Humana Remittance Advice Codes - Download Now PDF

Shared by: jty12086

Tags

remittance advice, cpt codes, electronic claims, health plan, anthem bcbs, medicare claims, american medical association, health net, blue cross and blue shield of florida, reason code, the settlement, health care, credentialed physicians, medicare reimbursement, claim status

Stats

views:: 123
posted:: 2/16/2010
language:: English
pages:: 75

Public Domain

Document Sample

Humana Remittance Advice Codes

The following codes are updated on a monthly basis. Some codes may have changed since last update.

Last Update: 12/5/07
** To search for a particular code select Edit from the top toolbar,then select search. **
Code Description
C(C DUE TO CONTRACT AGREEMENT, YOUR INTEREST/PENALTY HAS BEEN ISSUED.
C(J INVALID REVENUE CODE. PLEASE SUBMIT A CORRECTED CLAIM.
MEDICAID ALLOWED AMOUNT IS LESS THAN THE PRIMARY CARRIER ALLOWED AMOUNT,
C(K THEREFORE NO ADDITIONAL PAYMENT IS DUE.

TELEMEDICINE SERVICES PROVIDED VIA STANDARD TELEPHONE, FACSIMILE (FAX)
C(L TRANSMISSION, AND/OR ELECTRONIC MAIL ARE NOT A COVERED EXPENSE UNDER THE PLAN.
ASSISTANT SURGEON'S CLAIM CANNOT BE PROCESSED WITHOUT PRIMARY SURGEON'S CLAIM,
C(M PLEASE SUBMIT.
C(P PAID IN ACCORDANCE WITH QUALCARE PPO CONTRACT
C(Q PAID IN ACCORDANCE WITH THE GHI NETWORK ACCESS PROGRAM.

PLEASE SUBMIT A COPY OF THE PRESCRIPTION WHICH IS REQUIRED TO REVIEW THE MOBILITY
DEVICE FOR MEDICAL NECESSITY. PLEASE INCLUDE ALL OF THE FOLLOWING REQUIRED
ELEMENTS: BENEFICIARY NAME, DATE OF FACE-TO-FACE EXAM AND RENDERING
PHYSICIAN/PRACTITIONER NAME, DIAGNOSIS AND CONDITIONS DEVICE IS EXPECTED TO MODIFY,
C(T DESCRIPTION OF THE ITEM, LENGTH OF NEED, AND DATE OF PRESCRIPTION.

PLEASE SUBMIT A COPY OF THE PRESCRIPTION FOR THIS MOBILITY DEVICE AND INCLUDE ALL OF
THE FOLLOWING REQUIRED ELEMENTS: BENEFICIARY NAME, DATE OF FACE-TO-FACE EXAM AND
RENDERING PHYSICIAN/PRACTITIONERNAME, DIAGNOSIS AND CONDITIONS DEVICE IS EXPECTED
C(U TO MODIFY, DESCRIPTION OF THE ITEM, LENGTH OF NEED, AND DATE OF PRESCRIPTION.
THE CLAIM YOU SUBMITTED WAS BILLED WITH A TYPE OF BILL THAT IS NOT ACCURATE FOR
C(W SERVICES RENDERED. P LEASE RESUBMIT CLAIM WITH CORRECT TYPE OF BILL.
C(X NO DESCRIPTION AVAILABLE

C(Z SERVICES COVERED BY THE FEDERAL BLACK LUNG PROGRAM ARE NOT COVERED BY THE PLAN.
FEDERAL BLACK LUNG PROGRAM EXPLANATION OF BENEFITS IS NEEDED FOR CLAIM TO BE
C(1 CONSIDERED.
THE MAXIMUM PAYABLE BENEFIT FOR TEMPROMANDIBULAR JOINT (TMJ) SERVICE HAS BEEN
REACHED FOR THE YEAR. THEREFORE, THIS SERVICE IS NOT COVERED. REFER TO THE BENEFIT
C(2 PLAN DOCUMENT.
C(3 CLAIM SUBMITTED AS VOID/CANCEL OF PREVIOUSLY SUBMITTED CLAIM.
THIS CLAIM IS PART OF AN INTERIM BILL.PROVIDER HAS RECEIVED THE FULL BENEFIT FOR THE
C(4 PATIENT'S STAY.
C(5 PLEASE SUBMIT CLAIMS DIRECTLY TO PMMI FOR PROCESSING.

THIS CLAIM IS DENIED BECAUSE THE PROVIDER DID NOT MEET CONTRACTUAL OBLIGATIONS
C(6 UNDER THE MENTAL HEALTH CARRIER'S AGREEMENT. MEMBER CANNOT BE BALANCE BILLED.
THE MEDICAL RECORDS SUBMITTED WILL BE USED AS PART OF THE ELIGIBILITY REVIEW BEING
CONDUCTED ON THISMEMBER. WE ARE STILL WAITING FOR INFORMATION FROM OTHER
C(7 SOURCES BEFORE COMPLETING THE REVIEW.
THIS CLAIM HAS BEEN PROCESSED AT THE PAR BENEFIT LEVEL ACCORDING TO YOUR PLAN
C(8 BENEFITS.

THIS AMOUNT EXCEEDS THE PAYMENT AGREEMENT FOR W&F ADMINISTRATION. ANY QUESTIONS
C&B REGARDING NETWORK SAVINGS, CONTACT COALITION AMERICA INC. AT 404-459-7201.
Humana Remittance Advice Codes

The following codes are updated on a monthly basis. Some codes may have changed since last update.

Last Update: 12/5/07
Code Description
PER TEXAS LEGISLATION THIS IS TO INFORM YOU THAT THE AFORE MENTIONED CLAIM WAS
C&C AUDITED AND DETERMINED TO BE CORRECT. NO FURTHER ACTION IS REQUIRED.
CLAIM HAS BEEN CLINICALLY REVIEWED AND DENIED. A LETTER OF MEDICAL NECESSITY WILL
C&D FOLLOW.
THIS AMOUNT REPRESENTS PREVIOUSLY PAID INTEREST INACCORDANCE WITH STATE
C&E REGULATIONS.

C&F THIS AMOUNT REPRESENTS THE PENALTY PREVIOUSLY PAIDIN ACCORDANCE WITH TX SB 418.
C&G BENEFIT MAXIMUM FOR THE ANESTHESIA SERVICE HAS BEEN PREVIOUSLY PAID.
C&I PLEASE RESUBMIT WITH THE APPROPRIATE SERVICE CODE AND/OR MODIFIER.
THIS CLAIM HAS BEEN FORWARDED TO THE DESIGNATED MENTAL HEALTH CARRIER;
C&O PSYCH/CARE,LLC. 10200 SUNSET DRIVE, MIAMI, FL 33173.
THE OBSERVATION SERVICES, AS BILLED, DID NOT MEET THE CRITERIA FOR SEPARATE
C&P COVERAGE. WE RELIED ON MEDICARE GUIDELINES TO MAKE THIS DETERMINATION.
THIS OBSERVATION SERVICE DID NOT MEET THE CRITERIA FOR SEPARATE COVERAGE. WE
C&Q RELIED ON MEDICARE GUIDELINES TO MAKE THIS DETERMINATION.

C&R THIS CLAIM HAS BEEN DENIED AS THE REQUESTED MEDICAL RECORDS WERE NOT RECEIVED.
THIS APPEARS TO BE A DUPLICATE OF A CHARGE PREVIOUSLY PROCESSED AND APPLIED TO THE
C&U MEMBER'S DEDUCTIBLE
THIS LINE WAS PAID IN ACCORDANCE WITH THE LONG TERM CARE PROSPECTIVE PAYMENT
C&X SYSTEM RATE.
THIS LINE WAS PAID IN ACCORDANCE WITH THE INPATIENT REHABILITATION FACILITY
C&Y PROSPECTIVE PAYMENT SYSTEM RATE.
THE PHARMACY CLAIM SUBMITTED HAS BEEN FORWARDED TO A THIRD PARTY ADMINISTRATOR
C&6 FOR PROCESSING. ESI, P.O.BOX 66518, ST LOUIS, MO. 63166-6518.

C&7 THIS IS AN ALC LEASED NETWORK. MEMBER NOT RESPONSIBLE FOR THIS DISCOUNTED AMOUNT.
C!A ORTHONET DENIED AUTHORIZATION FOR THIS SERVICE.
THIS AMOUNT IS OVER THE ALLOWABLE FEE. THE PROVIDER ACCEPTS MEDICARE ASSIGNMENT
C!K AND CANNOT BILL THEMEMBER FOR THIS AMOUNT.
CLAIM WAS PAID UNDER THE INPATIENT PSYCHIATRIC FACILITY PROSPECTIVE PAYMENT SYSTEM.
C!L TEFRA PAYMENTS ALSO INCLUDED BASED ON BLEND YEAR PERCENTAGES.
THIS TREATMENT IS NOT MEDICALLY NECESSARY AS DEFINED BY THE PLAN AND IS NOT ELIGIBLE
C!M FOR COVERAGE. MEMBER IS NOT RESPONSIBLE FOR THESE CHARGES.

C!O PAID IN ACCORDANCE TO COMMUNITY PARTNERS HEALTH PLAN CONTRACTUAL AGREEMENT.
C!S PLEASE SUBMIT WITH UPIN OR STATE LICENSE INFORMATION.
C!T PLEASE SUBMIT THE MEMBER'S HEIGHT AND/OR WEIGHT FOR DATE OF SERVICE
MEDICARE EQUIVALENT REMITTANCE ADVICE IS NEEDED BEFORE PAYMENT CAN BE MADE.
C!U PLEASE SUBMIT THE APPROPRIATE INFORMATION TO THE CLAIMS ADDRESS.
C!4 CLAIM APPROVED, REPRICED BY ORTHONET NEGOTIATED AMOUNT.
C!5 NO DESCRIPTION AVAILABLE

THIS PROVIDER IS A MEMBER OF THE ORTHONET NETWORK. SERVICES ARE DISCOUNTED
C!8 ACCORDING TO NEGOTIATED RATE. MEMBER NOT RESPONSIBLE FOR THIS DISCOUNT AMOUNT.
ORTHONET REPRICED AT ZERO PER CONTRACT-INCLUDED IN DAILY PER DIEM FOR THIS
C!9 DISCOUNTED AMOUNT.
C$B THIS HAS BEEN SUBMITTED TO A THIRD PARTY ADMINISTRATOR TO BE PROCESSED.
Humana Remittance Advice Codes

The following codes are updated on a monthly basis. Some codes may have changed since last update.

Last Update: 12/5/07
Code Description
IMPLANTS AND RELATED SERVICES ARE ONLY COVERED IF IT IS THE LEAST COSTLY TREATMENT.
C$E PLEASE SUBMIT APPROPRIATE DOCUMENTATION.
CHARGES MUST BE FILED WITH UNITED RESOURCE TRANSPLANT NETWORK FOR DISCOUNT
C$F PRICING.
THIS AMOUNT EXCEEDS THE PAYMENT AGREEMENT FOR MANAGED CARE STRATEGIES. ANY
QUESTIONS REGARDING NETWORK SAVINGS, CONTACT COALITION AMERICA, INC. AT 404-459-
C$G 7201.
C$H THE GRACE PERIOD FOR PREMIUM PAYMENT HAS EXPIRED.
THIS IS A EMO/CHA/LCI/LPN DISCOUNT. MEMBER IS NOT RESPONSIBLE FOR THE DISCOUNTED
C$O AMOUNT.

