paper
        Hold
                  Claim
        code                                                                    835 Claim Adj.    835 Description of ANSI code                     Group        835 Line Level
                   Adj.               Paper Description
       (Paper                                                                    Reason code        (note will not print on 835)                   Codes         Adjustment
                 Reason
        only)
                  code
                          Benefit max for this period/occurrence is reached.                     Benefit maximum for this time period or
                          Benefit maximum met                                                    occurrence has been reached



            BN     119                                                                119                                                           PR             Non - Covered




                          Benefit max for this period/occurrence is                              Benefit maximum for this time period or
                          reached.Benefit maximum met                                            occurrence has been reached



            MX     119                                                                119                                                           PR             Non - Covered




                                                                                                 Submission/billing error(s). At least one
                                                                                                 Remark Code must be provided (may be
                          Submission/billing error(s). Submit HCFA for add'l
            Z3     125                                                                125        comprised of either the Remittance Advice          OA             Non - Covered
                          $
                                                                                                 Remark Code or NCPDP Reject Reason
                                                                                                 Code).
                          Prior processing information appears incorrect.                        Prior processing information appears incorrect.
                          Need EOB.

            OC     129                                                                129                                                           OA             Non - Covered



                          Claim specific negotiated discount. Negotiated fee                     Claim specific negotiated discount
                          with prov.
                                                                                                                                                           Difference between charged and
            NF     131                                                                131                                                           CO
                                                                                                                                                                   allowed amount



                          Claim specific negotiated discount. TRPN/HFN                           Claim specific negotiated discount
                                                                                                                                                           Difference between charged and
            R1     131                                                                131                                                           CO
                                                                                                                                                                   allowed amount


                          Claim specific negotiated discount. First Choice                       Claim specific negotiated discount
                          Health Netwk.
                                                                                                                                                           Difference between charged and
            R2     131                                                                131                                                           CO
                                                                                                                                                                   allowed amount


                          Claim specific negotiated discount. PPO                                Claim specific negotiated discount
                          Next/PHN/Healthstar
                                                                                                                                                           Difference between charged and
            R3     131                                                                131                                                           CO
                                                                                                                                                                   allowed amount


                          Claim specific negotiated discount. HFNID                              Claim specific negotiated discount

                                                                                                                                                           Difference between charged and
            R4     131                                                                131                                                           CO
                                                                                                                                                                   allowed amount



                          Claim specific negotiated discount. Primary Health                     Claim specific negotiated discount
                          Services
                                                                                                                                                           Difference between charged and
            R5     131                                                                131                                                           CO
                                                                                                                                                                   allowed amount

8/26/2012                                                                      01577e13-3c76-4734-a04d-aa2d9594a637.xls                                                                     8
                  DEAN HEALTH PLAN CLAIM ADJUSTMENT REASON CODES - 10/27/10

                  Paper
        Hold
                  Claim
        code                                                                   835 Claim Adj.    835 Description of ANSI code        Group        835 Line Level
                   Adj.               Paper Description
       (Paper                                                                   Reason code        (note will not print on 835)      Codes         Adjustment
                 Reason
        only)
                  code
                          Claim specific negotiated discount. Novanet                           Claim specific negotiated discount
                                                                                                                                             Difference between charged and
            R6     131                                                               131                                              CO
                                                                                                                                                     allowed amount


                          Claim specific negotiated discount. Galaxy Health                     Claim specific negotiated discount
                          Network
                                                                                                                                             Difference between charged and
            R7     131                                                               131                                              CO
                                                                                                                                                     allowed amount


                          Claim specific negotiated discount.                                   Claim specific negotiated discount
                          NPPN/Accountable
                                                                                                                                             Difference between charged and
            R8     131                                                               131                                              CO
                                                                                                                                                     allowed amount



                          Claim specific negotiated discount. Hygeia                            Claim specific negotiated discount
                          Corporation
                                                                                                                                             Difference between charged and
            R9     131                                                               131                                              CO
                                                                                                                                                     allowed amount



                          Claim specific negotiated discount. TRPN/FPN                          Claim specific negotiated discount

                                                                                                                                             Difference between charged and
            RA     131                                                               131                                              CO
                                                                                                                                                     allowed amount



