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					Independent Health Adjustment Reason Code Crosswalk
HIPAA Adjustment Reason Code * Current Payer HIPAA Remittance Adjustment HIPAA Adjustment Code (EX, Group Code Group Code Description EOP, etc.)

Updated 9/29/03

4

4

HIPAA Adjustment Reason Code Description The procedure code is inconsistent with the modifier used or required modifier is missing The procedure code is inconsistent with the modifier used or required modifier is missing The procedure code/bill type is inconsistent with the place of service. The procedure/revenue code is inconsistent with the patient's age The procedure/revenue code is inconsistent with the patient's age The procedure/revenue code is inconsistent with the patient's age The procedure/revenue code is inconsistent with the patient's gender The procedure/revenue code is inconsistent with the patient's gender

Payer Remittance Description

CO

Contractual Obligation

EB1

BILATERAL BILLING NOT ALLOWED

CO

Contractual Obligation

GB1

APPROPRIATE MODIFIER MISSING PROCEDURE INCONSISTENT WITH SITE OF SERVICE AGE INVALID FOR SERVICE AGE INVALID FOR SERVICE SERVICE INVALID FOR MEMBER AGE

5 6 6 6

CO CO CO CO

Contractual Obligation Contractual Obligation Contractual Obligation Contractual Obligation

I91 821 071 TJ1

7

CO

Contractual Obligation

171

SEX INVALID FOR BENEFIT

7 The procedure/revenue code is inconsistent with the patient's gender 7 9 10 11 11 The diagnosis is inconsistent with the patient's age The diagnosis is inconsistent with the patient's gender The diagnosisis inconsistent with the procedure The diagnosis is inconsistent with the procedure

CO

Contractual Obligation

831

SEX INVALID FOR SERVICE

CO CO CO CO CO

Contractual Obligation Contractual Obligation Contractual Obligation Contractual Obligation Contractual Obligation

091 341 351 BO1 OB1

SEX INVALID FOR SERVICE AGE INVALID FOR DIAGNOSIS SEX INVALID FOR DIAGNOSIS DIAG/PROCEDURE INSONSISTANT WITH POLICY NOT APPROPRIATE CODE FOR DIAGNOSIS

* HIPAA Remark Codes are not being used at this time. Expect to use for further clarification of denials at a later date.

Page 1 of 31

Independent Health Adjustment Reason Code Crosswalk
11 11 11 11 The diagnosis is inconsistent with the procedure The diagnosis is inconsistent with the procedure The diagnosis is inconsistent with the procedure The diagnosis is inconsistent with the procedure Claim/service lacks information which is needed for adjudication. Additional information is supplied using remittance advice remarks codes whenever appropriate. Claim/service lacks information which is needed for adjudication. Additional information is supplied using remittance advice remarks codes whenever appropriate. Claim/service lacks information which is needed for adjudication. Additional information is supplied using remittance advice remarks codes whenever appropriate. Claim/service lacks information which is needed for adjudication. Additional information is supplied using remittance advice remarks codes whenever appropriate. Claim/service lacks information which is needed for adjudication. Additional information is supplied using remittance advice remarks codes whenever appropriate. CO CO CO CO Contractual Obligation Contractual Obligation Contractual Obligation Contractual Obligation OC1 Z41 ZH1 ZK1

Updated 9/29/03

DIAGNOSIS INAPPROPRIATE FOR CHEST FILM DX NOT LISTED ON PFT POLICY DX NOT ALLOWED WITH THER. PHLEB. 99195 DX. NOT ALLOWED WITH NUTRITIONAL EVALUATION

16

PR

Patient Responsibility

BG1

NO INF PRECRT ON FILE;MBR RESP

16

CO

Contractual Obligation

CD1

ADDITIONAL INFORMATION REQUIRED

16

CO

Contractual Obligation

CK1

INCOMPLETE REPORT

16

CO

Contractual Obligation

D71

INSUFF / INVALID EOB / CORRECT EOB NEEDED

16

CO

Contractual Obligation

DH1

CPT CODE REQUIRED

* HIPAA Remark Codes are not being used at this time. Expect to use for further clarification of denials at a later date.

Page 2 of 31

Independent Health Adjustment Reason Code Crosswalk
Claim/service lacks information which is needed for adjudication. Additional information is supplied using remittance advice remarks codes whenever appropriate. Claim/service lacks information which is needed for adjudication. Additional information is supplied using remittance advice remarks codes whenever appropriate. Claim/service lacks information which is needed for adjudication. Additional information is supplied using remittance advice remarks codes whenever appropriate. Claim/service lacks information which is needed for adjudication. Additional information is supplied using remittance advice remarks codes whenever appropriate. Claim/service lacks information which is needed for adjudication. Additional information is supplied using remittance advice remarks codes whenever appropriate. Claim/service lacks information which is needed for adjudication. Additional information is supplied using remittance advice remarks codes whenever appropriate. Claim/service lacks information which is needed for adjudication. Additional information is supplied using remittance advice remarks codes whenever appropriate.

Updated 9/29/03

16

CO

Contractual Obligation

DN1

INVALID OR MISSING DATE OF SERVICE

16

CO

Contractual Obligation

DO1

INVALID LOCATION CODE

16

CO

Contractual Obligation

DX1

SERVICE DATE GREATER THAN END DATE

16

CO

Contractual Obligation

DY1

ENDING DATE MUST BE SPECIFIED FOR HCFA 1500

16

CO

Contractual Obligation

ER1

CODE SUBMITTED/NOT SUPPORTED BY DOCUMENTATION

16

CO

Contractual Obligation

FA1

MUST BILL ON UB FORM

16

CO

Contractual Obligation

FD1

INCORRECT VENDOR NUMBER

* HIPAA Remark Codes are not being used at this time. Expect to use for further clarification of denials at a later date.

Page 3 of 31

Independent Health Adjustment Reason Code Crosswalk
Claim/service lacks information which is needed for adjudication. Additional information is supplied using remittance advice remarks codes whenever appropriate. Claim/service lacks information which is needed for adjudication. Additional information is supplied using remittance advice remarks codes whenever appropriate. Claim/service lacks information which is needed for adjudication. Additional information is supplied using remittance advice remarks codes whenever appropriate. Claim/service lacks information which is needed for adjudication. Additional information is supplied using remittance advice remarks codes whenever appropriate. Claim/service lacks information which is needed for adjudication. Additional information is supplied using remittance advice remarks codes whenever appropriate. Claim/service lacks information which is needed for adjudication. Additional information is supplied using remittance advice remarks codes whenever appropriate. Claim/service lacks information which is needed for adjudication. Additional information is supplied using remittance advice remarks codes whenever appropriate.

Updated 9/29/03

16

CO

Contractual Obligation

FL1

VALUE CODE/UNITS REQUIRED FOR EPOGEN

16

CO

Contractual Obligation

FO1

CONTACT PROVIDER RELATIONS

16

CO

Contractual Obligation

I11

CALL RX VENDOR FOR YOUR DRUG REPLACEMENT

16

CO

Contractual Obligation

I21

CALL RX VENDOR FOR YOUR DRUG REPLACEMEN+F207T

16

CO

Contractual Obligation

J31

REVIEWED ADJUSTMENT REQ. DENIAL UPHELD

16

CO

Contractual Obligation

JE1

INVALID/MISSING DRG

16

CO

Contractual Obligation

KG1

UNABLE TO PROCESS CLAIM/NEED PROV NAME/ADDRESS/TAX

* HIPAA Remark Codes are not being used at this time. Expect to use for further clarification of denials at a later date.