C$P THIS IS A MEDCOST DISCOUNT. MEMBER NOT RESPONSIBLE FOR THE DISCOUNTED AMOUNT.
C$V SERVICE DETERMINED AS NOT MEDICALLY NECESSARY.
BENEFITS PAYABLE FOR MEDICAL SCREENING EXAM TO EVALUATE NECESSITY OF EMERGENCY
C$X TREATMENT.
THIS AMOUNT EXCEEDS THE PAYMENT AGREEMENT FOR INDEPENDENT MEDICAL SYSTEMS. ANY
QUESTIONS REGARDING NETWORK SAVINGS, CONTACT COALITION AMERICA, INC. AT 404-459-
C$Y 7201.
THIS SERVICE IS NOT DOCUMENTED IN THE RECORDS SUBMITTED FOR REVIEW. MEMBER NOT
C$1 RESPONSIBLE FOR CHARGES.
ROUTINE HEARING/TESTING SERVICES ARE NOT COVERED. PLEASE SUBMIT TO THE NATIONAL
C$4 EAR CARE PLAN.
C$5 NO DESCRIPTION AVAILABLE
C$7 MAXIMUM BENEFIT FOR THIS TYPE OF SERVICE HAS BEEN ALLOWED.
C$8 LOUISIANA HEARING AID BENEFIT HAS BEEN EXHAUSTED.
THE MENTAL HEALTH AND CHEMICAL DEPENDENCY PROGRAM NON-NETWORK COVERAGE ONLY
C*C APPLIES TO LICENSED PH.D., M.D., E.D.D., AND PYS.D. PROVIDERS
C*D MEMBER ENROLLED IN HMO. SERVICES NOT COVERED BY THE MEDICAL PLAN.
C*E RETIREES ARE NOT COVERED BY THIS PLAN.
C*F OVER AGE MEMBER NOT COVERED BY THE PLAN.
C*J COORDINATE WITH ANY HMO.
C*K TERMINATION DUE TO DEATH
THE SERVICES RENDERED FOR THIS PROCEDURE ARE NOT MEDICAL INDICATED FOR THIS
C*L PATIENT.
SERVICE IS NOT DOCUMENTED IN THE RECORDS RECEIVED,THEREFORE, NO BENEFIT IS
C*M PAYABLE.
C*N THIS BENEFIT APPLIES ONLY TO THE MEMBER, THEREFORE, NO BENEFIT PAYABLE.
C*O THIS BENEFIT APPLIES TO A CHILD, THEREFORE, NO BENEFIT PAYABLE.
C*Q BREAST PUMPS REQUIRE CALLCARE APPROVAL FOR COVERAGE.
C*V PLEASE SUBMIT THE APPROPRIATE CPT4 CODES FOR SERVICES.
WE HAVE ESTIMATED THE PRIMARY CARRIER'S PAYMENT. IF THEIR PAYMENT IS LESS THAN OUR
C*X ESTIMATE, PLEASE SEND THE WORKSHEET.
C*Y COMFORT ITEMS ARE NOT COVERED UNDER THE PLAN.
C*Z DIET/NUTRITIONAL COUNSELING IS NOT A COVERED EXPENSE.
TOTAL CHARGES REFLECT THE AMOUNT APPROVED BY THE PRIMARY INSURANCE CARRIER.
C/A MEMBER NOT RESPONSIBLE FOR WRITE-OFF AMOUNT.
RESUBMIT TO: MOTOROLA REWARDS ADMINISTRATION CENTER P.O. BOX 29005 PHOENIX, AZ
C/B 85038-9005 OR THROUGH WEBMD PAYER CODE 36111
Humana Remittance Advice Codes

The following codes are updated on a monthly basis. Some codes may have changed since last update.

Last Update: 12/5/07
Code Description
THIS OUTPATIENT SURGERY WAS NOT PRE-CERTIFIED AS REQUIRED THROUGH CALLCARE. NO
C/C BENEFITS ARE PAYABLE FOR THIS PROCEDURE.
C/D OPERATING ROOM CHARGES ARE NOT PAYABLE FOR THIS PLACE OF SERVICE.
C/E DENTAL IMPLANT SURGERY REQUIRES CALLCARE APPROVAL FOR COVERAGE.
BASED ON THE INFORMATION SUBMITTED, THIS SERVICE CANNOT BE COVERED UNDER THE
C/G PLAN.

C/H TEST/TREATMENT WHICH IS NOT SCIENTIFICALLY PROVEN OR FDA APPROVED IS NOT COVERED.
THE SERVICES RENDERED APPEAR TO BE COSMETIC IN NATURE AND ARE NOT COVERED UNDER
C/I THE TERMS OF YOUR PLAN.
SERVICES WERE RENDERED BY A NON-NETWORK PROVIDER. BENEFITS REDUCED TO 50% OF
C/J THE ALLOWABLE.
C/K THE MAXIMUM ALLOWABLE FOR THE RENTAL OR PURCHASE OF EQUIPMENT HAS BEEN MET.
C/L THIS PROCEDURE IS NOT COVERED UNDER THE PLAN.
DENTAL IMPLANT AND ASSOCIATED PROCEDURES NOT COVERED IN THE ABSENCE OF A MEDICAL
C/M CONDITION.
THE PRIMARY INSURANCE CARRIER PAID THESE SERVICES IN FULL. NO PAYMENT DUE FROM THE
C/N MOTOROLA PLAN.
THE PRIMARY INSURANCE CARRIER PAID GREATER THAN OR EQUAL TO OUR ALLOWABLE BENIFIT
C/O AMOUNT. NO PAYMENT IS DUE.
ALLOWED AMOUNT REPRESENTS THE AVERAGE WHOLESALE PRICE FOR SPECIFIC DRUG
C/Q SUBMITTED.
C/R THIS BENEFIT DETERMINATION IS PER CONSULTANT REVIEW.

C/S FACILITY FEES BILLED FROM NETWORK PHYSICIANS ARE NOT REIMBURSABLE SEPARATELY.
C/T SERVICE DATES ARE PRIOR TO THE MEMBER'S BIRTHDATE.
C/U THE SERVICE DATES ARE PRIOR TO THE PATIENT'S BIRTHDATE.
C/V SPOUSE NO LONER ELIGIBLE FOR BENEFITS DUE TO DIVORCE.
WHEN PERFORMED AT THE SAME TIME AS A PRIMARY PROCEDURE, SECONDARY PROCEDURES
C/W ARE NOT COVERED UNDER YOUR PLAN.
C/X THIS PROCEDURE IS ONLY COVERED WHEN PERFORMED ON AN OUT-PATIENT BASIS.
NO BENEFITS ARE PAYABLE FOR THE PROVIDER WRITE-OFF AMOUNT. YOU ARE NOT
C/Y RESPONSIBLE FOR THIS AMOUNT.
THIS BILL WAS PROCESSED AS TWO SEPARATE CLAIMS DUE TO A CONTRACTUAL NETWORK
C/Z AGREEMENT WITH THIS HOSPITAL.
THE SERVICES RENDERED FOR THIS PROCEDURE ARE NOT CONSIDERED MEDICALLY
C/1 APPROPRIATE FOR THIS TYPE OF CONDITION.
C/2 COINSURANCE AMOUNT.
C/3 OVER AGE DEPENDENT NOT COVERED BY THE PLAN.
C/4 THIS APPEARS TO BE A DUPLICATE OF A CHARGE PREVIOUSLY CONSIDERED.
C/5 THIS APPEARS TO BE A DUPLICATE OF A CHARGE PREVIOUSLY CONSIDERED.

C/6 CALLCARE WAS NOT CONTACTED. PAYMENT REPRESENTS 50% OF THE ALLOWABLE AMOUNT.
THIS AMOUNT EXCEEDS THE PYMT AGREEMENT FOR PRIME HEALTH/UHN. ANY QUESTIONS
C%A REGARDING NETWORK SAVINGS, CONTACT COALITION AMERICA INC. AT 404-459-7201.
C%B YOU ARE NOT RESPONSIBLE FOR THIS AMOUNT.
C%C PLEASE SUBMIT CLAIM TO COMPSYCH AT P.O. BOX 8379, CHICAGO, IL 60680-8379.
Humana Remittance Advice Codes

The following codes are updated on a monthly basis. Some codes may have changed since last update.

Last Update: 12/5/07
Code Description

THIS AMOUNT EXCEEDS THE PYMT AGREEMENT FOR MEDICAL RESOURCES. ANY QUESTIONS
C%D REGARDING NETWORK SAVINGS, CONTACT COALITION AMERICA INC. AT 404-459-7201.
TELEMEDICINE SERVICES RENDERED VIA STANDARD TELEPHONE, FACSIMILE TRANSMISSIONS,
UNSECURED ELECTRONICMAIL, OR A COMBINATION THEREOF ARE NOT COVERED EXPENSES
C%K UNDER THE PLAN.
THIS SERVICE DOES NOT MEET ESTABLISHED CRITERIA FOR MEDICAL NECESSITY AND
C%M THEREFORE IS NOT COVERED.
THIS CLAIM WAS DENIED BECAUSE THE EMERGENCY ROOM REPORT RECEIVED FROM THE
PROVIDER WAS ILLEGIBLE AND /OR INCOMPLETE. THE CLAIM WILL BE RECONSIDERED UPON
C%N RECEIPT OF A LEGIBLE AND/OR COMPLETE REPORT.
C%O HEALTHEOS PLUS CONTRACTED PROVIDER, CLAIM MUST BE SUBMITTED FOR REPRICING.
THIS IS THE HEALTHEOS PLUS DISCOUNT. THE MEMEBER IS NOT RESPONSIBLE FOR THIS
C%P AMOUNT.
VISION THERAPY IS NOT COVERED ON YOUR PLAN. PLEASE REVIEW YOUR BENEFIT PLAN
C%Q DOCUMENT.
THIS AMOUNT IS THE DISCOUNT ARRANGED BETWEEN MHNET (MENTAL HEALTH NETWORK) AND
C%R YOUR PROVIDER. YOU ARE NOT RESPONSIBLE FOR THIS AMOUNT.
TECHNICAL COMPONENT OF SERVICE REDUCED DUE TO MULTIPLE PROCEDURES BILLED ON THE
C%S SAME DATE OF SERVICE .
C%T SERVICE DETERMINED TO BE NOT MEDICALLY NECESSARY.
THIS AMOUNT EXCEEDS THE PAYMENT AGREEMENT FOR MMPP. ANY QUESTIONS REGARDING
C%U NETWORK SAVINGS, CONTACT COALITION AMERICA, INC. AT 404-459-7201.
THE SERVICE/PROCEDURE PROVIDED PRIOR TO THE NATIONAL COVERAGE DETERMINATION
C%V (NCD) EFFECTIVE DATE.
DISCOUNT TAKEN THROUGH TRPN/THREE RIVERS PROVIDER NETWORK. PLEASE CALL
C%W CONCENTRA AT 800-854-3986 FOR QUESTIONS REGARDING THIS DISCOUNT.
DISCOUNT TAKEN THROUGH TRPN/BUCKEYE. PLEASE CALL CONCENTRA AT 800-854-3986 FOR
C%X QUESTIONS REGARDING THE DISCOUNT.
DISCOUNT TAKEN THROUGH TRPN/MCS - MANAGED CARE STRATEGIES. PLEASE CALL
C%Y CONCENTRA AT 800-854-3986 FOR QUESTIONS REGARDING THE DISCOUNT.
DISCOUNT TAKEN THROUGH IHP/INTEGRATED HEALTH PLAN. PLEASE CALL CONCENTRA AT 800-
C%Z 854-3986 FOR QUESTIONS REGARDING THE DISCOUNT.
AMOUNT ALLOWED IS THE NPPN-DIRECT ALLOWABLE FEE. YOU ARE NOT REQUIRED TO PAY THE
C?A PROVIDER ADJUSTMENT.
AMOUNT ALLOWED IS THE PPONEXT ALLOWABLE FEE. YOU ARE NOT REQUIRED TO PAY THE
C?B PROVIDER ADJUSTMENT.
AMOUNT ALLOWED IS THE INTERPLAN ALLOWABLE FEE. YOU ARE NOT REQUIRED TO PAY THE
C?C PROVIDER ADJUSTMENT.
AMOUNT ALLOWED IS THE HNA ALLOWABLE FEE. YOU ARE NOT REQUIRED TO PAY THE
C?D PROVIDER ADJUSTMENT.
AMOUNT ALLOWED IS THE TRPN ALLOWABLE FEE. YOU ARE NOT REQUIRED TO PAY THE
C?E PROVIDER ADJUSTMENT.
AMOUNT ALLOWED IS THE AHI/UNICARE ALLOWABLE FEE. YOU ARE NOT REQUIRED TO PAY THE
C?F PROVIDER ADJUSTMENT.
AMOUNT ALLOWED IS THE MR/GHN ALLOWABLE FEE. YOU ARE NOT REQUIRED TO PAY THE
C?G PROVIDER ADJUSTMENT.
AMOUNT ALLOWED IS THE DIMENSION ALLOWABLE FEE. YOU ARE NOT REQUIRED TO PAY THE
C?H PROVIDER ADJUSTMENT.
Humana Remittance Advice Codes

The following codes are updated on a monthly basis. Some codes may have changed since last update.

