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CURRENT ADJUSTMENT REASON CODES

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CURRENT ADJUSTMENT REASON CODES Powered By Docstoc
					             ADJUSTMENT REASON CODES
The following is a listing of the current Adjustment Reason Codes that can be used when
performing adjustments.

          Adjustment            Adjustment Reason             RA Language
          Reason Code           Description
          A01, F01, P01, S01,   Corrected Billing             Corrected Billing
          X01
          A02, F02, P02, S02,   Duplicate Claim               Duplicate Billing
          X02
          A03, F03, P03, S03,   Member Contract Not in        Member Policy Not
          X03                   Effect                        in Effect
          A04, F04, P04, S04,   Paid to Wrong Entity          Wrong Payee
          X04
          A05, F05, P05, S05,   COB                           Adjustment COB
          X05
          A06, F06, P06, S06,   Medicare                      Adjustment Medicare
          X06
          A07, F07, P07, S07,   Worker's Comp                 Adjustment Worker
          X07                                                 Comp
          A08, F08, P08, S08,   TPL Recovery                  Adjustment 3rd Party
          X08                                                 Liab
          A10, F10, P10, S10,   MRU Decision                  MRU
          X10
          A11, F11, P11, S11,   Administrative Decision-BCC   Administrative
          X11                                                 Decision
          A12, F12, P12, S12,   Adm Decision from Brokers     Administrative
          X12                   and Groups                    Decision from
                                                              Brokers and Groups
          A13, F13, P13, S13,   ADM Decision Case Mgmt        Personal Case
          X13                                                 Management
          A14, F14, P14, S14,   Credit Balance Audit          Credit Balance Audit
          X14
          A15, F15, P15, S15,   Work Comp Recov Oth Car       Adjustment Worker
          X15                                                 Comp
          A16, F16, P16, S16,   TPL Recov Oth Car             Adjustment 3rd Party
          X16                                                 Liab
          A17, F17, P17, S17,   Wrong Prov Location           Wrong Location
          X17
          A18, F18, P18, S18,   Infusion Therapy Services     Infusion Therapy
          X18                   Incorrectly Calculated
          A20, F20, P20, S20,   Reimb Can't Exceed Max %      Blank
          X20                   of Medicare Allowed
          A21, F21, P21, S21,   Audit Reduced Chgs Brings     Corrected stoploss
          X21                   Payment Below Stop Loss       calc
          A22, F22, P22, S22,   Medicare is Prime             Medicare is Prime
          X22
          A23, F23, P23, S23,   Reimb Can't Exceed Medicare   Blank
          X23                   Allowed Amount




       OPERATIONS PERFORMANCE DEPARTMENT
       Your Performance Partner                                         Revised: 3/25/04
 A24, F24, P24, S24,   Overpayment Set Up in Error     Reversing Prior
 X24                                                   Overpayment
 Adjustment            Adjustment Reason               RA Language
 Reason Code           Description
 A25, F25, P25, S25,   Incorrect Benefits Applied to   Ambulance Paid in
 X25                   Ambulance Services              Error
 A27, F27, P27, S27,   Hospital Audit                  Hospital
 X27                                                   Audit/Reduced Bill
 A29, F29, P29, S29,   Center of Expertise Pricing     Priced incorrectly
 X29
 A30, F30, P30, S30,   PMG Services Not Authorized     Not authorized by
 X30                                                   PMG
 A31, F31, P31, S31,   PMG is Fully Capitated          PMG is fully
 X31                                                   capitated
 A32, F32, P32, S32,   Non-Payable Provider            Non-Payable
 X32                                                   Provider
 A34, F34, P34, S34,   Services Exceeded the Timely    Exceeds Timely
 X34                   Filing Limit                    Filing Limit
 A36, F36, P36, S36,   Bill Audit Late Charges         Late charges paid in
 X36                                                   error
 S40                   Timely Filing ACC Proof         Timely Filing Proof
                       Provided                        Provided
 F41, P41, S41, X41    ADM Decision – Network          Administrative
                       Svcs/Prov Contracting           Decision
 F42, P42, S42, X42    ADM Decision – Legal            Administrative
                                                       Decision
 F43, P43, S43, X43    ADM Decision – DMHC/DOI         Administrative
                       or Grievance & Appeals          Decision
 F44, P44, S44, X44    ADM Decision – Sales            Administrative
                                                       Decision
 F45, P45, S45, X45    ADM Decision – Associate        Administrative
                       Empowerment PGM                 Decision
 F46, P46, S46, X46    ADM Decision –                  Administrative
                       Empowerment Misquoted           Decision
 F47, P47, S47, X47    Asst Surgeon Not Allowed        Asst surgeon not
                                                       allowed
 F48, P48, S48, X48    Member’s Contract Penalty       Member Contract
                                                       Penalty
 F49, P49, S49, X49    Co-Surgeon’s Claim              Co-surgeon claim
                       Misapplied                      mispriced
 F50, P50, S50, X50    Services Not Preauthorized      Services not
                                                       preauthorized
 F51, P51, S51, X51    Member Benefit/Contract         Member benefit
                       Exclusion                       exclusion
 F52, P52, S52, X52    Member/Family Stoploss          Member Stoploss
                       Misapplied                      misapplied
 F53, P53, S53, X53    Out-Of-Pocket Maximum           Out-of-pocket
                       Misapplied                      maximum error
 F54, P54, S54, X54    Provider Stoploss Misapplied    Discount misapplied