Page 4 of 31

Independent Health Adjustment Reason Code Crosswalk
Claim/service lacks information which is needed for adjudication. Additional information is supplied using remittance advice remarks codes whenever appropriate. Claim/service lacks information which is needed for adjudication. Additional information is supplied using remittance advice remarks codes whenever appropriate. Claim/service lacks information which is needed for adjudication. Additional information is supplied using remittance advice remarks codes whenever appropriate. Claim/service lacks information which is needed for adjudication. Additional information is supplied using remittance advice remarks codes whenever appropriate. Claim/service lacks information which is needed for adjudication. Additional information is supplied using remittance advice remarks codes whenever appropriate. Claim/service lacks information which is needed for adjudication. Additional information is supplied using remittance advice remarks codes whenever appropriate. Claim/service lacks information which is needed for adjudication. Additional information is supplied using remittance advice remarks codes whenever appropriate.

Updated 9/29/03

16

CO

Contractual Obligation

KN1

SUBMIT WITH PROVIDER NUMBER

16

CO

Contractual Obligation

ND1

NDC CODE REQUIRED

16

CO

Contractual Obligation

OE1

INVALID VENDOR/DO NOT BILL MEMBER

16

PR

Patient Responsibility

OV1

NECESSARY COB INFO NOT RECEIVED

16

CO

Contractual Obligation

P21

REFERRING MD NAME RQUIRED

16

CO

Contractual Obligation

P91

INSUFF. INFO/SUBMIT REC.:ATTN: SIC

16

CO

Contractual Obligation

PJ1

CALL COB 1-800-247-1466 EXT.2931

* HIPAA Remark Codes are not being used at this time. Expect to use for further clarification of denials at a later date.

Page 5 of 31

Independent Health Adjustment Reason Code Crosswalk
Claim/service lacks information which is needed for adjudication. Additional information is supplied using remittance advice remarks codes whenever appropriate. Claim/service lacks information which is needed for adjudication. Additional information is supplied using remittance advice remarks codes whenever appropriate. Claim/service lacks information which is needed for adjudication. Additional information is supplied using remittance advice remarks codes whenever appropriate. Claim/service lacks information which is needed for adjudication. Additional information is supplied using remittance advice remarks codes whenever appropriate. Claim/service lacks information which is needed for adjudication. Additional information is supplied using remittance advice remarks codes whenever appropriate. Claim/service lacks information which is needed for adjudication. Additional information is supplied using remittance advice remarks codes whenever appropriate. Claim/service lacks information which is needed for adjudication. Additional information is supplied using remittance advice remarks codes whenever appropriate.

Updated 9/29/03

16

CO

Contractual Obligation

PV1

PROVIDER HAS BEEN NOTIFIED OF DENIED SERVICES

16

PR

Patient Responsibility

RJ1

INSUFFICIENT INFORMATION

16

CO

Contractual Obligation

TP1

SURFACE CODE INVALID FOR SERVICE

16

CO

Contractual Obligation

TQ1

SURFACE CODE REQUIRED

16

CO

Contractual Obligation

TZ1

BILL SEPARATELY

16

CO

Contractual Obligation

U1

UPIN NUMBER NOT VALID

16

CO

Contractual Obligation

WA1

TOOTH NUMBER REQUIRED

* HIPAA Remark Codes are not being used at this time. Expect to use for further clarification of denials at a later date.

Page 6 of 31

Independent Health Adjustment Reason Code Crosswalk
Claim/service lacks information which is needed for adjudication. Additional information is supplied using remittance advice remarks codes CO whenever appropriate. Claim/service lacks information which is needed for adjudication. Additional information is supplied using remittance advice remarks codes CO whenever appropriate. Duplicate claim/service CO CO Duplicate claim/service CO Duplicate claim/service CO Duplicate claim/service CO Duplicate claim/service Duplicate claim/service CO CO Duplicate claim/service Claim denied because this is a workrelated injury/illness and thus the liability of the Worker's Compensation CO Carrier Claim denied because this injury/illness is the liability of the noCO fault carrier Payment adjusted because this care may be covered by another payer per CO coordination of benefits. Payment adjusted because this care may be covered by another payer per CO coordination of benefits. Payment adjusted because this care may be covered by another payer per CO coordination of benefits.

Updated 9/29/03

16

Contractual Obligation

Y91

ATTENDING THERAPIST REQUIRED

16 18 18 18 18 18 18 18

Contractual Obligation Contractual Obligation Contractual Obligation Contractual Obligation Contractual Obligation Contractual Obligation Contractual Obligation Contractual Obligation

YJ1 DD1 DUP G51 R41 S41 Z81 ZD1

MEMBER NUMBER INC. WITH DIAG/PROCEDURE DUPLICATE CLAIM PREVIOUSLY PROCESSED EXACT DUPLICATE DUPLICATE SERVICE SERVICE(S) ARE DUPLICATE DUPLICATE PAYMENT DUPLICATIVE PAYMENT TO RELATED AC/HC ENTITIES DENIED DUPLICATE

19

Contractual Obligation

D51

WORKERS COMP PRIMARY

21

Contractual Obligation

D41

NO FAULT PRIMARY THIS PROVIDER IS NOT AFFIILIATED WITH ENCOMPASS 65

22

Contractual Obligation

D11

22

Contractual Obligation

D21

MEDICARE PRIMARY SUBMIT EOMB

22

Contractual Obligation

D31

OTHER INS. PRIMARY/SUBMIT EOB

* HIPAA Remark Codes are not being used at this time. Expect to use for further clarification of denials at a later date.

Page 7 of 31

Independent Health Adjustment Reason Code Crosswalk
22 Payment adjusted because this care may be covered by another payer per coordination of benefits. Payment adjusted because this care may be covered by another payer per coordination of benefits. Payment adjusted because this care may be covered by another payer per coordination of benefits. Payment adjusted because this care may be covered by another payer per coordination of benefits Payment adjusted because this care may be covered by another payer per coordination of benefits. Payment adjusted because this care may be covered by another payer per coordination of benefits. Payment adjusted because this care may be covered by another payer per coordination of benefits. Payment adjusted because this care may be covered by another payer per coordination of benefits. The time limit for filing has expired The time limit for filing has expired The time limit for filing has expired CO Contractual Obligation D61

Updated 9/29/03

EXCEEDS PRIMARY INSURANCE

22

PR

Patient Responsibility

R31

COB DENIAL/IHA NOT PRIMARY COB, OTHER INSURANCE CARRIER PRIMARY

22

CO

Contractual Obligation

SB1

22

CO

Contractual Obligation

SV1

COB ADJUSTMENT CASH ADJUSTMENT/SETTLEMENT REC'D

22

CO

Contractual Obligation

XA1

22

CO

Contractual Obligation

XB1

CASH ADJUSTMENT/MED RECOVERY CASH ADJUSTMENT/OTHER INS PRIMARY

22

CO

Contractual Obligation

XC1

22 29 29 29 29 29

CO CO CO CO PR CO

Contractual Obligation Contractual Obligation Contractual Obligation Contractual Obligation Patient Responsibility Contractual Obligation

XF1 G31 KW1 KZ1 RE1 X1

CASH ADJUST / AIM REC'D 90 DAYS AFTER SERVICE DATE OVER 2 YEAR FILING LIMIT REC'D 150 DAYS AFTER SERV. DATE REC'D AFTER CONTRACT LIMIT OVER 90 DAY TIME LIMIT

30 31

The time limit for filing has expired The time limit for filing has expired Payment adjusted because the patient has not met the required eligibility, spend down, waiting, or residency PR requirements. Claim denied as patient cannot be PR identified as our insured

Patient Responsibility Patient Responsibility

RF1 371

MEMBER NOT IN DRUG PLAN SERVICE BEFORE/AFTER GROUP EFFECT

* HIPAA Remark Codes are not being used at this time. Expect to use for further clarification of denials at a later date.