Last Update: 12/5/07
Code Description
AMOUNT ALLOWED IS THE TRPN-MCS PPO ALLOWABLE FEE. YOU ARE NOT REQUIRED TO PAY
C?I THE PROVIDER ADJUSTMENT.
AMOUNT ALLOWED IS THE HEALTH PAYERS ORG (HPO)DISCOUNT ALLOWABLE FEE. YOU ARE NOT
C?J REQUIRED TO PAY THE PROVIDER ADJUSTMENT
AMOUNT ALLOWED IS THE ARIZONA MEDICAL NETWORK ALLOWABLE FEE. YOU ARE NOT
C?K REQUIRED TO PAY THE PROVIDER ADJUSTMENT.
AMOUNT ALLOWED IS THE AMERICAS PPO ALLOWABLE FEE. YOU ARE NOT REQUIRED TO PAY
C?L THE PROVIDER ADJUSTMENT.
AMOUNT ALLOWED IS THE MRI/NATIONAL PROV NETWORK DISCOUNT ALLOWABLE FEE. YOU ARE
C?M NOT REQUIRED TO PAY THE PROVIDER ADJUSTMENT
AMOUNT ALLOWED IS THE MR/PSI DISCOUNT ALLOWABLE FEE. YOU ARE NOT REQUIRED TO PAY
C?N THE PROVIDER ADJUSTMENT.
THIS AMOUNT EXCEEDS THE NEGOTIATED RATE WITH BAPTIST BEHAVIOR HEALTH. THE MEMBER
C?P IS NOT RESPONSIBLE FOR THIS AMOUNT.
BEFORE BENEFIT CAN BE CONSIDERED, CORRECT HIPPS CODING IS NEEDED FOR BILLED
C?Q SERVICES.
REPAIR, REPLACEMENT OR MAINTENANCE OF AN APPLIANCE, ORTHOTIC OR MEDICAL EQUIPMENT
C?R IS NOT COVERED BY THE PLAN.
SITE OF SERVICE NOT INCLUDED IN THE OUTPATIENT PROSPECT PAYMENT SYSTEM. WE RELIED
C?S ON INTERNAL CRITERIA TO MAKE THIS DETERMINATION.
DUPLICATE CHARGE(S) OR AN INAPPROPRIATE NUMBER OF UNITS WERE BILLED. WE RELIED ON
C?T INTERNAL CRITERIATO MAKE THIS DETERMINATION.
A BILATERAL PROCEDURE WAS REPORTED WITHOUT THE APPROPRIATE MODIFIER(S). WE
C?U RELIED ON INTERNAL CRITERIA TO MAKE THIS DETERMINATION.

TERMINATED PROCEDURES ARE NOT ALLOWED WHEN BILLED AS A BILATERAL PROCEDURE OR
C?V WITH MULTIPLE UNITS. WE RELIED ON INTERNAL CRITERIA TO MAKE THIS DETERMINATION.
THERE IS AN INCONSISTENCY BETWEEN IMPLANT DEVICE AND IMPLANTATION PROCEDURE. WE
C?W RELIED ON INTERNAL CRITERIA TO MAKE THIS DETERMINATION.
MULTIPLE MEDICAL VISITS ON SAME DAY BILLED WITHOUT THE APPROPRIATE CONDITION CODE.
C?X WE RELIED ON INTERNAL CRITERIA TO MAKE THIS DETERMINATION.
ROOM CHARGE IS NOT COVERED SEPARATELY AS THE CLAIM DOES NOT CONTAIN A VALID
PROCEDURE REQUIRING OBSERVATION. WE RELIED ON INTERNAL CRITERIA TO MAKE THIS
C?Y DETERMINATION.
OBSERVATION SERVICES ARE NOT PAID SEPARATELY. WE RELIED ON INTERNAL CRITERIA TO
C?Z MAKE THIS DETERMINATION.

C?0 THIS APPEARS TO BE A CHARGE PREVIOUSLY PROCESSED TO ANOTHER PROVIDER/FACILITY.
C?1 THIS CHARGE IS CONSIDERED AS PART OF THE PRIMARY PROCEDURE.
THIS CHARGE IS CONSIDERED PART OF ANOTHER SERVICE ALREADY PAID FOR THE SAME DATE.
WE RELIED ON INTERNAL CRITERIA TO MAKE THIS DETERMINATION. THIS INFORMATION WILL BE
C?2 SUPPLIED TO YOU UPON REQUEST, FREE OF CHARGE.

C?3 SERVICE WILL NOT BE REIMBURSED ON SAME DATE AS ANOTHER COMPREHENSIVE SERVICE.

C?4 SERVICE WILL NOT BE REIMBURSED ON SAME DATE AS ANOTHER COMPREHENSIVE SERVICE.
SUBMITTED CHARGES WERE REDISTRIBUTED FOR A MORE ACCURATE BENEFIT. THE PROVIDER
OF SERVICE IS RESPONSIBLE FOR SUBMITTING SUPPORTING MEDICAL DOCUMENTATION FOR
C?5 RECONSIDERATION.
Humana Remittance Advice Codes

The following codes are updated on a monthly basis. Some codes may have changed since last update.

Last Update: 12/5/07
Code Description

C?7 THIS LINE WAS PAID IN ACCORDANCE WITH THE HOME HEALTH PROSPECTIVE PAYMENT SYSTEM.
C#A SURCHARGE PAID THROUGH POOL ELECTION. REMOVE GROUP FROM SURCHARGE BILLING.
COLLECT APPLICABLE DEDUCTIBLE AND COINSURANCE AT POINT OF SALE. ASSIGNMENT OF
C#B BENEFITS NOT ALLOWED.
NO BENEFITS IN FORCE AT THIS TIME. MEMBER ADVISED TO CONTACT THE REWARDS
C#C ADMINISTRATION CENTER.
C#D NO BENEFITS IN FORCE AT THIS TIME. PLEASE CALL 1-800-421-3973 WITH ANY QUESTIONS.
OUR RECORDS INDICATE THAT THIS PATIENT IS NOT ELIGIBLE FOR BENEFITS FOR SERVICES
C#E RENDERED ON THESE DATES.
C#F VERIFICATION OF THE PLACE OF SERVICE FOR THE PROCEDURE CODE (CPT) SUBMITTED.
C#G CHARGES FOR CANCELLED OR MISSED APPOINTMENTS ARE NOT COVERED.
C#H PLEASE SUBMIT A DESCRIPTION OF SERVICE WITH THE CPT/HCPCS CODE THAT WAS USED.
C#I DEPENDENT ELIGIBILITY INFORMATION NEEDED FROM THE PLAN PARTICIPANT.
C#M THE AGGREGATE MAXIMUM INFERTILITY BENEFIT HAS BEEN MET.
THE PLAN WILL CONSIDER ONLY THOSE CHARGES THAT THE PATIENT IS LEGALLY OBLIGATED TO
C#N PAY.
PATIENT INFORMATION SUBMITTED IS NOT LISTED UNDER SUBMITTED MEMBER ID AS HAVING
C#P COVERAGE. PLEASE RESUBMIT WITH CORRECT MEMBER ID INFORMATION.
C#Q THE TIMES THIS SERVICE CAN BE ALLOWED HAS BEEN EXCEEDED.
C#R NO DESCRIPTION AVAILABLE
C#T THIS AMOUNT HAS BEEN PAID TO THE MEMBER, IT IS MEMBER'S RESPONSIBILITY.
C#U INFORMATION REQUESTED FROM THE MEMBER HAS NOT BEEN RECEIVED.
WE CANNOT CONSIDER PAYMENT BECAUSE THIS PROCEDURE DOES NOT REQUIRE AN
C#X ASSISTANT SURGEON.
C#Y THE $200 CALENDAR YEAR LIMIT FOR OUT OF AREA VISION COVERAGE HAS BEEN MET.
C#Z NO DESCRIPTION AVAILABLE
C#1 THIS SERVICE IS NOT COVERED FOR THIS DIAGNOSIS.
THIS PROVIDER IS NO LONGER IN OUR NETWORK. FUTURE CLAIMS WILL NOT BE PAID AT THE
C#2 NETWORK RATE.
C#3 60 DAY GRACE PERIOD.
C#4 THIS SERVICE IS NOT COVERED BY YOUR PLAN.
THE PLAN DOES NOT PROVIDE BENEFITS FOR EXPENSES THAT THE PATIENT IS NOT REQUIRED
C#5 TO PAY
C#8 MEDICARE'S PAYMENT WAS ESTIMATED IN ACCORDANCE WITH PLAN PROVISIONS.
THE PRIMARY INSURANCE CARRIER PAID GREATER THAN OR EQUAL TO OUR ALLOWABLE
C#9 BENEFIT AMOUNT. NO PAYMENT IS DUE.
CA! NO DESCRIPTION AVAILABLE
CA$ NO DESCRIPTION AVAILABLE
PROVIDER FAILED TO OBTAIN REQUIRED AUTHORIZATION FOR REQUESTED SERVICES. NO
CA? MEMBER RESPONSIBILITY.
CA# CLAIM HAS BEEN DENIED. REQUESTED INFORMATION WAS NOT RECEIVED.
SERVICE RECEIVED FROM A CONTACT BEHAVIOR HEALTH PROVIDER. CHARGES DISCOUNTED
CA ACCORDING TO THE CONTACT BEHAVIOR HEALTH CONTRACTED RATE.
ADDITIONAL EMERGENCY AND/OR SUPPLEMENTAL ACCIDENT BENEFITS WERE APPLIED TO THIS
CAB CLAIM.
THIS CLAIM HAS BEEN FORWARDED TO PSYCH CARE, OUR DESIGNATED CARRIER. TO EXPEDITE
FUTURE CLAIM CONSIDERATIONS PLEASE SEND DIRECTLY TO: PSYCH CARE 10200 SUNSET DRIVE,
CA0 MIAMI, FL 33173.
Humana Remittance Advice Codes

The following codes are updated on a monthly basis. Some codes may have changed since last update.

Last Update: 12/5/07
Code Description
(/A) TOTAL CHARGES REFLECT THE AMOUNT APPROVED BY THE PRIMARY INSURANCE CARRIER.
CA01 MEMBER NOT RESPONSIBLE FOR WRITE-OFF AMOUNT.
CA02 (/2) COINSURANCE AMOUNT.
CA03 (/4) THIS APPEARS TO BE A DUPLICATE OF A CHARGE PREVIOUSLY CONSIDERED.
CA04 (/5) THIS APPEARS TO BE A DUPLICATE OF A CHARGE PREVIOUSLY CONSIDERED.