                          Claim specific negotiated discount. PHCS Healthy                      Claim specific negotiated discount
                          Directions contract
                                                                                                                                             Difference between charged and
            RE     131                                                               131                                              CO
                                                                                                                                                     allowed amount


                          Claim specific negotiated discount.Health Payors                      Claim specific negotiated discount
                          organization contract
                                                                                                                                             Difference between charged and
            RF     131                                                               131                                              CO
                                                                                                                                                     allowed amount


                          Claim specific negotiated discount. PPO Next                          Claim specific negotiated discount
                          contract.
                                                                                                                                             Difference between charged and
            RG     131                                                               131                                              CO
                                                                                                                                                     allowed amount



                          Claim specific negotiated discount. PHCS contract                     Claim specific negotiated discount
                                                                                                                                             Difference between charged and
            RH     131                                                               131                                              CO
                                                                                                                                                     allowed amount


                          Claim specific negotiated discount. Hygeia Corp                       Claim specific negotiated discount
                          contract
                                                                                                                                             Difference between charged and
            RI     131                                                               131                                              CO
                                                                                                                                                     allowed amount


                          Claim specific negotiated discount. Multiplan                         Claim specific negotiated discount
                          contract
                                                                                                                                             Difference between charged and
            RJ     131                                                               131                                              CO
                                                                                                                                                     allowed amount


                          Claim specific negotiated discount. HealthEOS                         Claim specific negotiated discount
                          contract
                                                                                                                                             Difference between charged and
            RK     131                                                               131                                              CO
                                                                                                                                                     allowed amount


8/26/2012                                                                     01577e13-3c76-4734-a04d-aa2d9594a637.xls                                                        9
                  DEAN HEALTH PLAN CLAIM ADJUSTMENT REASON CODES - 10/27/10

                  Paper
        Hold
                  Claim
        code                                                                    835 Claim Adj.    835 Description of ANSI code        Group        835 Line Level
                   Adj.               Paper Description
       (Paper                                                                    Reason code        (note will not print on 835)      Codes         Adjustment
                 Reason
        only)
                  code
                          Claim specific negotiated discount Accountable                         Claim specific negotiated discount
                          Health Plans.

                                                                                                                                              Difference between charged and
            RL     131                                                                131                                              CO
                                                                                                                                                      allowed amount




                          Claim specific negotiated discount. NPPN                               Claim specific negotiated discount
                          Community Health Partners.
                                                                                                                                              Difference between charged and
            RN     131                                                                131                                              CO
                                                                                                                                                       allowed amount



                          Claim specific negotiated discount. URN Network                        Claim specific negotiated discount
                          contract)
                                                                                                                                              Difference between charged and
            RO     131                                                                131                                              CO
                                                                                                                                                      allowed amount



                          Claim specific negotiated discount.                                    Claim specific negotiated discount
                          ARAZ/Americas PPO
                                                                                                                                              Difference between charged and
            RP     131                                                                131                                              CO
                                                                                                                                                      allowed amount


                          Claim specific negotiated discount. Coalition                          Claim specific negotiated discount
                          America contract
                                                                                                                                              Difference between charged and
            RQ     131                                                                131                                              CO
                                                                                                                                                      allowed amount


                          Claim specific negotiated discount. Provider Select                    Claim specific negotiated discount
                                                                                                                                              Difference between charged and
            RU     131                                                                131                                              CO
                                                                                                                                                      allowed amount


                          Claim specific negotiated discount. HMN/RAN/AMN                        Claim specific negotiated discount

                                                                                                                                              Difference between charged and
            RX     131                                                                131                                              CO
                                                                                                                                                      allowed amount



                          Claim specific negotiated discount. NPPN Direct                        Claim specific negotiated discount
                                                                                                                                              Difference between charged and
            RY     131                                                                131                                              CO
                                                                                                                                                      allowed amount


                          Claim specific negotiated discount. Medical                            Claim specific negotiated discount
                          Resource/Natl Prvd
                                                                                                                                              Difference between charged and
            RZ     131                                                                131                                              CO
                                                                                                                                                      allowed amount


                          Claim specific negotiated discount. PlanCare                           Claim specific negotiated discount
                          America.
                                                                                                                                              Difference between charged and
            T1     131                                                                131                                              CO
                                                                                                                                                       allowed amount


                          Claim specific negotiated discount. Negotiated fee                     Claim specific negotiated discount
                                                                                                                                              Difference between charged and
            Y6     131                                                                131                                              CO
                                                                                                                                                      allowed amount