Page 8 of 31

Independent Health Adjustment Reason Code Crosswalk
31 31 31 31 31 31 31 31 31 31 31 31 31 Claim denied as patient cannot be identified as our insured Claim denied as patient cannot be identified as our insured Claim denied as member cannot beidentified as our insured. Claim denied as patient cannot be identified as our insured Claim denied as patient cannot be identified as our insured Claim denied as patient cannot be identified as our insured Claim denied as patient cannot be identified as our insured Claim denied as patient cannot be identified as our insured Claim denied as patient cannot be identified as our insured Claim denied as patient cannot be identified as our insured Claim denied as patient cannot be identified as our insured Claim denied as patient cannot be identified as our insured Claim denied as patient cannot be identified as our insured Our records indicate that this dependent is not an eligible dependent as defined Services not provided or authorized by designated (network/primary care) providers. Services not provided or authorized by designated (network/primary care) providers. PR CO PR CO PR PR CO PR CO PR PR PR PR Patient Responsibility Contractual Obligation Patient Responsibility Contractual Obligation Patient Responsibility Patient Responsibility Contractual Obligation Patient Responsibility Contractual Obligation Patient Responsibility Patient Responsibility Patient Responsibility Patient Responsibility 031 CN1 DQ1 FF1 KB1 KD1 KY1 R11 SC1 TB1 TC1 TG1 XE1

Updated 9/29/03

CLAIM OUTSIDE MEMBER EFFECTIVE DATE INVALID MEMBER CLAIM OUTSIDE MEMBERS EFFECTIVE DATE ADMINISTRATIVE CONTRACT EXPIRED, BILL EMPLOYER CLAIM OUTSIDE MEMBER EFFECTIVE DATE SERVICE BEFORE/AFTER GROUP EFFECTIVE CONTRACT WITH IH TERM/CONTACT GROUP NO COVERAGE ON DATE OF SERVICE MEMBER TERMED ON DATE OF SERVICE GROUP NOT COVERED FOR SERVICE DATE MEMBER NOT COVERED ON SERVICE DATE SERVICE AFTER TERMINATION DATE PATIENT INELIGIBLE FOR COVERAGE DEPENDENT OVER AGE LIMIT/SUBMIT PROOF IF ELIGIBLE SERVICE RENDERED BY NONPAR WITHOUT AUTH THIS PROVIDER IS NOT AFFILIATED WITH ENCOMPASS 65

32

PR

Patient Responsibility

XD1

38

PR

Patient Responsibility

BN1

38

PR

Patient Responsibility

D1

* HIPAA Remark Codes are not being used at this time. Expect to use for further clarification of denials at a later date.

Page 9 of 31

Independent Health Adjustment Reason Code Crosswalk
38 Services not provided or authorized by designated (network/primary care) providers. Services not provided or authorized by designated (network/primary care) providers. Services not provided or authorized by designated (network/primary care) providers. Services not provided or authorized by designated (network/primary care) providers. Services not provided or authorized by designated (network/primary care) providers. Services not provided or authorized by designated (network/primary care) providers. Services not provided or authorized by designated (network/primary care) providers. Services not provided or authorized by designated (network/primary care) providers. Services not provided or authorized by designated (network/primary care) providers. Services not provided or authorized by designated (network/primary care) providers. Services not provided or authorized by designated (network/primary care) providers. Services denied at the time authorization/pre-certification was requested PR Patient Responsibility J41

Updated 9/29/03

SERVICE REQUESTED BY NON AFFILIATED ENC 65 PROV NON MEDISOURCE PROVIDER/NOT COVERED PROVIDER NOT AFFILIATED WITH ENCOMPASS 65 NON PAR PROV. N/A DO NOT BILL MEMBER NON PAR PHARMACY OR PRESCRIBER

38

CO

Contractual Obligation

JV1

38

PR

Patient Responsibility

KI1

38

CO

Contractual Obligation

PK1

38

PR

Patient Responsibility

RB1

38

PR

Patient Responsibility

RD1

NONPAR/INVALID PRESCRIBER UNAUTHORIZED ADM. BY NON PARTICIPATING PAID OUT OFNETWORK, SHOULD BE IN NETWORK MUST USE NET PROVIDER AND REGISTER CARE

38

CO

Contractual Obligation

S31

38

CO

Contractual Obligation

SE1

38

CO

Contractual Obligation

Y81

38

PR

Patient Responsibility

YT1

NO OUT OF NETWORK BENEFIT

38

PR

Patient Responsibility

YY1

TPA/OUTSIDE OF SERVICE AREA

39

PR

Patient Responsibility

KR1

AUTH WAS DENIED/BILL MEMBER

* HIPAA Remark Codes are not being used at this time. Expect to use for further clarification of denials at a later date.

Page 10 of 31

Independent Health Adjustment Reason Code Crosswalk
39 40 40 40 42 42 42 42 42 42 Services denied at the time authorization/pre-certification was requested Charges do not meet qualifications for emergent/urgent care Charges do not meet qualifications for emergent/urgent care Charges do not meet qualifications for emergent/urgent care Charges exceed our fee schedule or maximum allowable amount Charges exceed our fee schedule or maximum allowable amount Charges exceed our fee schedule or maximum allowable amount Charges exceed our fee schedule or maximum allowable amount Charges exceed our fee schedule or maximum allowable amount Charges exceed our fee schedule or maximum allowable amount. Charges exceed your contracted/legislated fee arrangement. Charges exceed your contracted/legislated fee arrangement. 45 47 CO This(these) diagnosis(es) is(are) not CO covered, missing, or are invalid. These are non-covered services because this is a pre-existing condition CO The referring/prescribing/rendering provider is not eligible to refer/prescribe/order/perform the CO service billed Contractual Obligation Contractual Obligation OY1 DS1 DENIED/INCLUDED SETL INVALID DIAGNOSIS CO PR PR CO PR CO CO CO CO CO Contractual Obligation Patient Responsibility Patient Responsibility Contractual Obligation Patient Responsibility Contractual Obligation Contractual Obligation Contractual Obligation Contractual Obligation Contractual Obligation UD1 C51 KA1 SI1 381 EG1 EH1 EI1 FS1 K81

Updated 9/29/03

REVIEWED BY MEDICAL DIRECTOR & FAILED MED CRITERIA NON MEDICAL EMERGENCY/BILL MEMBER DIAGNOSIS BILLED NOT CONSIDERED AN EMERGENCY NON MEDICAL EMERGENCY COVERAGE DOLLAR LIMIT EXCEEDED HCFA LIMITING CHGS. APPLIED. MEDICAID RATE APPLIED LOCAL FEE SCHEDULE RATE APPLIED LOCAL FEE SCHEDULE RATE APPLIED EXCEEDS BENEFIT DOLLAR AMOUNT REIMBURSEMENT INC. IN CONTRACT SETTLEMENT

45

CO

Contractual Obligation

IS1

51

Contractual Obligation

S71

PRE EXISTING CONDITION

52

Contractual Obligation

CY1

INACTIVE PROVIDER

* HIPAA Remark Codes are not being used at this time. Expect to use for further clarification of denials at a later date.