CA05 (/6) CALLCARE WAS NOT CONTACTED. PAYMENT REPRESENTS 50% OF THE ALLOWABLE AMOUNT.
CA06 (E/) AMOUNT OVER THE ACCEPTED FEE SCHEDULE
(G/) PER TEXAS PROMPT PAY LEGISLATION, THIS CLAIM IS BEING PAID AT 50 PERCENT OF BILLED
CA07 CHARGES MINUS ANY MEMBER'S RESPONSIBILITY.
(H/) PER TEXAS LEGISLATION, THIS CLAIM IS BEING PAID AT100 PERCENT OF CONTRACTED
AMOUNT AND WILL BE AUDITED. AT THE END OF AUDIT PERIOD, YOU AND/OR YOUR PROVIDER
CA08 WILL RECEIVE NOTIFICATION OF THE RESULTS.
CA09 (I/) THIS AMOUNT EXCEEDS THE ALLOWABLE CHARGE.
CA1 EXCEEDS CUSTOMARY DURATION OF SERVICES FOR CONDITION

CA10 (N/) PENALTY AMOUNT PAID TO PROVIDER AS REQUIRED BY TEXAS PROMPT PAY LEGISLATION.
(1/) SERVICES WERE RENDERED BY A NON-NETWORK PROVIDER. BENEFITS REDUCED TO 50% OF
CA12 THE ALLOWABLE.
CA13 (4/) THIS AMOUNT WAS PAID BY YOUR PRIMARY INSURANCE CARRIER.
(*C) THE MENTAL HEALTH AND CHEMICAL DEPENDENCY PROGRAM NON-NETWORK COVERAGE
CA14 ONLY APPLIES TO LICENSED PH.D., M.D., E.D.D., AND PYS.D. PROVIDERS
CA15 (*D) MEMBER ENROLLED IN HMO. SERVICES NOT COVERED BY THE MEDICAL PLAN.
CA16 (*E) RETIREES ARE NOT COVERED BY THIS PLAN.
CA17 (*F) OVER AGE MEMBER NOT COVERED BY THE PLAN.
CA18 (*J) COORDINATE WITH ANY HMO.
CA19 (*K) TERMINATION DUE TO DEATH
CA2 EXCEEDS CUSTOMARY NUMBER OF SERVICES FOR CONDITION
(*L) THE SERVICES RENDERED FOR THIS PROCEDURE ARE NOT MEDICAL INDICATED FOR THIS
CA20 PATIENT.
(*M) SERVICE IS NOT DOCUMENTED IN THE RECORDS RECEIVED,THEREFORE, NO BENEFIT IS
CA21 PAYABLE.
CA22 (*N) THIS BENEFIT APPLIES ONLY TO THE MEMBER, THEREFORE, NO BENEFIT PAYABLE.
CA23 (*O) THIS BENEFIT APPLIES TO A CHILD, THEREFORE, NO BENEFIT PAYABLE.
CA24 (*Q) BREAST PUMPS REQUIRE CALLCARE APPROVAL FOR COVERAGE.
CA25 (*V) PLEASE SUBMIT THE APPROPRIATE CPT4 CODES FOR SERVICES.
(*X) WE HAVE ESTIMATED THE PRIMARY CARRIER'S PAYMENT. IF THEIR PAYMENT IS LESS THAN
CA26 OUR ESTIMATE, PLEASE SEND THE WORKSHEET.
CA27 (*Y) COMFORT ITEMS ARE NOT COVERED UNDER THE PLAN.
CA28 (*Z) DIET/NUTRITIONAL COUNSELING IS NOT A COVERED EXPENSE.
(/B) RESUBMIT TO: MOTOROLA REWARDS ADMINISTRATION CENTER P.O. BOX 29005 PHOENIX, AZ
CA30 85038-9005 OR THROUGH WEBMD PAYER CODE 36111
(/C) THIS OUTPATIENT SURGERY WAS NOT PRE-CERTIFIED AS REQUIRED THROUGH CALLCARE.
CA31 NO BENEFITS ARE PAYABLE FOR THIS PROCEDURE.
CA32 (/D) OPERATING ROOM CHARGES ARE NOT PAYABLE FOR THIS PLACE OF SERVICE.
CA33 (/E) DENTAL IMPLANT SURGERY REQUIRES CALLCARE APPROVAL FOR COVERAGE.
(/G) BASED ON THE INFORMATION SUBMITTED, THIS SERVICE CANNOT BE COVERED UNDER THE
CA34 PLAN.
Humana Remittance Advice Codes

The following codes are updated on a monthly basis. Some codes may have changed since last update.

Last Update: 12/5/07
Code Description
(/H) TEST/TREATMENT WHICH IS NOT SCIENTIFICALLY PROVEN OR FDA APPROVED IS NOT
CA35 COVERED.
(/I) THE SERVICES RENDERED APPEAR TO BE COSMETIC IN NATURE AND ARE NOT COVERED
CA36 UNDER THE TERMS OF YOUR PLAN.
(/J) SERVICES WERE RENDERED BY A NON-NETWORK PROVIDER. BENEFITS REDUCED TO 50% OF
CA37 THE ALLOWABLE.

CA38 (/K) THE MAXIMUM ALLOWABLE FOR THE RENTAL OR PURCHASE OF EQUIPMENT HAS BEEN MET.
CA39 (/L) THIS PROCEDURE IS NOT COVERED UNDER THE PLAN.
(/M) DENTAL IMPLANT AND ASSOCIATED PROCEDURES NOT COVERED IN THE ABSENCE OF A
CA40 MEDICAL CONDITION.
(/N) THE PRIMARY INSURANCE CARRIER PAID THESE SERVICES IN FULL. NO PAYMENT DUE FROM
CA41 THE MOTOROLA PLAN.
(/O) THE PRIMARY INSURANCE CARRIER PAID GREATER THAN OR EQUAL TO OUR ALLOWABLE
CA42 BENIFIT AMOUNT. NO PAYMENT IS DUE.
(/Q) ALLOWED AMOUNT REPRESENTS THE AVERAGE WHOLESALE PRICE FOR SPECIFIC DRUG
CA43 SUBMITTED.
CA44 (/R) THIS BENEFIT DETERMINATION IS PER CONSULTANT REVIEW.

CA45 (/S) FACILITY FEES BILLED FROM NETWORK PHYSICIANS ARE NOT REIMBURSABLE SEPARATELY.
CA46 (/T) SERVICE DATES ARE PRIOR TO THE MEMBER'S BIRTHDATE.
CA47 (/U) THE SERVICE DATES ARE PRIOR TO THE PATIENT'S BIRTHDATE.
CA48 (/V) SPOUSE NO LONER ELIGIBLE FOR BENEFITS DUE TO DIVORCE.
(/W) WHEN PERFORMED AT THE SAME TIME AS A PRIMARY PROCEDURE, SECONDARY
CA49 PROCEDURES ARE NOT COVERED UNDER YOUR PLAN.
CA50 (/X) THIS PROCEDURE IS ONLY COVERED WHEN PERFORMED ON AN OUT-PATIENT BASIS.
(/Y) NO BENEFITS ARE PAYABLE FOR THE PROVIDER WRITE-OFF AMOUNT. YOU ARE NOT
CA51 RESPONSIBLE FOR THIS AMOUNT.
(/Z) THIS BILL WAS PROCESSED AS TWO SEPARATE CLAIMS DUE TO A CONTRACTUAL NETWORK
CA52 AGREEMENT WITH THIS HOSPITAL.
(/1) THE SERVICES RENDERED FOR THIS PROCEDURE ARE NOT CONSIDERED MEDICALLY
CA53 APPROPRIATE FOR THIS TYPE OF CONDITION.
CA54 (/3) OVER AGE DEPENDENT NOT COVERED BY THE PLAN.
CA55 (C*) THE AGGREGATE MAXIMUM TMJ BENEFIT HAS BEEN MET

CA56 (D*) CALLCARE WAS NOT CONTACTED. PAYMENT REPRESENTS 50% OF THE ALLOWABLE AMOUNT.
(E*) THE YEARLY PSYCHOTHERAPY 20 VISIT MAXIMUM HAS BEEN MET. A TREATMENT PLAN IS
CA57 REQUIRED FOR CONSIDERATION OF FUTURE VISITS.
(F*) AGGREGATE MAXIMUM NON-NETWORK MENTAL HEALTH/CHEMICAL DEPENDENCY PROGRAM
CA58 BENEFITS HAVE BEEN MET.
CA59 (F/) THIS IS YOUR PRIMARY CARRIER COPAY/COINSURANCE.
CA60 (H*) YEARLY MAXIMUM ACUPUNCTURE BENEFIT HAS BEEN MET.
(J/) THIS CLAIM HAS BEEN FORWARDED TO PREMIER EYECARE OF FLORIDA. TO EXPEDITE
FUTURE CLAIM CONSIDERATIONS PLEASE SEND DIRECTLY TO: PREMIER EYECARE OF FLORIDA,
CA61 120 NORTH SWINTON AVENUE, DEL RAY BEACH, FL. 33444.
(L*) SERVICES WERE RENDERED BY A NON-NETWORK PROVIDER AND NOT PRE-CERTIFIED
CA62 THEREFORE, BENEFITS WERE REDUCED 50%.
CA63 (M*) THE AGGREGATE MAXIMUM INFERTILITY BENEFIT HAS BEEN MET.
Humana Remittance Advice Codes

The following codes are updated on a monthly basis. Some codes may have changed since last update.

Last Update: 12/5/07
Code Description
(N*) THE AGGREGATE MAXIMUM BENEFIT HAS BEEN MET FOR THE PURCHASE OR RENTAL OF A
CA64 BREAST PUMP.
CA65 (O*) YOUR PLAN LIMITS COVERAGE OF CHARGES FOR THIS TYPEOF SERVICE.
CA66 (P*) THE YEARLY MAXIMUM BENEFIT FOR LENSES/CONTACTS HAS BEEN MET.
CA67 (P/) SCRATCH COATING AND/OR TINTING IS NOT A COVERABLE BENEFIT.
CA68 (Q*) MAXIMUM BENEFIT FOR THIS TYPE OF SERVICE IS $200.00 (U.S.) PER PATIENT.
CA69 (Q/) MAXIMUM ORTHOTIC BENEFIT HAS BEEN MET.
CA7 THIS AMOUNT EXCEEDS THE GLOBAL CLAIMS SERVICES PAYMENT AGREEMENT.
CA70 (R*) THE YEARLY MAXIMUM NON-NETWORK PHYSICAL THERAPY BENEFIT HAS BEEN MET.
CA71 (R/) COSMETIC SERVICES/SUPPLIES ARE NOT A COVERED BENEFIT UNDER THE PLAN.
CA72 (S*) THE YEARLY MAXIMUM NON-NETWORK OCCUPATIONAL BENEFIT HAS BEEN MET.
(S/) REPAIR AND MAINTENANCE OF AN APPLIANCE, ORTHOTIC OR MEDICAL EQUIPMENT IS NOT
CA73 COVERED BY THE PLAN.
CA74 (T*) THE YEARLY MAXIMUM NON-NETWORK SPEECH THERAPY BENEFIT HAS BEEN MET.
CA75 (U*) AMOUNT OVER ACCEPTED FEE SCHEDULE.
(U/) YEARLY MAXIMUM NON-NETWORK RESIDENTIAL, DAY/EVENING, OR INTENSIVE OUTPATIENT
CA76 TREATMENT HAS BEEN MET.
(V*) A PORTION OF YOUR BENEFITS ARE NOT COVERED DUE TO A PRE-EXISTING CONDITON.
CA77 PLEASE REFER TO THE LETTER UNDER SEPARATE COVER.
CA78 (V/) YOUR YEARLY MAXIMUM NON-NETWORK INPATIENT HOSPITAL BENEFIT HAS BEEN MET.