8/26/2012                                                                      01577e13-3c76-4734-a04d-aa2d9594a637.xls                                                        10
                  DEAN HEALTH PLAN CLAIM ADJUSTMENT REASON CODES - 10/27/10

                  Paper
        Hold
                  Claim
        code                                                                   835 Claim Adj.    835 Description of ANSI code                     Group   835 Line Level
                   Adj.                Paper Description
       (Paper                                                                   Reason code        (note will not print on 835)                   Codes    Adjustment
                 Reason
        only)
                  code
                          The disposition of the clm/svc is pending review.                     The disposition of the claim/service is pending
                          Submit NDC/ name of RX drug.                                          further review.

            YA     133                                                               133                                                           OA       Non - Covered



                          The disposition of the clm/svc is pending further                     The disposition of the claim/service is pending
                          review. Submit office notes/ records.                                 further review.

            XO     133                                                               133                                                           OA       Non - Covered



                          The disposition of the clm/svc is pending review.                     The disposition of the claim/service is pending
                          Notes req. w/ medical need.                                           further review.

            ZY     133                                                               133                                                           OA       Non - Covered



                          Interim bills cannot be processed                                     Interim bills cannot be processed


            I2     135                                                               135                                                           CO       Non-Covered



                          Failure to follow prior payer's coverage rules.                       Failure to follow prior payer's coverage rules.


            GG     136                                                               136                                                           OA       Non-Covered



                          Appeal procedures not followed or time limits not                     Appeal procedures not followed or time limits
                          met                                                                   not met

            TL     138                                                               138                                                           CO       Non-Covered



                          Patient/insured health identification number and                      allowed amt reduced because component of
                          name do not match.                                                    the basic prodcedure/test was paid. The
                                                                                                beneficiary is not liable for more than the
            N3     140                                                               140        charge limit for the basic procedure/test          PR       Non-Covered



                          Claim spans eligible & ineligible periods of                          Claim spans eligible & ineligible periods of
                          coverage.                                                             coverage.

            N4     141                                                               141                                                           PR       Non-Covered



                          Monthly Medicaid patient liability amount.                            Monthly Medicaid patient liability amount.


            N5     142                                                               142                                                           PR       Non-Covered



                          Diagnosis was invalid for date(s) of service                          Diagnosis was invalid for date(s) of service
                          reported.                                                             reported.

            N7     146                                                               146                                                           OA       Non-Covered




8/26/2012                                                                     01577e13-3c76-4734-a04d-aa2d9594a637.xls                                                      11
                  DEAN HEALTH PLAN CLAIM ADJUSTMENT REASON CODES - 10/27/10

                  Paper
        Hold
                  Claim
        code                                                                     835 Claim Adj.    835 Description of ANSI code                     Group   835 Line Level
                   Adj.               Paper Description
       (Paper                                                                     Reason code        (note will not print on 835)                   Codes    Adjustment
                 Reason
        only)
                  code

                          Diagnosis was invalid for date(s) of service                            Diagnosis was invalid for date(s) of
                          reported.                                                               service reported.
            XX     146                                                                 146                                                           OA       Non - Covered



                          Provider contracted/negotiated rate expired or rate                     Provider contracted/negotiated rate expired or
                          not on file.                                                            rate not on file.

            N9     147                                                                 147                                                           CO       Non-Covered



                          Information from another provider was not                               Information from another provider was not
                          provided or was incomplete.                                             provided or was insufficient/incomplete.

            FA     148                                                                 148                                                           PR       Non-Covered



                          Lifetime benefit maximum has been reached for                           Lifetime benefit maximum has been reached
                          this service/benefit category.                                          for this service/benefit category.

            M5     149                                                                 149                                                           PR       Non-Covered



                          Payer deems the information submitted does not                          Payer deems the information submitted does
                          support level of svc.                                                   not support this level of service.

            M7     150                                                                 150                                                           OA       Non-Covered



                          Payer deems the information submitted does not                          Payer deems the information submitted does
                          support level of svc.                                                   not support this level of service.