Page 11 of 31

Independent Health Adjustment Reason Code Crosswalk
The referring/prescribing/rendering provider is not eligible to refer/prescribe/order/perform the service billed The referring/prescribing/rendering provider is not eligible to refer/prescribe/order/perform the service billed The referring/prescribing/rendering provider is not eligible to refer/prescribe/order/perform the service billed The referring/prescribing/rendering provider is not eligible to refer/prescribe/order/perform the service billed Multiple physicians/assistants are not covered in this case Payment denied/reduced because the payer deems the information submitted does not support this level of service, this many services, this length of service, this dosage, or this day's supply Payment denied/reduced because the payer deems the information submitted does not support this level of service, this many services, this length of service, this dosage, or this day's supply Payment denied/reduced because the payer deems the information submitted does not support this level of service, this many services, this length of service, this dosage, or this day's supply

Updated 9/29/03

52

CO

Contractual Obligation

JP1

NO CLAIMS/AUTHORIZATIONS FOR PROVIDER

52

CO

Contractual Obligation

KX1

RENDERING MD UNAUTHORIZED

52

CO

Contractual Obligation

RL1

PHARMACY UNDER REVIEW

52 54

PR CO

Patient Responsibility Contractual Obligation

RP1 CT1

PROVIDER SPECIALTY NOT COVERED SURGICAL ASSIST NOT ALLOWED

57

CO

Contractual Obligation

DT1

INVALID DISCHARGE STATUS

57

CO

Contractual Obligation

DU1

INVALID BILL TYPE

57

CO

Contractual Obligation

DV1

INVALID BIRTH WEIGHT

* HIPAA Remark Codes are not being used at this time. Expect to use for further clarification of denials at a later date.

Page 12 of 31

Independent Health Adjustment Reason Code Crosswalk
Payment denied/reduced because the payer deems the information submitted does not support this level of service, this many services, this length of service, this dosage, or this day's supply Payment denied/reduced because the payer deems the information submitted does not support this level of service, this many services, this length of service, this dosage, or this day's supply Payment denied/reduced because the payer deems the information submitted does not support this level of service, this many services, this length of service, this dosage, or this day's supply Payment denied/reduced because the payer deems the information submitted does not support this level of service, this many services, this length of service, this dosage, or this day's supply Payment denied/reduced because the payer deems the information submitted does not support this level of service, this many services, this length of service, this dosage, or this day's supply Payment denied/reduced because the payer deems the information submitted does not support this level of service, this many services, this length of service, this dosage, or this day's supply

Updated 9/29/03

57

CO

Contractual Obligation

DW1

INVALID ENDING SERVICE DATE

57

CO

Contractual Obligation

FC1

MUST BE ER/OBS BED/AMB. SURG CLAIM

57

CO

Contractual Obligation

GI1

UNITS NOT EQUAL TO DATE SPAN

57

CO

Contractual Obligation

H11

99221-99223 AND 99233: 1X PER STAY/ADMIT:MD/ASSOC.

57

CO

Contractual Obligation

H31

2 PCP INPT. VISITS/7 DAYS UNLESS MED. NEC.

57

CO

Contractual Obligation

J51

DATE SPAN NOT EQUAL TO UNITS

* HIPAA Remark Codes are not being used at this time. Expect to use for further clarification of denials at a later date.

Page 13 of 31

Independent Health Adjustment Reason Code Crosswalk
Payment denied/reduced because the payer deems the information submitted does not support this level of service, this many services, this length of service, this dosage, or this day's supply Payment denied/reduced because the payer deems the information submitted does not support this level of service, this many services, this length of service, this dosage, or this day's supply Payment denied/reduced because the payer deems the information submitted does not support this level of service, this many services, this length of service, this dosage, or this day's supply Payment denied/reduced because the payer deems the information submitted does not support this level of service, this many services, this length of service, this dosage, or this day's supply Payment denied/reduced because the payer deems the information submitted does not support this level of service, this many services, this length of service, this dosage, or this day's supply Payment denied/reduced because the payer deems the information submitted does not support this level of service, this many services, this length of service, this dosage, or this day's supply

Updated 9/29/03

57

PR

Patient Responsibility

R51

MEDICATION DISPENSED TOO EARLY

57

PR

Patient Responsibility

RC1

NONFORMULARY DRUG DISPENSED

57

PR

Patient Responsibility

RI1

EXCEEDS ALLOWABLE SUPPLY

57

PR

Patient Responsibility

RO1

DUR

57

CO

Contractual Obligation

ST1

UNAUTHORIZED LOS/MEDICALLY UNNECESSARY

57

CO

Contractual Obligation

TU1

SERVICE INVALID AFTER PREVIOUS SERVICE

* HIPAA Remark Codes are not being used at this time. Expect to use for further clarification of denials at a later date.

Page 14 of 31

Independent Health Adjustment Reason Code Crosswalk
Payment denied/reduced because the payer deems the information submitted does not support this level of service, this many services, this length of service, this dosage, or this CO day's supply Payment denied/reduced because the payer deems the information submitted does not support this level of service, this many services, this length of service, this dosage, or this CO day's supply Payment adjusted because treatment was deemed by the payer to have been rendered in an inappropriate or invalid place of service. CO Payment denied/reduced for absence of, or exceeded, preCO certification/authorization. Payment denied/reduced for absence of, or exceeded, preCO certification/authorization. Payment denied/reduced for absence of, or exceeded, preCO certification/authorization. Payment denied/reduced for absence of, or exceeded, preCO certification/authorization. Payment denied/reduced for absence of, or exceeded, prePR certification/authorization. Payment denied/reduced for absence of, or exceeded, prePR certification/authorization.

Updated 9/29/03

57

Contractual Obligation

TV1

TOOTH INVALID FOR SERVICE

57

Contractual Obligation

ZA1

ALLOW 1 NEW PT. E&M PER MD/ASSOC.

58

Contractual Obligation

KO1

MUST BE 2 CLAIMS, LOC. CHANGE INPATIENT ADMISSION NOT AUTHORIZED PREAUTHORIZATION REQUIRED FOR SERVICE - NOT FOUND

62

Contractual Obligation

AA1

62

Contractual Obligation

BE1

62

Contractual Obligation

EQ1

REFERRAL NOT EFFECTIVE FOR DOS VALID REFERRAL NOT ON FILE/NOT THE MEM. PCP

62

Contractual Obligation

G41

62

Patient Responsibility

GX1

NO REFERRAL, WAIVER SIGNED

62

Patient Responsibility

KE1

REFERRAL REQUIRED/NOT THE PCP

* HIPAA Remark Codes are not being used at this time. Expect to use for further clarification of denials at a later date.

Page 15 of 31

Independent Health Adjustment Reason Code Crosswalk
62 Payment denied/reduced for absence of, or exceeded, precertification/authorization. Payment denied/reduced for absence of, or exceeded, precertification/authorization. Payment denied/reduced for absence of, or exceeded, precertification/authorization. Payment denied/reduced for absence of, or exceeded, precertification/authorization. Payment denied/reduced for absence of, or exceeded, precertification/authorization. Payment denied/reduced for absence of, or exceeded, precertification/authorization. Payment denied/reduced for absence of, or exceeded, precertification/authorization. Payment denied/reduced for absence of, or exceeded, precertification/authorization. Payment denied/reduced for absence of, or exceeded, precertification/authorization. Payment denied/reduced for absence of, or exceeded, precertification/authorization. Payment denied/reduced for absence of, or exceeded, precertification/authorization. Adjustment amount represents collection against receivable created in prior overpayment PR Patient Responsibility KF1

Updated 9/29/03

WAIVER WAS SIGNED/NO REFERRAL SENT TO PROVIDER

62

PR

Patient Responsibility

R71

PRIOR AUTHORIZATION REQUIRED NON NOTIFICATION OF HOSPITAL ADMISSION REQUIRED AUTHORIZATION NOT ON FILE PRETREATMENT REQUIRED/NOT FOUND

62

CO

Contractual Obligation

SK1

62

CO

Contractual Obligation

SL1

62

CO

Contractual Obligation

T31

62

CO

Contractual Obligation

TN1

SERVICE REQUIRES AUTHORIZATION SERVICE COUNT WITHIN PER REQUIRES AUTHORIZATION PRECERTIFICATION IS REQUIRED FOR THESE SERVICES CERTIFICATION WAS NOT GRANTED FOR THIS PROVIDER MAX CERTIFIED VISITS/DAYS FOR THIS TREAT. PERIOD

62

CO

Contractual Obligation

TS1

62

PR

Patient Responsibility

Y31

62

CO

Contractual Obligation

Y41

62

CO

Contractual Obligation

Y51

62

CO

Contractual Obligation

YZ1

AUTHORIZATION REQUIRED

88

CO

Contractual Obligation

SY1

CASH/VOID ADJUSTMENT

* HIPAA Remark Codes are not being used at this time. Expect to use for further clarification of denials at a later date.