(W*) THIS AMOUNT HAS BEEN COORDINATED WITH THE WORKER'S COMPENSATION BENEFIT YOU
CA79 HAVE RECEIVED THROUGH YOUR EMPLOYER. REFER TO YOUR BENEFIT PLAN DOCUMENT.
THIS DISCOUNT WAS OBTAINED BY HUMANA THROUGH A ONE TIME NEGOTIATION BETWEEN
YOUR ORGANIZATION AND CONCENTRA. THIS DISCOUNT AMOUNT IS NOT THE RESPONSIBILITY
CA8 OF THE MEMBER OR THE INSURER.
CA80 (W/) THE 90 DAY COURSE OF TREATMENT LIMIT FOR THIS BENEFIT HAS BEEN MET.
CA81 (X*) PAYMENT IS 50% OF ELIGIBLE CHARGES
CA82 (Y*) HOME CARE DEVICE NOT COVERED
CA83 (Y/) THIS SERVICE REQUIRES CALLCARE PRE-APPROVAL FOR COVERAGE.
CA84 (0*) NON-EMERGENT SERVICES IN THE EMERGENCY ROOM ARE NOT A COVERED BENEFIT.
CA85 (6*) THE YEARLY MAXIMUM PSYCHIATRIC VISITS HAS BEEN MET.
PLEASE SUBMIT CLAIM TO CORPHEALTH AT 1300 SUMMIT AVENUE SUITE 811, FORT WORTH, TX
CB? 76102.
CB# OVER THE COUNTER DRUGS AND SUPPLIES ARE NOT COVERED UNDER THIS PLAN.
THE ER MAXIMUM BENEFIT HAS BEEN MET, THEREFORE THIS SERVICE IS NOT COVERED. PLEASE
CB SEE YOUR BENEFITPLAN DOCUMENT.
CB1 CODAY INFORMATION NOT SUBMITTED
CB2 THIS PROVIDER NOT RECOGNIZED UNDER CAPITATED BENEFIT RIDER
CB4 CLAIM FORWARDED TO LOCAL MARKET OFFICE FOR ADDITIONAL REVIEW

THIS CLAIM HAS BEEN FORWARDED TO MAGELLAN BEHAVIORAL HEALTH, OUR DESIGNATED
MENTAL HEALTH CARRIER. TO EXPEDITE FUTURE CLAIM CONSIDERATIONS, PLEASE SEND
CB5 DIRECTLY TO: ASC-MAGELLAN BEHAVIORAL HEALTH, PO BOX 13000, TALLAHASSEE, FL. 32317.
THIS IS A DISCOUNT OBTAINED BY HUMANA THROUGH THE CHOICECARE NETWORK. THIS
CB7 DISCOUNT AMOUNT IS NOT THE RESPONSIBILITY OF THE MEMBER OR INSURER.
CC( MASSAGE THERAPY IS NOT A COVERED BENEFIT.
THIS SERVICE/PROCEDURE IS CONSIDERED TO BE MUTUALLY EXCLUSIVE TO ANOTHER
CC& SERVICE(S). WE RELIED ON INTERNAL CRITERIA TO MAKE THIS DETERMINATION.
Humana Remittance Advice Codes

The following codes are updated on a monthly basis. Some codes may have changed since last update.

Last Update: 12/5/07
Code Description
CC* THE AGGREGATE MAXIMUM TMJ BENEFIT HAS BEEN MET
CC% CHARGE IS DENIED AS PART OF A PREVIOUS PAID CLAIM ON SAME DAY.
CC? CLAIM ADJUSTED MEMBER LIABILITY REDUCED.
CC# VITAMINS/FOOD SUPPLEMENTS/HERBAL MEDICATIONS ARE NOT A COVERED EXPENSE.
CC0 OFFICE VISITS ARE NOT COVERED.
CC4 CLAIM SHOULD BE FILED WITH THE PLAN'S MENTAL HEALTH PROVIDER
CC6 DONOR CHARGES DENIED BY TRANSPLANT MANAGEMENT - NONCOVERED BENEFIT.
CC7 ROUTINE CARE PROVIDED OUT-OF-SERVICE AREA IS NOT COVERED.
CC8 THE SERVICE BILLED SHOULD BE BILLED DIRECTLY TO CMS FOR CONSIDERATION.
THIS INJURY/ILLNESS IS DETERMINED TO BE WORK RELATED. SUBMIT THESE CHARGES TO THE
WORKERS COMPENSATION INSURANCE CARRIER FOR CONSIDERATION. REFER TO THE BENEFIT
CC9 PLAN DOCUMENT.
THE AMOUNT EXCEEDS THE PAYMENT AGREEMENT FOR THE PRIME HEALTH NETWORK. ANY
QUESTIONS REGARDING NETWORK SAVINGS, CONTACT COALITION AMERICA, INC. AT 404-459-
CD( 7201.
THIS SERVICE/PROCEDURE IS CONSIDERED AN INTEGRAL PART OF THE PRIMARY PROCEDURE
AND SHOULD NOT BE BILLED SEPARATELY. WE RELIED ON INTERNAL CRITERIA TO MAKE THIS
CD& DETERMINATION.

CD! CLAIM NOT PROCESSED BY HUMANA, PLEASE RESUBMIT TO BRADMAN/UNIPSYCH COMPANY.
THIS AMOUNT IS OVER YOUR INPATIENT DAILY MAXIMUM, PLEASE REFER TO YOUR BENEFIT PLAN
CD$ DOCUMENT.

CD* CALLCARE WAS NOT CONTACTED. PAYMENT REPRESENTS 50% OF THE ALLOWABLE AMOUNT.
THESE SERVICES NEEDED TO BE AUTHORIZED BY OASIS IN ORDER TO BE CONSIDERED AS A
CD% COVERED BENEFIT UNDERYOUR MEDICAL PLAN.
CHIROPRACTORS, MASSAGE THERAPISTS, ACUPUNCTURISTS, HOMEOPATHS AND NATUROPATHS
CD# ARE NOT COVERED PROVIDERS UNDER YOUR PLAN.
THIS AMOUNT EXCEEDS THE PAYMENT AGREEMENT FOR IHPFPN. ANY QUESTIONS REGARDING
CD NETWORK SAVINGS, CONTACT COALITION AMERICA, INC. AT 404-459-7201.
CDC CHARGES REDUCED BY CONTRACTED ARRANGEMENT
CD1 EYE GLASSES AND CONTACT LENSES ARE NOT COVERED.
THIS CLAIM WAS SUBMITTED TO HUMANA IN ERROR. WE ARE NOT THE DENTAL CARRIER. WE
HAVE FORWARDED THISCLAIM TO YOUR DENTAL CARRIER. PLEASE SUBMIT FUTURE CLAIMS
CD2 DIRECTLY TO THE DENTAL CARRIER.
THIS AMOUNT EXCEEDS THE PRIMARY CARRIER'S APPROVED AMOUNT AND IS NOT ELIGIBLE FOR
CD3 BENEFIT CONSIDERATION.
THE NEWBORNS PER ADMISSION DEDUCTIBLE OR MAJOR MEDICAL DEDUCTIBLE HAS BEEN
CD4 DEDUCTED FROM MOTHER'S PAYMENT.
CD5 ROUTINE SERVICES ARE NOT COVERED BY THIS POLICY.
BENEFITS REDUCED AS SERVICES WERE EITHER FROM NON-NETWORK PROVIDER, OR REFERRAL
CD6 WAS REQUIRED BUT NOTOBTAINED FROM THE PRIMARY CARE PHYSICIAN.
AMOUNT REPRESENTS UNSUPPORTED HOSPITAL CHARGES AFTER COMPLETION OF HOSPITAL
CD9 BILL AUDIT. THE PATIENT IS NOT RESPONSIBLE FOR THIS AMOUNT.

CE( VACCINE IS PAYABLE BY MEDICARE PART D. PLEASE REQUEST PAYMENT FROM THE MEMBER.
SERVICE(S) AND/OR SUPPLIES BILLED SEPARATELY ARE NOT REIMBURSABLE BY THE PLAN. WE
CE& RELIED ON INTERNAL CRITERIA TO MAKE THIS DETERMINATION.
Humana Remittance Advice Codes

The following codes are updated on a monthly basis. Some codes may have changed since last update.

Last Update: 12/5/07
Code Description
THE YEARLY PSYCHOTHERAPY 20 VISIT MAXIMUM HAS BEEN MET. A TREATMENT PLAN IS
CE* REQUIRED FOR CONSIDERATION OF FUTURE VISITS.
CE/ AMOUNT OVER THE ACCEPTED FEE SCHEDULE
CE? CHARGES HAVE BEEN REDUCED.

CE# PLEASE SUBMIT CLAIM TO EMO/CHA/LCI/LPN, P.O.BOX 957495, HOFFMANN ESTATES, IL. 60195-7495
CE THIS AMOUNT EXCEEDS THE CONTACT PAYMENT AGREEMENT.
CLAIM IS DENIED DUE TO NO AUTHORIZATION OR THE SERVICES PROVIDED DO NOT MATCH THE
CE1 AUTHORIZATION ON FILE BY THE MENTAL HEALTH PROVIDER.
THIS BENEFIT HAS BEEN REDUCED BY 33 1/3% DUE TO THE ABSENCE OF A SECOND SURGICAL
CE2 OPINION AS REQUIREDBY ASHLAND UNION.
CE3 THIS DENTAL CLAIM WAS FORWARDED TO ACMG
THIS MEMBER IS NO LONGER A HUMANA MEDICAID MEMBER. NEED TO CONTACT EDS FOR THE
CE4 CURRRENT HMO CARRIER FOR THIS MEMBER.
THIS IS AN INTEREST PAYMENT MADE TO THE PROVIDER OF SERVICE, ACCORDING TO
CE5 GOVERNMENT REGULATIONS.
THIS CLAIM WAS SUBMITTED TO HUMANA IN ERROR. WE ARE NOT THE MENTAL HEALTH
CARRIER. PLEASE SUBMIT THIS CLAIM TO: VALUE OPTIONS, INC. ATTN: CLAIMS DEPARTMENT, 240
CE7 CORPORATE BLVD., NORFOLK, VA 23502.
CE8 SERVICE DATES NOT INCURRED WITHIN SUBMISSION PERIOD.
EXPENSES THAT THE SUBSCRIBER IS NOT REQUIRED TO PAY ARE NOT COVERED. THESE
SERVICES ARE COVERED BY TELECTRONICS. CLAIM SHOULD BE FORWARDED TO TELETRONICS
CE9 WARRANTY DEPARTMENT 7400 S. TUSCON WAY ENGLEWOOD, CO 80012
THIS PROVIDER IS A MEMBER OF THE QUALCARE PPO. SERVICES ARE PAID IN ACCORDANCE
CF( WITH QUALCARE PPO CONTRACT.
SERVICE/PROCEDURE IS MISSING THE REQUIRED CORRESPONDING HCPC CODE. WE RELIED ON
CF& INTERNAL CRITERIA TO MAKE THIS DETERMINATION.