            XC     150                                                                 150                                                           OA       Non - Covered



                          Payment adj. because the payer deems the info                           Payment adjusted because the payer deems
                          rec'd does not support these svc.                                       the information submitted does not support
                                                                                                  this many/frequency of services.
            M8     151                                                                 151                                                           OA       Non-Covered



                          This (these) diagnosis (es) is (are) not covered                        This (these) diagnosis(es) is (are) not covered


            DX     167                                                                 167                                                           PR       Non-Covered



                          Payment is denied when billed by this type of                           Payment is denied when performed/billed by
                          provider. Included in NH rate.                                          this type of provider in this type of facility.

            ZK     171                                                                 171                                                           CO       Non - Covered



                          Payment adjusted when performed/billed by a                             Payment adjusted when perfomed/billed by a
                          provider of this specialty                                              provider of this specialty

            P4     172                                                                 172                                                           OA       Non-Covered




8/26/2012                                                                       01577e13-3c76-4734-a04d-aa2d9594a637.xls                                                      12
                  DEAN HEALTH PLAN CLAIM ADJUSTMENT REASON CODES - 10/27/10

                  Paper
        Hold
                  Claim
        code                                                                     835 Claim Adj.    835 Description of ANSI code                  Group         835 Line Level
                   Adj.                Paper Description
       (Paper                                                                     Reason code        (note will not print on 835)                Codes          Adjustment
                 Reason
        only)
                  code
                          Procedure code was invalid on the date of service.                      Procedure code was invalid on the date of
                                                                                                  service.

            XN     181                                                                 181                                                           OA          Non-Covered



                          Procedure modifer was invalid on the date of                            Procedure modifer was invalid on the date of
                          service.                                                                service.

            M9     182                                                                 182                                                           OA          Non-Covered



                          The rendering provider is not eligible to perform                       The rendering provider is not eligible to
                          the service billed                                                      perform the service billed

            P1     185                                                                 185                                                       1)CO 2) PR      Non-Covered



                          Unlisted procedure code billed when there is a                          "Not otherwise classified " or "unlisted"
                          specific code for this svc.                                             procedure code (CPT/HCPCS) was billed
                                                                                                  when there is a specific procedure code for
            T3     189                                                                 189        this procedure/service                             OA          Non-Covered



                          Precertification/authorization/notification absent.                     Precertification/authorization/notification
                                                                                                  absent.

            X8     197                                                                 197                                                       1) CO 2) PR     Non - Covered



                          Precertification/authorization/notification absent.                     Precertification/authorization/notification
                          Medicaid Member, file w/EDS.                                            absent.

            YR     197                                                                 197                                                       1) CO 2) PR      Non-covered



                          Noncovered personal comfort or convenience                              Non covered personal comfort or convenience
                          services.                                                               services.

            NP     202                                                                 202                                                           PR           Non-covered



                          Information requested from the                                          Information requested from the
                          patient/insured/responsible party was not provided                      patient/insured/responsible party was not
                          or was insufficient/incomplete                                          provided or was insufficient/incomplete. At
            FN     227                                                                 227        least one Remark Code must be provided             PR          Non- Covered
                                                                                                  (may be comprised of either the Remittance
                                                                                                  Advice Remark Code or NCPDP Reject
                                                                                                  Reason Code).
                          Information requested from the                                          Information requested from the
                          patient/insured/responsible party was not provided                      patient/insured/responsible party was not
                          or was insufficient/incomplete. Medical Records                         provided or was insufficient/incomplete. At
            MR     227    Requested.                                                   227        least one Remark Code must be provided             PR          Non-Covered
                                                                                                  (may be comprised of either the Remittance
                                                                                                  Advice Remark Code or NCPDP Reject
                                                                                                  Reason Code).
                          Information requested from the                                          Information requested from the
                          patient/insured/responsible party was not provided                      patient/insured/responsible party was not
                          or was insufficient/incomplete                                          provided or was insufficient/incomplete. At
            WN     227                                                                 227        least one Remark Code must be provided             PR          Non - Covered
                                                                                                  (may be comprised of either the Remittance
                                                                                                  Advice Remark Code or NCPDP Reject
                                                                                                  Reason Code).
8/26/2012                                                                       01577e13-3c76-4734-a04d-aa2d9594a637.xls                                                         13
                  DEAN HEALTH PLAN CLAIM ADJUSTMENT REASON CODES - 10/27/10

                  Paper
        Hold
                  Claim
        code                                                                    835 Claim Adj.    835 Description of ANSI code                  Group         835 Line Level
                   Adj.               Paper Description
       (Paper                                                                    Reason code        (note will not print on 835)                Codes          Adjustment
                 Reason
        only)
                  code
                          Mutually exclusive procedures cannot be done in                        Mutually exclusive procedures cannot be
                          the same day/setting.                                                  done in the same day/setting.