Page 16 of 31

Independent Health Adjustment Reason Code Crosswalk
88 95 96 96 96 96 96 96 96 96 96 96 96 96 96 96 96 96 Adjustment amount represents collection against receivable created in CO prior overpayment Benefits adjusted. Plan procedures CO not followed Non-covered charge(s) PR Non-covered charge(s) PR Non-covered charge(s) PR Non-covered charge(s) PR Non-covered charge(s) PR Non-covered charge(s) PR Non-covered charge(s) PR Non-covered charge(s) PR Non-covered charge(s) PR Non-covered charge(s) PR Non-covered charge(s) PR Non-covered charge(s) PR Non-covered charge(s) PR Non-covered charge(s) PR Non-covered charge(s) CO Non-covered charge(s) PR Contractual Obligation Contractual Obligation Patient Responsibility Patient Responsibility Patient Responsibility Patient Responsibility Patient Responsibility Patient Responsibility Patient Responsibility Patient Responsibility Patient Responsibility Patient Responsibility Patient Responsibility Patient Responsibility Patient Responsibility Patient Responsibility Contractual Obligation Patient Responsibility XG1 RN1 861 B31 B41 B61 B81 BA1 BC1 BH1 BJ1 BL1 BU1 BV1 BX1 BZ1 C31 C41 CASH ADJUST / AIM

Updated 9/29/03

MUST BILL CLAIM ON LINE SERVICES LIMITED BY RELATIONSHIP DEPOPROVERA NOT COVERED, MEMBER HAS NO RX COVERAGE NORPLANT/DEPOPROVERA N/C MEMBER HAS NO RX COVERAGE HEARING AIDS NOT COVERED UNDER MEMBERS PLAN INVITRO IS NOT COVERED UNDER MEMBERS PLAN ACUPUNCTURE IS NON COVERED UNDER MEMBERS PLAN COSMETIC PROCEDURE IS NOT COVERED IN MEMBERS PLAN HEARING AID TEST NOT COVERED UNDER MEMBER CONTRACT DURABLE MEDICAL EQUIPMENT (DME) NOT A COVERED ITEM DIABETIC SHOES NOT COVERED UNDER MEMBERS PLAN INPT SUBSTANCE ABUSE NOT COVERED IN MEMBERS PLAN PROSTHETIC & APPLIANCE NOT COVERED IN MEMBERS PLAN ORTHOTICS ARE NOT COVERED UNDER MEMBER CONTRACT SERVICE NOT COVERED UNDER MEMBERS CONTRACT NOT ALLOWED - DO NOT BILL MEMBER NOT COVERED SERVICE / BILL MEMBER

* HIPAA Remark Codes are not being used at this time. Expect to use for further clarification of denials at a later date.

Page 17 of 31

Independent Health Adjustment Reason Code Crosswalk
Non-covered charge(s) 96 96 96 Non-covered charge(s) 96 Non-covered charge(s) 96 96 96 96 96 96 96 96 Non-covered charge(s) 96 Non-covered charge(s) 96 Non-covered charge(s) 96 96 96 96 Non-covered charge(s) 96 Non-covered charge(s) 96 96 96 Non-covered charge(s) 96 PR Patient Responsibility YB1 Non-covered charge(s) Non-covered charge(s) PR PR PR Patient Responsibility Patient Responsibility Patient Responsibility TL1 Y01 YA1 CO Contractual Obligation TE1 Non-covered charge(s) Non-covered charge(s) Non-covered charge(s) CO CO PR PR Contractual Obligation Contractual Obligation Patient Responsibility Patient Responsibility SG1 SW1 T41 TD1 CO Contractual Obligation S21 PR Patient Responsibility RQ1 Non-covered charge(s) Non-covered charge(s) Non-covered charge(s) Non-covered charge(s) Non-covered charge(s) Non-covered charge(s) Non-covered charge(s) PR CO CO CO PR PR PR PR Patient Responsibility Contractual Obligation Contractual Obligation Contractual Obligation Patient Responsibility Patient Responsibility Patient Responsibility Patient Responsibility NF1 QC1 QD1 R/1 R61 R91 RG1 RH1 PR Patient Responsibility K1 Non-covered charge(s) Non-covered charge(s) CO CO PR Contractual Obligation Contractual Obligation Patient Responsibility CF1 D81 DG1

Updated 9/29/03

SERVICE CODE NOT REIMBURSABLE BILL MEMBER/NOT COVERED THIS IS A NON-COVERED SERVICE. BILL MEMBER. SERVICE NOT COVERED BY BENEFIT GLUCOSE MONITOR NOT ON FORMULARY HPR DENIED HPR DENIED AVAILABLE OVER THE COUNTER CONTRACEPTIVE EXCLUDE AVAILABLE OVER THE COUNTER NON COVERED SERVICE NO DENTAL PLAN/RX NOT COVERED DIABETIC SUPPLY COVERAGE ONLY NON COVERED SERVICE/BILL PATIENT NOT ALLOWED, DO NOT BILL PATIENT DRUG OR OTC/NOT COVERED NON COVERED/NO DENTAL RIDER NON COVERED DENTAL SERVICE/BILL MEMBER NO ALLOWABLE CHARGE FOR SERVICE SERVICE NOT COVERED BY BENEFIT OPTOMETRISTS NOT COVERED ALC/DRUG RE NOT COV/PT. RESPONSIBLE DUN PLAN DOES NOT COOR. BEN / HMO

* HIPAA Remark Codes are not being used at this time. Expect to use for further clarification of denials at a later date.

Page 18 of 31

Independent Health Adjustment Reason Code Crosswalk
Non-covered charge(s) 96 Non-covered charge(s) 96 Non-covered charge(s) 96 Non-covered charge(s) 96 Non-covered charge(s) 96 Non-covered charge(s) 96 Payment is included in the allowance for another service/procedure 97 Payment is included in the allowance for another service/procedure 97 Payment is included in the allowance for another service/procedure 97 Payment is included in the allowance for another service/procedure 97 Payment is included in the allowance for another service/procedure 97 Payment is included in the allowance for another service/procedure. 97 Payment is included in the allowance for another service/procedure 97 Payment is included in the allowance for another service/procedure 97 CO Contractual Obligation KT1 DENIED/GLOBAL CO Contractual Obligation KS1 CO Contractual Obligation IY1 CO Contractual Obligation FG1 CO Contractual Obligation EW1 CO Contractual Obligation CL1 CO Contractual Obligation C61 CO Contractual Obligation 211 PR Patient Responsibility YO1 PR Patient Responsibility YG1 PR Patient Responsibility YF1 PR Patient Responsibility YE1 PR Patient Responsibility YD1 PR Patient Responsibility YC1

Updated 9/29/03

NON COV. SERV./WELL ADULT/PT. RESPONSIBLE NON COV. SERV./WELL CHILD/PT. RESPONSIBLE NON COV. SERV/ROUT OB/GYN/PT. RESPONSIBLE NON COV. SERV/ROUT. EYE EXAM/PT. RESPONSIBLE NON COV. SERV/MATERN CARE/OF DEPENDENTS DENTAL COVERAGE ONLY/PT. RESPONSIBLE

INCLUDED IN GLOBAL FEE SHOULD BE GLOBAL FEE, SERVICE DENIED

E+M VISIT N/A WITH PROCEDURE

INPAT. ADMISSIONS COMBINED

INCLUDED IN GLOBAL FEE CHARGES INCLUDED IN URN CONTRACT PER DIEM RATE INCLUDES CHANGES/MEM. NOT RESP

* HIPAA Remark Codes are not being used at this time. Expect to use for further clarification of denials at a later date.