CF! CLAIM NOT PROCESSED BY HUMANA, PLEASE RESUBMIT TO BRADMAN UNIPSYCH COMPANY.
AGGREGATE MAXIMUM NON-NETWORK MENTAL HEALTH/CHEMICAL DEPENDENCY PROGRAM
CF* BENEFITS HAVE BEEN MET.
CF/ THIS IS YOUR PRIMARY CARRIER COPAY/COINSURANCE.
THIS CODE IS APPLICABLE TO A MEDICARE DEMONSTRATION ONLY AND IS NOT REIMBURSABLE
CF? BY THE HEALTH PLAN.
CF THESE SERVICES WERE DISCOUNTED ACCORDING TO BEECH STREET AP NETWORK.
THIS AMOUNT EXCEEDS THE PAYMENT AGREEMENT FOR PROVIDER SELECT/FLORA HEALTH
NTWK. ANY QUESTIONS REGARDING NETWORK SAVINGS, CONTACT COALITION AMERICA, INC. AT
CFK 404-459-7201.
SUBSCRIBERS CONTRACT DOES NOT COVER THIS FOOT OR ANKLE SERVICE. COVERED FOOT
AND ANKLE BENEFITS AREFOR AMPUTATIONS AND CARE OF ACCIDENTAL INJURIES. REFER
CLAIMS TO THE NATIONAL FOOT CARE PROGRAM; P.O. BOX 760547; LATHRUP VILLAGE,
CFQ MICHIGAN 48076 OR CALL 1-800-922-1695.
THIS AMOUNT EXCEEDS THE PAYMENT AGREEMENT FOR PROVIDER SELECT/UNIVERSAL HEALTH
NTWK. ANY QUESTIONS REGARDING NETWORK SAVINGS, CONTACT COALITION AMERICA, INC. AT
CFS 404-459-7201.
THIS AMOUNT EXCEEDS THE PAYMENT AGREEMENT FOR PROVIDER SELECT/HEALTH CARE
PARTNERS. ANY QUESTIONS REGARDING NETWORK SAVINGS, CONTACT COALITION AMERICA,
CFV INC. AT 404-459-7201.
Humana Remittance Advice Codes

The following codes are updated on a monthly basis. Some codes may have changed since last update.

Last Update: 12/5/07
Code Description
THIS AMOUNT EXCEEDS THE PAYMENT AGREEMENT FOR INTEGRATED HEALTH PLAN. ANY
QUESTIONS REGARDING NETWORK SAVINGS, CONTACT COALITION AMERICA, INC. AT 404-459-
CFW 7201.
CF0 RESUBMIT CLAIM THROUGH THE SPECIALTY NETWORK.
CF1 SUBMIT CORRESPONDING DRG/CDM CODE FOR THIS DATE OF SERVICE.
NOTICE-EFFECTIVE FOR SERVICES RENDERED ON 03-01-01 AND AFTER, ALL MEDICAID CLAIMS
SHOULD BE SENT TO SUPERIOR HEALTH PLANS AT P.O. BOX 3003, FARMINGTON, MISSOURI 63640.
PLEASE NOTE THAT THIS CLAIM HASBEEN FORWARDED TO SUPERIOR HEALTH PLAN FOR
PROCESSING. ANY QUESTIONS CAN BE DIRECTED TO SUPERIOR HEALTH PLAN AT 1-800-216-
CF2 8512.
CF3 CLAIM FORWARDED TO THE MEDICAL CARE GROUP FOR BULK PAYMENT

THIS CLAIM HAS BEEN FORWARDED TO INNOVATIVE RESOURCE GROUP (IRG), OUR DESIGNATED
MENTAL HEALTH PROVIDER. TO EXPEDITE FUTURE CLAIM CONSIDERATIONS PLEASE SEND
CF4 DIRECTLY TO : INNOVATIVE RESOURCE GROUP (IRG), P.O.BOX 916, BROOKFIELD, WI 53008-0916.
THESE CHARGES SHOULD BE SUBMITTED TO: AMERICAN PSYCH. MANAGMENT P.O. BOX 1459
CF5 MERRIFIELD, VA 22116
THIS AMOUNT EXCEEDS THE PAYMENT AGREEMENT FOR MEDICAL RESOURCE/GALAXY HEALTH
NTWK. ANY QUESTIONS REGARDING NETWORK SAVINGS, CONTACT COALITION AMERICA, INC. AT
CF9 404-459-7201.
THIS PROVIDER IS A MEMBER OF THE GHI NETWORK ACCESS PROGRAM. SERVICES ARE PAID IN
CG( ACCORDANCE WITH THE GHI NETWORK ACCESS PROGRAM.
CG$ PAYMENT IS CALCULATED BASED ON YOUR CONTRACT WITH VIRGINIA HEALTH NETWORK.
PER TEXAS PROMPT PAY LEGISLATION, THIS CLAIM IS BEING PAID AT 50 PERCENT OF BILLED
CG/ CHARGES MINUS ANY MEMBER'S RESPONSIBILITY.
CG% PAID IN ACCORDANCE WITH YOUR HNM/RAN PARTICIPATING PROVIDER AGREEMENT.
PROVIDER DOES NOT TAKE ASSIGNMENT FROM MEDICARE. PLAN ALLOWS ADDITIONAL PAYMENT
CG? BEYOND MEDICARE ALLO WABLE.
THIS CLAIM HAS BEEN FORWARDED TO WPPN FOR REPRICING. TO EXPEDITE FUTURE CLAIM
CGR CONSIDERATIONS, PLEASE SEND DIRECTLY TO: WPPN, PO BOX 6090, DE PERE, WI 54115.
CGT PLEASE SUBMIT AN ITEMIZED BILL.
CGU PLEASE SUBMIT THE NAME OF THE DRUG USED.
CGV PLEASE SUBMIT A COPY OF THE ADMISSION HISTORY AND/OR DISCHARGE SUMMARY.
THIS CLAIM WAS SUBMITTED WITH INCOMPLETE INFORMATION REGARDING THE PLACE OF
CGW TREATMENT. PLEASE SUBMIT A CORRECTED CLAIM FOR PAYMENT CONSIDERATION.
CGX PLEASE SUBMIT THE NAME AND ADDRESS OF THE ATTENDING PHYSICIAN.
CGY PLEASE SUBMIT A COMPLETED CLAIM FORM.
CGZ PLEASE SUBMIT THE ORIGINAL DRUG RECEIPT OR ITEMIZED PHARMACY STATEMENT.

CHARGES FOR THIS SERVICE ARE CONSIDERED PART OF THE WEEKLY NEGOTIATED PAYMENT
WITH THE PROVIDER. OUR RECORDS INDICATE THAT PAYMENT WAS PREVIOUSLY ISSUED UNDER
CG0 ANOTHER DATE OF SERVICE OR WITHIN THE SAME WEEK. NO MEMBER RESPONSIBILITY.
CG1 THIS AMOUNT HAS BEEN DISCOUNTED PER YOUR AGREEMENT WITH KENTUCKY KARE.
THESE CHARGES SHOULD BE SUBMITTED TO: PREFERRED HEALTHCARE LTD. 4709 GOLF ROAD,
CG2 STE. 1100 SKOKIE IL 60076
THESE CHARGES SHOULD BE SUBMITTED TO: PSYCARE 8555 W FOREST HOME AVE, STE 201
CG3 GREENFIELD, WI 53220
THESE CHARGES SHOULD BE SUBMITTED TO: CNR HEALTH INC. 2400 S. 102 #100 MILWAUKEE, WI
CG4 53227
Humana Remittance Advice Codes

The following codes are updated on a monthly basis. Some codes may have changed since last update.

Last Update: 12/5/07
Code Description
THESE SERVICES SHOULD BE SUBMITTED TO: MEDCO BEHAVIORAL CARE/ATTENTION: MISSOURI
CG6 MEDICAID CLAIMS. P.O. BOX 1007 MARYLAND HEIGHTS, MO 63043
CG8 THIS SERVICE IS NOT COVERED. PLEASE SUBMIT TO THE STATE FOR CONSIDERATION.
THE OBSERVATION SERVICE BILLED IS NOT ALLOWED WITH THE TYPE OF BILL SUBMITTED. WE
CH& USED MEDICARE GUIDELINES TO MAKE THIS DETERMINATION
THIS PROVIDER IS A MEMBER OF THE CHN SOLUTIONS/NORTHEAST HEALTH DIRECT NETWORK.
SERVICES ARE DISCOUNTED ACCORDING TO THE CHN SOLUTIONS/NORTHEAST HEALTH DIRECT
CH$ NEGOTIATED RATES.
CH* YEARLY MAXIMUM ACUPUNCTURE BENEFIT HAS BEEN MET.
PER TEXAS LEGISLATION, THIS CLAIM IS BEING PAID AT100 PERCENT OF CONTRACTED AMOUNT
AND WILL BE AUDITED. AT THE END OF AUDIT PERIOD, YOU AND/OR YOUR PROVIDER WILL
CH/ RECEIVE NOTIFICATION OF THE RESULTS.
CH% PAID IN ACCORDANCE WITH YOUR RAN EPO PARTICIPATING PROVIDER AGREEMENT.
THIS AMOUNT EXCEEDS THE PYMT AGREEMENT FOR HPO/CHP/PHA. ANY QUESTIONS REGARDING
CH? NETWORK SAVINGS, CONTACT COALITION AMERICA INC. AT 404-459-7201.
CH# PAID ACCORDING TO MULTIPLAN NETWORK.
CH NEED RUG SCORE TO ADJUDICATE CLAIM.
CHQ THE VISION CLAIM HAS BEEN FORWARDED TO EYE MED VISION CARE.
CHS PLEASE SUBMIT DETAILS ABOUT THE ACCIDENT.

CHT PLEASE SUBMIT A STATEMENT FROM THE ATTENDING PHYSICIAN FOR THE MEDICAL NECESSITY.
CH1 PAYMENT FOR THIS SERVICE IS INCLUDED IN THE HOSPITAL REIMBURSEMENT.
THIS AMOUNT EXCEEDS THE PAYMENT AGREEMENT FOR PROVIDER SELECT/MANAGED HEALTH
NTWK. ANY QUESTIONS REGARDING NETWORK SAVINGS, CONTACT COALITION AMERICA, INC. AT
CH2 404-459-7201.
CH3 THIS AMOUNT WAS PAID BY YOUR PRIMARY INSURANCE CARRIER.
CH5 THIS IS AN ADJUSTMENT TO A PREVIOUSLY PROCESSED CLAIM.
CH6 PRE-OPERATIVE VISIT IS INCLUDED IN THE GLOBAL SURGICAL PROCEDURE.

CH7 CHARGE IS CONSIDERED PART OF ANOTHER SERVICE PREVIOUSLY PAID FOR THE SAME DATE.

CH8 CHARGE IS CONSIDERED PART OF ANOTHER SERVICE PREVIOUSLY PAID FOR THE SAME DATE.
SERVICE WILL NOT BE REIMBURSED ON THE SAME DATE AS ANOTHER MORE COMPREHENSIVE
CH9 SERVICE.
NO INPATIENT AUTHORIZATION WAS OBTAINED. THE MEMBER CANNOT BE BILLED FOR THIS
CI( AMOUNT.
THIS SERVICE IS NOT COVERED. WE USED MEDICARE GUIDELINES TO MAKE THIS
CI& DETERMINCATION.
CI! NO DESCRIPTION AVAILABLE
THE CODE YOU ARE BILLING IS NOT REFLECTED AS BEING RENDERED ACCORDING TO THE
RECORDS WE REVIEWED. PLEASE REVIEW YOUR RECORDS AND BILLING FOR THE APPROPRIATE
CI) SERVICES BEING RENDERED.
CI/ THIS AMOUNT EXCEEDS THE ALLOWABLE CHARGE.
CI% PAID IN ACCORDANCE WITH YOUR HEALTH EOS CONTRACTUAL AGREEMENT.
THIS AMOUNT EXCEEDS THE PYMT AGREEMENT FOR HPO/PHP. ANY QUESTIONS REGARDING
CI? NETWORK SAVINGS, CONTACT COALITION AMERICA INC. AT 404-459-7201.
CI# CHARGE BILLED IN ERROR. PAID AMOUNT FULLY RECOVERED.
THIS CLAIM WAS SUBMITTED WITH INCOMPLETE DIAGNOSIS INFORMATION. PLEASE SUBMIT A
CIQ CORRECTED CLAIM FORPAYMENT CONSIDERATION.
Humana Remittance Advice Codes

The following codes are updated on a monthly basis. Some codes may have changed since last update.