            YG     231                                                                231                                                       1) CO 2) PR      Non-covered




                          Ungroupable DRG                                                        Ungroupable DRG


            UG     A8                                                                 A8                                                            OA          Non - Covered



                          Non Covered visits. This visit is not covered.                         Non Covered visits


            NV     B1                                                                 B1                                                            PR          Non - Covered



                          Coverage/program guidelines were not met or                            Coverage/program guidelines were not met or
                          were exceeded.                                                         were exceeded.

            HB     B5                                                                 B5                                                            PR          Non- Covered



                          Alternative services were available and not used.                      Alternative services were available and
                                                                                                 should have been utilized.

            AS     B8                                                                 B8                                                            PR          Non -covered



                          Allowed amt reduced because component of the                           Allowed amt reduced because component of
                          basic prodcedure/test was paid                                         the basic prodcedure/test was paid. The
                                                                                                 beneficiary is not liable for more than the
            YD     B10                                                               B10         charge limit for the basic procedure/test          OA          Non - Covered



                          Services not documented in patient's medical                           Services not documented in patient's medical
                          records. No documentation for svc.                                     records

            ZU     B12                                                               B12                                                            OA          Non - Covered



                          Previously paid. Payment for this clm/svc provided                     Previously paid. Payment for this
                          in a previous payment.                                                 claim/service may have been provided in a
                                                                                                 previous payment.
            YK     B13                                                               B13                                                            OA          Non - Covered



                          Only one visit or consultation per physician per                       Only one visit or consultation per physician
                          day is covered.                                                        per day is covered.

            ZV     B14                                                               B14                                                            OA          Non - Covered




8/26/2012                                                                      01577e13-3c76-4734-a04d-aa2d9594a637.xls                                                         14
                  DEAN HEALTH PLAN CLAIM ADJUSTMENT REASON CODES - 10/27/10

                  Paper
        Hold
                  Claim
        code                                                                    835 Claim Adj.    835 Description of ANSI code                     Group          835 Line Level
                   Adj.                Paper Description
       (Paper                                                                    Reason code        (note will not print on 835)                   Codes           Adjustment
                 Reason
        only)
                  code
                          This service requires that a qualifying service be                     This service/procedure requires that a
                          received and covered. Included in other service.                       qualifying service/procedure be received and
                                                                                                 covered. The qualifying other
            XA     B15                                                               B15         service/procedure has not been                  (1) CO, (2) PR      Non - Covered
                                                                                                 received/adjudicated.


                          "New Patient" qualifications were not met                              "New Patient" qualifications were not met


            XK     B16                                                               B16                                                              OA             Non - Covered



                          Coinsurance Amount met. Member has reached
                          their out of pocket maximum.

            M2     02G                                                             No Set up     Used for paper only



                          Correction to a prior claim

                                                                                                  **Do not set up reason code per Cyndy - file
            76     63                                                              No Set up                                                                      Negatives - all buckets
                                                                                                                places in bucket



                          Correction to a prior claim


            RV     63C                                                             No Set up                  Used for paper only



                          Interest amount. Interest payment.

                                                                                                  **Do not set up reason code per Cyndy - file
            YL     85                                                              No Set up                                                                             To - Pay
                                                                                                               places $'s in bucket


                          No claim level adjustments. Excluded from
                          DRG/Flat fee.

                   93A                                                             No Set up                  Used for paper only


            LE




8/26/2012                                                                      01577e13-3c76-4734-a04d-aa2d9594a637.xls                                                                     15
                 DEAN HEALTH PLAN CLAIM ADJUSTMENT REASON CODES - 10/27/10

                 Paper
        Hold
                 Claim
        code                                  835 Claim Adj.   835 Description of ANSI code     Group   835 Line Level
                  Adj.   Paper Description
       (Paper                                  Reason code       (note will not print on 835)   Codes    Adjustment
                Reason
        only)
                 code




8/26/2012                                    01577e13-3c76-4734-a04d-aa2d9594a637.xls                                    16

				
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