Page 19 of 31

Independent Health Adjustment Reason Code Crosswalk
Payment is included in the allowance for another service/procedure 97 Payment is included in the allowance for another service/procedure 97 Payment is included in the allowance for another service/procedure 97 Payment is included in the allowance for another service/procedure 97 Payment is included in the allowance for another service/procedure 97 Payment is included in the allowance for another service/procedure 97 Payment is included in the allowance for another service/procedure 97 Payment is included in the allowance for another service/procedure 97 Payment is included in the allowance for another service/procedure 97 Payment is included in the allowance for another service/procedure 97 Payment is included in the allowance for another service/procedure 97 Payment is included in the allowance for another service/procedure 97 CO Contractual Obligation ZW1 SVC. INCLUDED IN F/U CO Contractual Obligation ZT1 CO Contractual Obligation ZP1 CO Contractual Obligation ZO1 CO Contractual Obligation ZN1 CO Contractual Obligation ZM1 CO Contractual Obligation ZL1 CO Contractual Obligation ZG1 CO Contractual Obligation Y61 CO Contractual Obligation TY1 GLOBAL CO Contractual Obligation TI1 CO Contractual Obligation S51

Updated 9/29/03

INCLUDED IN GLOBAL FEE SERVICE COVERED BY OTHER PROCEDURE

PER DIEM RATE INCL. CHARGES/YOU ARE NOT RESPON. PAYMENT INC. IN STUDIES 9580895811 TYMPANOMETRY NOT ALLOWED WITH WELL VISIT VISION HEARING SCREEN N/A WITH WELL VISIT/COMP N/A WITHIN F/U PERIOD OR SAME DAY

J CODE GLOBAL TO INJECTION CODE TRAY FEE NOT ALLOWED WITH SVC CODE 90782 GLOBAL TO IMMUNIZATION CODE

* HIPAA Remark Codes are not being used at this time. Expect to use for further clarification of denials at a later date.

Page 20 of 31

Independent Health Adjustment Reason Code Crosswalk
Payment is included in the allowance for another service/procedure 97 100 100 Payment made to patient/insured/responsible party Payment made to patient/insured/responsible party Claim not covered by this payer/contractor. You must send the claim to the correct payer/contractor. Claim not covered by this payer/contractor. You must send the claim to the correct payer/contractor. 109 Claim not covered by this payer/contractor. You must send the claim to the correct payer/contractor. 109 Claim not covered by this payer/contractor. You must send the claim to the correct payer/contractor. 109 Claim not covered by this payer/contractor. You must send the claim to the correct payer/contractor. 109 Claim not covered by this payer/contractor. You must send the claim to the correct payer/contractor. 109 Not covered by this payer/contractor. You must send this claim to the correct payer/contractor. 109 CO Contractual Obligation IX1 CO Contractual Obligation FQ1 CO Contractual Obligation FB1 PR Patient Responsibility DA1 CO Contractual Obligation AS1 CO Contractual Obligation AI1 CO PR PR Contractual Obligation Patient Responsibility Patient Responsibility ZX1 D91 KL1

Updated 9/29/03

90782 N/A W/O J, Q, S CODE SETTLEMENT REC'D/BILL MEMBER MEMBER RECEIVED SETTLEMENT

109

CO

Contractual Obligation

AD1

NOT COVERED-BILL MEDICARE

NOT COVERED IN MEDISOURCE CONTRACT - BILL MEDICAID

BILL SERVICES TO EYEMED

DENY MEDICARE ELIGIBLE, NO PT A/B, BILL MEMBER

BILL MEDICAID NOT COVERED

REF LAB/BILL FACILITY/NOT MEMBER

FORWARD CLAIM TO CURBELL

* HIPAA Remark Codes are not being used at this time. Expect to use for further clarification of denials at a later date.

Page 21 of 31

Independent Health Adjustment Reason Code Crosswalk
Not covered by this payer/contractor. You must send this claim to the correct payer/contractor. 109 Claim not covered by this payer/contractor. You must send the claim to the correct payer/contractor. 109 Claim not covered by this payer/contractor. You must send the claim to the correct payer/contractor. 109 Claim not covered by this payer/contractor. You must send the claim to the correct payer/contractor. 109 Claim not covered by this payer/contractor. You mist send the claim to the correct payer/contractor. 109 Claim not covered by this payer/contractor. You mist send the claim to the correct payer/contractor. 109 119 119 119 119 119 119 Benefit maximum for this time period has been reached Benefit maximum for this time period has been reached Benefit maximum for this time period has been reached Benefit maximum for this time period has been reached Benefit maximum for this time period has been reached Benefit maximum for this time period has been reached CO CO CO PR CO CO CO Contractual Obligation Contractual Obligation Contractual Obligation Patient Responsibility Contractual Obligation Contractual Obligation Contractual Obligation YW1 111 191 391 591 631 641 CO Contractual Obligation YK1 CO Contractual Obligation NR1 CO Contractual Obligation NB1 CO Contractual Obligation NA1 CO Contractual Obligation IZ1 BILL SERVICES TO URN

Updated 9/29/03

FILE WITH NORTH AMERICAN

FILE WITH MOHAWK VALLEY PLAN

AMB SERV - BILL FAC / NOT MEMBER

NON COV SERV. UNDER CMMP/PAY BY UBH

NON COVERED/PAY BY VBH AUTHORIZED AMOUNT EXCEEDED AUTHORIZED UNITS EXCEEDED EXCEEDS BENEFIT COVERAGE COVERAGE LIMIT REACHED BY PREPAID AUTHORIZED DAYS REACHED AUTHORIZED DAYS EXCEEDED

* HIPAA Remark Codes are not being used at this time. Expect to use for further clarification of denials at a later date.

Page 22 of 31

Independent Health Adjustment Reason Code Crosswalk
119 119 119 119 119 119 119 119 119 119 119 119 119 119 119 119 119 119 Benefit maximum for this time period has been reached Benefit maximum for this time period has been reached Benefit maximum for this time period has been reached Benefit maximum for this time period has been reached Benefit maximum for this time period has been reached Benefit maximum for this time period has been reached Benefit maximum for this time period has been reached Benefit maximum for this time period has been reached Benefit maximum for this time period has been reached Benefit maximum for this time period has been reached Benefit maximum for this time period has been reached Benefit maximum for this time period has been reached Benefit maximum for this time period has been reached Benefit maximum for this time period has been reached Benefit maximum for this time period has been reached Benefit maximum for this time period has been reached Benefit maximum for this time period has been reached Benefit maximum for this time period has been reached CO PR PR PR PR PR PR PR PR CO CO PR CO PR CO PR CO CO Contractual Obligation Patient Responsibility Patient Responsibility Patient Responsibility Patient Responsibility Patient Responsibility Patient Responsibility Patient Responsibility Patient Responsibility Contractual Obligation Contractual Obligation Patient Responsibility Contractual Obligation Patient Responsibility Contractual Obligation Patient Responsibility Contractual Obligation Contractual Obligation 651 AB1 BK1 G11 KC1 R!1 R_1 RA1 RM1 SJ1 T21 TH1 XH1 YS1 ZE1 CQ1 SX1 TR1

Updated 9/29/03

DAYS APPROVED OVER LIMIT SERVICE OCCURRENCE LIMIT EXCEEDED EXCEEDS BENEFIT COVERAGE BENEFIT AMOUNT EXCEEDED EXCEEDS BENEFIT COVERAGE MEMBER EXCEEDED BENEFIT(S) MEMBER MET CAP MEMBER EXCEEDED BENEFITS MEMBER MET CAP EXCEEDS BENEFIT LIMITATION AUTHORIZED UNITS EXCEEDED SERVICE COUNT EXCEEDED BENEFITS LIMIT/REVIEW UBH NOT COVERED/BENEFIT LIMITED DENIED EXCEEDS POLICY EXCEEDS LIFETIME MAX BENEFIT/BILL MEMBER EXCEEDS PROPHYLAXIS LIMIT SERVICE COUNT EXCEEDED FOR MEM/TOOTH/PERIOD

* HIPAA Remark Codes are not being used at this time. Expect to use for further clarification of denials at a later date.