Last Update: 12/5/07
Code Description
CIR PLEASE SUBMIT AUTHORIZATION NUMBER/MEDICAL RECORDS
CI1 THIS SERVICE IS PART OF THE PRIMARY PROCEDURE PREVIOUSLY CONSIDERED.
CI2 PAYMENT REDUCED DUE TO PREVIOUSLY PAID POST OPERATIVE VISIT.
CI3 PAYMENT REDUCED DUE TO PREVIOUSLY PAID PRE-OPERATIVE VISIT.
CI5 THIS CLAIM HAS BEEN FORWARDED TO WISCONSIN EDUCATION ASSOCIATION (WEA).

CI6 THIS PHARMACY CLAIM HAS BEEN FORWARDED TO PBM+. (PHARMACY BENEFIT MANAGEMENT).
CI9 POST OPERATIVE VISIT IS INCLUDED IN THE GLOBAL SURGICAL PROCEDURE.
CJ( PROVIDER CONTRACTED CLEAN CLAIM PENALTY APPLIED.
UNDER THE OUTPATIENT PROSPECTIVE PAYMENT SYSTEM, MEDICARE DOES NOT RECOGNIZE
THIS CODE AS VALID, THEREFORE IT IS NOT COVERED. WE RELIED ON MEDICARE GUIDELINES TO
CJ& MAKE THIS DETERMINATION.
THIS SERVICE IS NOT DOCUMENTED IN THE RECORDS SUBMITTED FOR REVIEW. REVIEW HAS
CJ! BEEN COMPLETED BY ORTHONET, LLC. MEMBER IS NOT RESPONSIBLE FOR CHARGES.
THIS CLAIM HAS BEEN FORWARDED TO PREMIER EYECARE OF FLORIDA.TO EXPEDITE FUTURE
CLAIM CONSIDERATIONS PLEASE SEND DIRECTLY TO: PREMIER EYECARE OF FLORIDA, 120
CJ/ NORTH SWINTON AVENUE, DEL RAY BEACH, FL. 33444.
CJ% THIS PHARMACEUTICAL NEEDS TO BE PAID FOR BY SWIFT TRANSPORTATION'S RX CARRIER.
THIS AMOUNT EXCEEDS THE PYMT AGREEMENT FOR HPO/PH. ANY QUESTIONS REGARDING
CJ? NETWORK SAVINGS, CONTACT COALITION AMERICA INC. AT 404-459-7201.
THIS CLAIM HAS BEEN FORWARDED TO COLE VISION, OUR DESIGNATED VISION CARRIER. TO
EXPEDITE FUTURE CLAIM CONSIDERATIONS, PLEASE SEND DIRECTLY TO: COLE VISION SERVICES,
CJO P.O.BOX 8500-7425, PHILADELPHIA, PA. 19178-7425.
CJT PLEASE SUBMIT A CORRECTED CLAIM WITH COMPLETE ANESTHESIA INFORMATION.
CJU PLEASE SUBMIT A UB-92 CANNOT ACCEPT HAND WRITTEN BILLS.
CJV PLEASE SUBMIT A CORRESPONDING UB-92 FORM.
CJW PLEASE RESUBMIT THE CLAIM WITH A CURRENT CPT CODE.

CLAIM HAS BEEN CLINICALLY REVIEWED AND THE SUBMITTED PROCEDURE CODE DOES NOT
CJX MATCH THE SERVICE DOCUMENTED. PLEASE RESUBMIT WITH CORRECTED PROCEDURE CODE.
THIS CLAIM WAS SUBMITTED WITH INCOMPLETE SURGICAL PROCEDURE CODE(S). SUBMIT A
CJY CORRECTED CLAIM FOR PAYMENT CONSIDERATION.
CJZ PLEASE SUBMIT THE NAME OF THE HOSPITAL USED TO P ROVIDE THESE SERVICES.

CJ1 SERVICE IS UNEXPECTED WITH THE DIAGNOSIS.PLEASE PROVIDE SUPPORTING DOCUMENTS.
CJ2 POST-OPERATIVE VISIT IS INCLUDED IN THE GLOBAL SURGICAL PROCEDURE.
CJ3 PRE-OPERATIVE VISIT IS INCLUDED IN THE GLOBAL SURGICAL PROCEDURE.
CJ4 NEW PATIENT VISIT CODE WAS REPLACED WITH ESTABLISHED PATIENT VISIT CODE.

CJ5 NEW PATIENT VISIT CODES WAS REPLACED WITH COMPARABLE ESTABLISHED PATIENT CODE.
CJ6 PATIENT VISIT CODE CHANGED TO A MORE APPROPRIATE CODE BASED UPON DIAGNOSIS.

CJ7 PATIENT VISIT CODE WAS CHANGED TO A MORE APPROPRIATE CODE BASED ON DIAGNOSIS.
OVER THE COUNTER DURABLE MEDICAL EQUIPMENT IS NOT A COVERED EXPENSE. PLEASE
CJ8 REFER TO THE BENEFIT PLAN DOCUMENT.

OCCUPATIONAL THERAPY SERVICES CAN ONLY BE BILLED ON A PARTIAL HOSPITALIZATION CLAIM.
CK( CONDITION CODE 41 TO INDICATE PARTIAL HOSPITALIZATION WAS NOT SUBMITTED ON CLAIM.
Humana Remittance Advice Codes

The following codes are updated on a monthly basis. Some codes may have changed since last update.

Last Update: 12/5/07
Code Description
THIS SERVICE HAS BEEN DENIED AS THE CODE SUBMITTED IS INVALID. WE USED MEDICARE
CK& GUIDELINES TO MAKE THIS DETERMINATION.
CHARGES FOR THIS SERVICE ARE CONSIDERED TO BE PART OF ANOTHER SERVICE PROVIDED AT
CK! THE SAME TIME. SERVICES HAVE BEEN REVIEWED BY ORTHONET, LLC.
CK$ NO DESCRIPTION AVAILABLE
THIS PLAN ONLY REIMBURSES 20% OF YOUR MEDICARE PART B DEDUCTIBLE. THIS AMOUNT
CK% REFLECTS THE 80% THAT IS MEMBER'S RESPONSIBILITY.
THIS AMOUNT EXCEEDS THE PYMT AGREEMENT FOR HPO/MHN. ANY QUESTIONS REGARDING
CK? NETWORK SAVINGS, CONTACT COALITION AMERICA INC. AT 404-459-7201.
THIS AMOUNT EXCEEDS THE PAYMENT AGREEMENT FOR COALITION OF AMERICA INC. ANY
QUESTIONS REGARDING NETWORK SAVINGS, CONTACT COALITION AMERICA, INC. AT 404-459-
CK 7201.
CKO PLEASE SUBMIT AN ITEMIZED UB-92.
CKV PLEASE SUBMIT A HCPC CODE AND/OR A DESCRIPTION OF SERVICE.
CKW PLEASE SUBMIT A DESCRIPTION OF THE SERVICE AND/OR A VALID CPT OR REVENUE CODE.
CKY TYPE OF BILL RECEIVED DOES NOT REFLECT SERVICES AUTHORIZED.
THE DOCUMENTATION SUBMITTED FOR THIS CLAIM DOES NOT SUPPPORT THE SERVICE LEVEL
BILLED. THEREFORE, THE ALLOWED AMOUNT HAS BEEN REDUCED. WE RELIED ON INTERNAL
GUIDELINES TO MAKE THIS DETERMINATION. THIS INFORMATION WILL BE SUPPLIED TO YOU
CK0 UPON REQUEST, FREE OF CHARGE.
CK1 APPROVED PRIMARY CARE REFERRAL NOT ON FILE. CLAIM IS REJECTED.
WE CANNOT CONSIDER PAYMENT BECAUSE THESE SERVICES WERE NOT URGENT/EMERGENT,
CK2 NOR WERE THEY APPROVED IN ADVANCE.
THIS AMOUNT EXCEEDS THE PAYMENT AGREEMENT FOR PROVIDER SELECT/CONSUMER HEALTH
NTWK. ANY QUESTIONS REGARDING NETWORK SAVINGS, CONTACT COALITION AMERICA, INC. AT
CK3 404-459-7201.
THIS AMOUNT EXCEEDS THE PAYMENT AGREEMENT FOR PROVIDER SELECT/PREFERRED CARE.
ANY QUESTIONS REGARDING NETWORK SAVINGS, CONTACT COALITION AMERICA, INC. AT 404-459-
CK4 7201.
CK7 NO DESCRIPTION AVAILABLE
THIS AMOUNT EXCEEDS THE PAYMENT AGREEMENT FOR EMDX. ANY QUESTIONS REGARDING
CK9 NETWORK SAVINGS, CONTACT COALITION AMERICA, INC. AT 404-459-7201.

CL( ASSISTANT SURGEON SERVICES PERFORMED BY PHYSICIAN ASSISTANTS ARE NOT COVERED.
ORTHONET - CHARGES ARE DENIED AS MEDICAL RECORDS DO NOT SUPPORT THE NUMBER OF
CL! UNITS.
CLAIM WAS SUBMITTED TO HUMANA IN ERROR. WE ARE NOT THE PHARMACY CARRIER. PLEASE
CL$ SUBMIT THIS CLAIM TO: CAREMARK PO BOX 52116 PHOENIX, AZ 85072-2116
SERVICES WERE RENDERED BY A NON-NETWORK PROVIDER AND NOT PRE-CERTIFIED
CL* THEREFORE, BENEFITS WERE REDUCED 50%.
THIS CLAIM WAS SUBMITTED WITH INCOMPLETE PRICING INFORMATION. SUBMIT THIS CLAIM TO:
CL) GROUP HEALTH INC., PO BOX 2832, NEW YORK, NY. 10116.
PHYSICAL THERAPY AND OCCUPATIONAL THERAPY REQUIRE REVIEW FOR PROGRESS OR
CL% IMPROVEMENT AFTER 12 VISITS PER DIAGNOSIS.
THIS AMOUNT EXCEEDS THE PYMT AGREEMENT FOR HPO/CHP/ARH. ANY QUESTIONS
CL? REGARDING NETWORK SAVINGS, CONTACT COALITION AMERICA INC. AT 404-459-7201.
CL# COPAYMENT AND/OR COINSURANCE.
THIS AMOUNT EXCEEDS THE PAYMENT AGREEMENT FOR NPPN-DIRECT. ANY QUESTIONS
CL REGARDING NETWORK SAVINGS,CONTACT COALITION AMERICA, INC AT 404-459-7201.
Humana Remittance Advice Codes

The following codes are updated on a monthly basis. Some codes may have changed since last update.