 F55, P55, S55, X55    Waiting Period                  Waiting period not
                                                       covered




OPERATIONS PERFORMANCE DEPARTMENT
Your Performance Partner                                         Revised: 3/25/04
 F56, P56, S56, X56    Waiver-Related                Waiver-related not
                                                     covered
 F57, P57, S57, X57    TCC Audit Payment Forfeited   Audit Payment
                                                     Forfeited
 Adjustment            Adjustment Reason             RA Language
 Reason Code           Description
 F58, P58, S58, X58    Rental Network Pricing        Discount misapplied
                       Misapplied
 A59, F59, P59, S59,   Deductible                    Deductible
 X59                                                 Misapplied
 A60, F60, P60, S60,   Co-payment                    Co-payment
 X60                                                 Misapplied
 A61, F61, P61, S61,   Wrong Provider Location       Paid the wrong entity
 X61                   Selected
 A62, F62, P62, S62,   HMO-PMG/IPA Authorized        PMG/IPA authorized
 X62                                                 Services
 A63, F63, P63, S63,   POS-Member Using PPO          PPO Benefits utilized
 X63
 A64, F64, P64, S64,   POS-Member Using HMO          HMO Benefits
 X64                                                 utilized
 A65, F65, P65, S65,   HMO-Emergency Services        Emergency
 X65                                                 Treatment Benefits
 A66, F66, P66, S66,   PPO-Emergency Services        Emergency
 X66                                                 Treatment Benefits
 A67, F67, P67, S67,   ITS-PPO Provider Handle       PPO Provider Handle
 X67                   Direct                        Direct
 A68, F68, P68, S68,   Inclusive to another claim    Inclusive to another
 X68                                                 claim
 A69, F69, P69, S69,   Incorrect level of care       Incorrect level of care
 X69
 A70, F70, P70, S70,   Maximum Benefits Allowed      Maximum Benefits
 X70                                                 Allowed
 A71, F71, P71, S71,   Database EOB address          Paid the wrong entity
 X71                   incorrect
 A72, F72, P72, S72,   Assistant Surgeon             Paid as Assistant
 X72                                                 Surgeon
 A73, F73, P73, S73,   Anesthesia                    Paid as Anesthesia
 X73
 A74, F74, P74, S74,   Billing Error                 Rebill with current
 X74                                                 codes
 A75, F75, P75, S75,   Member Benefits Incorrectly   Benefits Incorrectly
 X75                   Applied                       Applied
 A76, F76, P76, S76,   Manual Pricing Error          Allowable
 X76                                                 miscalculated
 A77, F77, P77, S77,   Claim Data Miskeyed           Claim Data
 X77                                                 Misapplied
 A78, F78, P78, S78,   Medicare Part B Deductible    Medicare Part B
 X78                                                 Deductible
 A79, F79, P79, S79,   Medicare Part A Deductible    Medicare Part A
 X79                                                 Deductible
 A80, F80, P80, S80,   Pre-Existing                  Pre-Existing
 X80




OPERATIONS PERFORMANCE DEPARTMENT
Your Performance Partner                                        Revised: 3/25/04
 A81, F81, P81, S81,   Prior deductible credit         Prior deductible
 X81                                                   credit
 A82, F82, P82, S82,   Rental Network Pricing Error    Allowable
 X82                                                   miscalculated
 A83, F83, P83, S83,   EOMB-R/A                        Medicare EOMB or
 X83                                                   R/A
 Adjustment            Adjustment Reason               RA Language
 Reason Code           Description
 A84, F84, P84, S84,   Policy Reinstatement            Member policy
 X84                                                   reinstated
 A85, F85, P85, S85,   Incorrect Policy Number         Incorrect Policy
 X85                                                   Number
 A86, F86, P86, S86,   Medicare-Wrong Patient          Medicare-Wrong
 X86                                                   Patient
 A87, F87, P87, S87,   DME Rental Exceeds              Exceeds Purchase
 X87                   Purchase Price                  Price
 A88, F88, P88, S88,   Rental Network Pricing          Pricing recalculated
 X88                   Correction
 A89, F89, P89, S89,   Rejected as a Duplicate claim   Claim Denied
 X89                   in Error                        Incorrectly
 A90, F90, P90, S90,   System Problems                 Incorrect Benefits
 X90                                                   Applied
 A91, F91, P91, S91,   Inpatient vs. Outpatient        Processed as
 X91                                                   Inpatient
 A92, F92, P92, S92,   RAAP Non Emergency Pay          Professional Svcs
 X92                   Up Participating Facility       rendered
 A93, F93, P93, S93,   Patient did not receive         Incorrect Member
 X93                   services
 A94, F94, P94, S94,   Provider contract retro         Provider Contract
 X94                   added/retro termed              Modified
 X95                   Request for Info Not Received   Info complete. No
                       ERISA Letter                    benefits
 X96                   Delete Request for ERISA 45     Delete Req ERISA
                       Day Letter                      45 Day Ltr
 X97                   Interest For Late Claim         Interest for Late Clm
                       Payment                         Pymt
 A98, F98, P98         CCS - Payee Refunded            Not Applicable
                       Payment. Won't Send O/P
                       Letter.
 A99, F99,P99, S99,    Incorrect Provider Discount     Priced Incorrectly
 X99                   Taken




OPERATIONS PERFORMANCE DEPARTMENT
Your Performance Partner                                          Revised: 3/25/04

				
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