Page 23 of 31

Independent Health Adjustment Reason Code Crosswalk
119 119 119 119 119 119 119 119 119 119 119 Benefit maximum for this time period has been reached Benefit maximum for this time period has been reached Benefit maximum for this time period has been reached Benefit maximum for this time period has been reached Benefit maximum for this time period has been reached Benefit maximum for this time period has been reached Benefit maximum for this time period has been reached Benefit maximum for this time period has been reached Benefit maximum for this time period has been reached Benefit maximum for this time period has been reached Benefit maximum for this time period has been reached Payment adjusted due to a submission/billing error(s). Additional information is supplied using the remittance advice using the remittance advice codes whenever appropriate. Payment adjusted due to a submission/billing error(s). Additional information is supplied using the remittance advice remarks codes whenever appropriate. PR PR PR PR CO CO CO PR PR CO CO Patient Responsibility Patient Responsibility Patient Responsibility Patient Responsibility Contractual Obligation Contractual Obligation Contractual Obligation Patient Responsibility Patient Responsibility Contractual Obligation Contractual Obligation Y1 YL1 YM1 YN1 Z01 Z21 Z61 ZI1 ZJ1 ZQ1 ZV1

Updated 9/29/03

EXCEEDS DENTAL DOLLARS:BILL MEMBER DUP. ROUT. MAMMO IN 2YR./PT. RESPONSIBLE DUP. ROUT. MAMMO IN 1 YR./PT. RESPONSIBLE DUPLICATE ROUT. PAP IN 1 YR./PT. RESONSIBLE ESTABLISHED VISIT EXCEEDS POLICY 99215+92014:ALLOW 1X PER MD/ASSOC/CAL. YR. 78464+78465:MUST BE DONE W/IN 3 DAYS ONE EVAL. ALLOWED PER EPISODE OF CARE TWO FLU INJ. ALLOWED PER CALENDAR YEAR TWO UNITS ALLOWED PER DATE OF SERVICE TWO PNEUMO. INJ. ALLOWED PER CAL. YEAR

125

CO

Contractual Obligation

NC1

MUST BILL ON HCFA 1500

125

CO

Contractual Obligation

NO1

PLEASE SUBMIT ON ADA FORM

* HIPAA Remark Codes are not being used at this time. Expect to use for further clarification of denials at a later date.

Page 24 of 31

Independent Health Adjustment Reason Code Crosswalk
Payment adjusted due to a submission/billing error(s). Additional information is supplied using the remittance advice remarks codes whenever appropriate. Payment adjusted due to a submission/billing error(s). Additional information is supplied using the remittance advice remarks codes whenever appropriate. Payment adjusted due to a submission/billing error(s). Additional information is supplied using the remittance advice remarks codes whenever appropriate. Payment adjusted due to a submission/billing error(s). Additional information is supplied using the remittance advice remarks codes whenever appropriate. Payment adjusted due to a submission/billing error(s). Additional information is supplied using the remittance advice remarks codes whenever appropriate. Payment adjusted due to a submission/billing error(s). Additional information is supplied using the remittance advice remarks codes whenever appropriate. Payment adjusted due to a submission/billing error(s). Additional information is supplied using the remittance advice remarks codes whenever appropriate.

Updated 9/29/03

125

CO

Contractual Obligation

S11

CLM PROCESSED WRONG PROVIDER

125

CO

Contractual Obligation

S61

CLAIM PROCESSED WRONG MEMBER

125

CO

Contractual Obligation

SP1

PROVIDER SUBMITTAL ERROR

125

CO

Contractual Obligation

SQ1

CLAIM BEING PROCESSED AS HOSP/PHYS. CLAIM

125

CO

Contractual Obligation

511

CLAIM HAS BEEN REPROCESSED

125

CO

Contractual Obligation

S91

ENTIRE CLAIM BEING ADJUSTED

125

CO

Contractual Obligation

SA1

MISCELLANEOUS CREDIT ADJUSTMENT

* HIPAA Remark Codes are not being used at this time. Expect to use for further clarification of denials at a later date.

Page 25 of 31

Independent Health Adjustment Reason Code Crosswalk
Payment adjusted due to a submission/billing error(s). Additional information is supplied using the remittance advice remarks codes whenever appropriate. Payment adjusted due to a submission/billing error(s). Additional information is supplied using the remittance advice remarks codes whenever appropriate. Payment adjusted due to a submission/billing error(s). Additional information is supplied using the remittance advice remarks codes whenever appropriate. Payment adjusted due to a submission/billing error(s). Additional information is supplied using the remittance advice remarks codes whenever appropriate. Payment adjusted due to a submission/billing error(s). Additional information is supplied using the remittance advice remarks codes whenever appropriate. Payment adjusted due to a submission/billing error(s). Additional information is supplied using the remittance advice remarks codes whenever appropriate. Payment adjusted due to a submission/billing error(s). Additional information is supplied using the remittance advice remarks codes whenever appropriate.

Updated 9/29/03

125

CO

Contractual Obligation

SH1

PAID IN NETWORK, SHOULD BE OUT OF NETWORK

125

CO

Contractual Obligation

SM1

PAID INCORRECT FEE

125

CO

Contractual Obligation

SR1

COPAY ADJUSTMENTS

125

CO

Contractual Obligation

YP1

CLAIM BEING REPROCESSED UNDER SUBSTANCE ABUSE PROG

125

CO

Contractual Obligation

S81

DRG AUDIT

125

CO

Contractual Obligation

SD1

RETROACTIVE REVIEW/MRS PROCEDURE

125

CO

Contractual Obligation

SN1

RETROACTIVE AMBULATORY REVIEW

* HIPAA Remark Codes are not being used at this time. Expect to use for further clarification of denials at a later date.

Page 26 of 31

Independent Health Adjustment Reason Code Crosswalk
Payment adjusted due to a submission/billing error(s). Additional information is supplied using the remittance advice remarks codes CO whenever appropriate. Payment adjusted due to a submission/billing error(s). Additional information is supplied using the remittance advice remarks codes CO whenever appropriate. Claim specific negotiated discount CO Claim specific negotiated discount CO CO Claim specific negotiated discount CO Claim specific negotiated discount CO Claim specific negotiated discount CO Claim specific negotiated discount Claim specific negotiated discount CO Claim specific negotiated discount CO Claim specific negotiated discount. CO CO Claim specific negotiated discount. Claim specific negotiated discount CO CO Claim specific negotiated discount Claim specific negotiated discount CO CO Claim specific negotiated discount CO Claim specific negotiated discount The disposition of this claim/service is CO pending further review The disposition of this claim/service is PR pending further review

Updated 9/29/03

125

Contractual Obligation

SS1

ADJUST DENY E/PER MD LETTER

125 131 131 131 131 131 131 131 131 131 131 131 131 131 131 131 133 133

Contractual Obligation Contractual Obligation Contractual Obligation Contractual Obligation Contractual Obligation Contractual Obligation Contractual Obligation Contractual Obligation Contractual Obligation Contractual Obligation Contractual Obligation Contractual Obligation Contractual Obligation Contractual Obligation Contractual Obligation Contractual Obligation Contractual Obligation Patient Responsibility

SU1 CH1 DP1 EJ1 EK1 EL1 EM1 EN1 G61 IG1 IJ1 JI1 M81 PF1 PH1 PP1 IB1 RO1

REVIEWED BY AMBULATORY REVIEW CLEVELAND CLINIC/NEGOTIATED RATE APPLIED MULTIPLAN DISCOUNT RATE APPLIED 0-10% DISCOUNT RATE APPLIED 11%-20% DISCOUNT RATE APPLIED 21%-30% DISCOUNT RATE APPLIED 31%-40% DISCOUNT RATE APPLIED 90% PERCENTILE UCR RATE APPLIED NEGOTIATED DISCOUNT RATE APPLIED PAID PER PPO NEXT/AMERA-NET RATE PAID PER CCN/AMERA-NET PD IN ACCORD W/ MULTIPLAN INC. DISC RATE PAID AT URN CONTRACT RATE BEECH STREET DISCOUNT APPLIED PHCS PPO DISCOUNT APPLIED PHCS, PPO BENEFIT APPLIED NEGOTIATION/NURSE AUDIT DUR

* HIPAA Remark Codes are not being used at this time. Expect to use for further clarification of denials at a later date.

Page 27 of 31

Independent Health Adjustment Reason Code Crosswalk
133 133 The disposition of this claim/service is pending further review The disposition of this claim/service is pending further review Payment/Reduction for Regulatory Surcharges, Assessments, Allowances or Health Related Taxes Services not documented in patients' medical records Services not documented in patients' medical records Services not documented in patients' medical records Previously paid. Payment for this claim/service may have been provided in a previous payment Payment denied because only one visit or consultation per physician per day is covered Payment denied because only one visit or consultation per physician per day is covered Payment denied because only one visit or consultation per physician per day is covered Payment denied because only one visit or consultation per physician per day is covered Payment denied because this procedure code/modifier was invalid on the date of service or claim submission Payment denied because this procedure code/modifier was invalid on the date of service or claim submission CO CO Contractual Obligation Contractual Obligation RR1 SZ1 PHARMACY AUDIT

Updated 9/29/03

DENIED/PENDING INVESTIGATION IHA PAYS NYS FOR HCRA SURCHARGE SERVICE NOT RENDERED DOCUMENTATION DOES NOT SUPPORT BILLING SERVICE NEVER RENDERED

137 B12 B12 B12

CO CO CO CO

Contractual Obligation Contractual Obligation Contractual Obligation Contractual Obligation

CR1 G1 OG1 SF1

B13

CO

Contractual Obligation

RK1

MISC. CREDIT ADJUSTMENT

B14

CO

Contractual Obligation

H21

CONSULTATIONS EXCEED POLICY

B14

CO

Contractual Obligation

H41

1 E&M VISIT PER MD/ASSOC/PER DAY BENEFITS LIMITED TO ONE VISIT PER DAY ONE 450 CODE ALLOWED PER SERVICE DATE

B14

CO

Contractual Obligation

Y71

B14

CO

Contractual Obligation

ZR1

B18

CO

Contractual Obligation

DE1

INVALID CPT CODE

B18

CO

Contractual Obligation

DF1

DELETED/INVALID REV.CODE

* HIPAA Remark Codes are not being used at this time. Expect to use for further clarification of denials at a later date.

Page 28 of 31

Independent Health Adjustment Reason Code Crosswalk
Payment denied because this procedure code/modifier was invalid on the date of service or claim submission Payment denied because this procedure code/modifier was invalid on the date of service or claim submission Payment denied because this procedure code/modifier was invalid on the date of service or claim submission Payment denied because this procedure code/modifier was invalid on the date of service or claim submission Payment denied because this procedure code/modifier was invalid on the date of service or claim submission This payment is adjusted based on the diagnosis. Payment adjusted because coverage/program guidelines were not met or were exceeded. Payment adjusted because coverage/program guidelines were not met or were exceeded. Payment adjusted because coverage/program guidelines were not met or were exceeded. Payment adjusted because coverage/program guidelines were not met or were exceeded.

Updated 9/29/03

B18

CO

Contractual Obligation

DR1

INVALID PROCEDURE

B18

CO

Contractual Obligation

EE1

CODE MUST BE P9010

B18

CO

Contractual Obligation

G71

INVALID CPT AND/OR MODIFIER

B18

CO

Contractual Obligation

JJ1

REV. CODE NOT ON FILE

B18 B22

CO CO

Contractual Obligation Contractual Obligation

JL1 OA1

CODE NOT VALID FOR IH MUST BILL LIMITED EXAM FOR DIAGNOSIS MBR. NONCOMPLIANT W/TREATMENT PLAN/RESP. FOR CHARGE PROCEDURE(S) DIFFER FROM CERTIFICATION CHIRO SERVICE NOT MET CRIT/PT. RESPONSIBLE POD. SERV. NOT MET CRIT/PT. RESPONSIBLE

B5

PR

Patient Responsibility

KH1

B5

CO

Contractual Obligation

Y21

B5

PR

Patient Responsibility

YH1

B5

PR

Patient Responsibility

YI1

* HIPAA Remark Codes are not being used at this time. Expect to use for further clarification of denials at a later date.

Page 29 of 31

Independent Health Adjustment Reason Code Crosswalk
This provider was not certified/eligible to be paid for this certified/eligible to be paid for this procedure/service on this date of service B7 This provider was not certified/eligible to be paid for this certified/eligible to be paid for this procedure/service on this date of service B7 This provider was not certified/eligible to be paid for this certified/eligible to be paid for this procedure/service on this date of service B7 This provider was not certified/eligible to be paid for this certified/eligible to be paid for this procedure/service on this date of service B7 This provider was not certified/eligible to be paid for this certified/eligible to be paid for this procedure/service on this date of service B7 This provider was not certified/eligible to be paid for this certified/eligible to be paid for this procedure/service on this date of service B7 This provider was not certified/eligible to be paid for this certified/eligible to be paid for this procedure/service on this date of service B7 CO Contractual Obligation YR1 CO Contractual Obligation P31 CO Contractual Obligation G81 CO Contractual Obligation EC1 CO Contractual Obligation EA1 CO Contractual Obligation CS1 CO Contractual Obligation 131

Updated 9/29/03

SERVICE INVALID FOR PROV/VENDOR

NO CLIA CERTIFICATION FOR SERVICE

SERVICE NOT ALLOWED FOR CLIA LEVEL

NOT ALLOWED TC BILLER

NOT CREDENTIALED FOR SERVICE

PROVIDER NOT CREDENTIALED FOR PROCEDURE

NOT COVERED/PROVIDER NOT MET VBH STANDARDS

* HIPAA Remark Codes are not being used at this time. Expect to use for further clarification of denials at a later date.

Page 30 of 31

Copay Deductible Coinsurance Withhold Prepaid Disallow (difference between billed and allowed) COB adjustment - paid claim line

Adjustment Group Code PR PR PR CO CO CO OA Qualifier I - AMT02; L6 - PLB03-1 D8 - AMT02; 90 - PLB03-1

Adjustment Reason Code 3 1 2 104 24 A2 23 Loop in 835 2100 2100

Loop in 835 2110 2110 2110 2110 2110 2110 2110 Location in Loop PLB03-2 and AMT02 PLB03-2 and AMT02

Location in Loop CAS03 and CLP05 CAS03 and CLP05 CAS03 and CLP05 CAS03 CAS03, CLP05 CAS03 CAS03

Interest Discount

Last modified 9/17/03


				
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posted:11/28/2009
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Description: Adj-Reason-Codes-denied