Last Update: 12/5/07
Code Description
CLA ADJUSTED PAYMENT MADE BASED ON AN AUDIT BY THE STATE OF MO.
CLB PLEASE SUBMIT FISCAL INTERMEDIARY RATE LETTER.
CLC PLEASE SUBMIT THE VALUE/UNITS OF EPOGEN/EPOTIN USED.
CLD PRIOR HEALTH COVERAGE FROM MEMBER NOT RECEIVED.
CLE PLEASE SUBMIT PRIOR TREATMENT INFORMATION FOR THIS CONDITION.
CLH MEDICARE PAYMENT DEEMED PAYMENT IN FULL NO ADDITIONAL AMOUNT IS DUE.
CLI PLEASE SUBMIT PURCHASE PRICE OF DURABLE MEDICAL EQUIPMENT.
THIS CLAIM HAS BEEN FORWARDED TO FABOH FOR REPRICING. TO EXPEDITE FUTURE CLAIM
CLK CONSIDERATIONS, PLEASE SEND TO: CHP REPRICER, PO BOX 46487,MADISON,WI 53744-6487
PER CORPHEALTH, CLAIM DENIED, DUE TO THERAPY SERVICES BEING INCLUSIVE TO INPATIENT
CLU STAY.
THIS CLAIM HAS BEEN FORWARDED TO SOUTH TEXAS BEHAVIORAL HEALTH, OUR DESIGNATED
MENTAL HEALTH CARRIER. TO EXPEDITE FUTURE CLAIMS CONSIDERATIONS PLEASE SEND
DIRECTLY TO: SOUTH TEXAS BEHAVIORAL HEALTH-CLAIMS, P.O.BOX 100155, SAN ANTONIO, TX.
CLZ 78201.
WE HAVE RECEIVED AND REVIEWED DOCUMENTATION THAT SUPPORTS A PREVIOUSLY
SUBMITTED CLAIM. THE ORIGINAL AND SUBSEQUENT DECISIONS HAVE BEEN UPHELD. WE RELIED
ON INTERNAL GUIDELINES TO MAKE THIS DETERMINATION. THIS INFORMATION WILL BE
CL0 SUPPLIED TO YOU UPON REQUEST, FREE OF CHARGE.
ALL BILLS FOR TRANSPLANT SERVICES RENDERED TO MEMBER SHALL BE SENT DIRECTLY TO:
NATIONAL TRANSPLANT NETWORK, ATTN: TRANSPLANT CLAIMS DEPARTMENT, WATERSIDE
CL1 BUILDING, 12TH FLOOR, 101 EAST MAIN STREET, LOUISVILLE, KY 40201.
CL2 CLAIM HAS BEEN FORWARDED FOR PROCESSING
CL6 SUBMIT INVOICE COST PER DRUG,ITEM,PROSTHETIC DEVICE, IMPLANT AND/OR DME.

THIS CLAIM HAS BEEN FORWARDED TO BETHESDA BEHAVIORAL, THE DESIGNATED MENTAL
HEALTH CARRIER. TO EXPEDITE FUTURE CLAIM CONSIDERATIONS, PLEASE SEND TO: BETHESDA
CL7 BEHAVIORAL, C/O TRISTATE BENEFIT SOLUTIONS, 619 OAK STREET, CINCINNATI, OHIO 45206
PAYMENT REDUCED FOR NON-COMPLIANCE OF ADMISSION'S NOTIFICATION POLICY. PROVIDER
CL8 CAN NOT BALANCE BILL.
CL9 MEDICAL SERVICES ARE NOT COVERED UNDER THE SHORT TERM DISABILITY PLAN.
THE LIFETIME MAXIMUM PAYABLE ROUTINE MEDICAL BENEFIT HAS BEEN EXHAUSTED. NO
CM( ADDITIONAL BENEFITS WILL BE PAID.
THIS SERVICE/PROCEDURE WAS RENDERED PRIOR TO FDA APPROVAL AND THEREFORE NOT
CM& COVERED. WE USED MEDICARE GUIDELINES TO MAKE THIS DETERMINATION.
ASSISTANT SURGEON/SURGICAL ASSISTANT SERVICES NOT WARRANTED FOR THIS PROCEDURE.
CM! REVIEW HAS BEEN COMPLETED BY ORTHONET, LLC.
CM$ THE CLAIM SUBMITTED IS ILLEGIBLE. PLEASE SUBMIT A NEW CLAIM FORM.
CM* THE AGGREGATE MAXIMUM INFERTILITY BENEFIT HAS BEEN MET.
CM) THIS AMOUNT IS THE ESTIMATED REIMBURSEMENT BASED ON MEDICARE PART A OR B.
THIS AMOUNT EXCEEDS THE PYMT AGREEMENT FOR HPO/IHP/FPN. ANY QUESTIONS REGARDING
CM? NETWORK SAVINGS, CONTACT COALITION AMERICA INC. AT 404-459-7201.
CM# DEDUCTIBLE AMOUNT.
CMC PAID PER RATE AGREEMENT WITH MULTIPLAN AND HUMANA
CMD THIS AMOUNT WAS PAID BY MEDICARE
CMF ROUTINE VISION SERVICES ARE ONLY COVERED THROUGH THE VISION SERVICE PLAN.
THE AMOUNT BILLED EXCEEDS THE FEE AGREED UPON WITH THE PROVIDER FOR THIS SERVICE.
THE MEMBER IS RESPONSIBLE FOR ANY COINSURANCE, DEDUCTIBLES AND/OR COPAYMENTS
CMH THAT MAY APPLY.
Humana Remittance Advice Codes

The following codes are updated on a monthly basis. Some codes may have changed since last update.

Last Update: 12/5/07
Code Description
SERVICE BILLED IS INVALID FOR PATIENT'S GENDER OR AGE. PLEASE SUBMIT CLAIM WITH
CMM APPROPRIATE CODING.

THESE SERVICES ARE FOR TREATMENT OF MENTAL HEALTH AND/OR SUBSTANCE ABUSE.
AUTHORIZATION FOR THESE SERVICES AND CLAIMS IS CORDINATED THROUGH THE
CMO DAIMLERCHRYSLER HELP LINE. PLEASE CALL 1-800-346-7651 TO OBTAIN MORE INFORMATION.
DUE TO THE STRUCTURE OF YOUR PLAN, BENEFIT PERCENTAGES VARY WITH THIS SERVICE.
CMP REFER TO THE BENEFIT PLAN DOCUMENT.
CMR MEMBER NOT RESPONSIBLE FOR EXCESS CHARGES.

THE AMOUNT BILLED EXCEEDS THE ALLOWED CHARGES FOR THIS SERVICE. THE MEMBER IS
CMS RESPONSIBLE FOR ANY COINSURANCE, DEDUCTIBLES AND/OR COPAYMENTS THAT MAY APPLY.
THIS AMOUNT IS PART OF THE PROVIDER'S CONTRACTED FEE THAT HAS ALREADY BEEN
CMW CONSIDERED FOR THIS SERVICE. NO ADDITIONAL BENEFITS WILL BE CONSIDERED.
THESE CHARGES ARE INCLUDED IN A CORRESPONDING FACILITY CLAIM THAT HAS ALREADY BEEN
CMX REJECTED. NO ADDITIONAL BENEFITS WILL BE CONSIDERED.

CM0 THE SERVICE LEVEL BILLED WAS REDUCED DUE TO LACK OF SUPPORTING DOCUMENTATION.
CM1 SERVICES NOT ON MEDICAID'S FEE SCHEDULE ARE NOT COVERED.
CM2 TV, PHONE, ETC. ARE NOT COVERED.
CM3 THIS TREATMENT WAS PROVIDED AFTER COVERAGE TERMINATED.
CM4 THIS TREATMENT WAS PROVIDED BEFORE THE PATIENT WAS COVERED.
CM5 THE PRIMARY CARE DOCTOR DID NOT APPROVE THESE SERVICES.
CM6 CHARGES OVER THE SEMI-PRIVATE RATE ARE NOT COVERED
CM8 INCLUDED IN GLOBAL OR PER DIEM RATE
CM9 THE PRIMARY CARE DOCTOR DID NOT APPROVE THESE SERVICES.
CN! SERVICES DENIED. CALENDAR YEAR MAXIMUM HAS BEEN MET FOR FIRST STEPS BENEFIT.
CN$ THIS RX NEEDS TO BE OBTAINED BY CAREMARK.
THE AGGREGATE MAXIMUM BENEFIT HAS BEEN MET FOR THE PURCHASE OR RENTAL OF A
CN* BREAST PUMP.
CN/ PENALTY AMOUNT PAID TO PROVIDER AS REQUIRED BY TEXAS PROMPT PAY LEGISLATION.
CHARGES DENIED BY CONTRACTUAL ARRANGEMENT FOR RADIOLOGY SERVICES. MEMBER NOT
CN% RESPONSIBLE.
ACCORDING TO MEDICARE GUIDELINES, PROVIDER IS NOT RECOGNIZED AS A PHYSICIAN,
CN? THEREFORE, CANNOT BILL DIRECTLY FOR SERVICES RENDERED.
CN# THE AGGREGRATE MAXIMUM BENEFIT HAS BEEN MET FOR PSYCHIATRIC EVALUATION.
CLAIM COVERED UNDER PREPAYMENT AGREEMENT WITH HUMANA OR IPA. THE PATIENT IS NOT
CNE RESPONSIBLE FOR THIS AMOUNT.
THIS CLAIM WAS SUBMITTED WITH INCOMPLETE PRICING INFORMATION. SUBMIT THIS CLAIM TO:
CNM PPOM, PO BOX 2720, FARMINGTON HILLS, MI. 48333.
ALLOWED AMOUNT IS PROVIDER NETWORK ALLOWABLE FEE. YOU ARE NOT REQUIRED TO PAY
CNO THE PROVIDER ADJUSTMENT.
CNP APPLIED TO THE HOSPITAL DEDUCTIBLE
INTEREST PAYMENT ISSUED IN ACCORDANCE WITH STATE STATUTES GOVERNING TIMELY
CNT PAYMENT OF CLAIMS.
BOTH EYEGLASSES AND CONTACTS ARE NOT COVERABLE DURING THE SAME TIME PERIOD.
CNU PLEASE REFER TO YOUR BENEFIT PLAN DOCUMENT.
GROWTH HORMONES ARE NOT A COVERED BENEFIT. PLEASE REFER TO THE BENEFIT PLAN
CNV DOCUMENT.
Humana Remittance Advice Codes

The following codes are updated on a monthly basis. Some codes may have changed since last update.

Last Update: 12/5/07
Code Description

CNW ORTHOTICS ARE NOT COVERED FOR MEMBERS OVER AGE 18. THIS SERVICE IS NOT COVERED.
CLAIM WAS PREVIOUSLY CONSIDERED FOR PAYMENT BY THE EMPLOYER GROUP'S PRIOR
CNX HEALTH INSURANCE CARRIER. NO ADDITIONAL PAYMENT WILL BE MADE.
CNY RUN IN PERIOD HAS EXPIRED. NO FURTHER PAYMENTS CAN BE MADE.
CNZ RUN OUT PERIOD HAS ENDED. NO FURTHER PAYMENTS CAN BE MADE.
THIS CLAIM WAS SUBMITTED WITH INCOMPLETE PRICING INFORMATION. SUBMIT THIS CLAIM TO:
CN5 PREFERRED ONE,C/O PPO CLAIMS, P.O. BOX 1527, MINNEAPOLIS, MN 55440
SPECIALTY DRUGS ARE NOT ELIGIBLE FOR COVERAGE UNDER THIS MEDICAL PLAN. SPECIALTY
DRUG CLAIMS SHOULD BE SUBMITTED TO CAREMARK SPECIALTY PHARMACY SERVICES (800) 237-
CO$ 2767.
CO* YOUR PLAN LIMITS COVERAGE OF CHARGES FOR THIS TYPEOF SERVICE.
CHARGES DENIED BY CONTRACTUAL ARRANGEMENT FOR RADIOLOGY SERVICES. MEMBER NOT
CO% RESPONSIBLE.
THIS CLAIM WAS SUBMITTED WITH INCOMPLETE PRICING INFORMATION. SUBMIT THIS CLAIM TO
COB AMERICAN LIFECARE, 1100 PAYDRAS STREET, SUITE 2600, NEW ORLEANS, LA. 70163.

THIS WAS SUBMITTED TO HUMANA IN ERROR. WE ARE NOT THE PHARMACY CARRIER. PLEASE
COD SUBMIT THIS CLAIM TO: CAREMARK, 800 BIERMANN COURT, MOUNT PROSPECT, IL 60056.
CHIROPRACTIC MAINTENANCE THERAPY IS NOT A COVERED SERVICE. PLEASE REFER TO YOUR
COE BENEFIT PLAN DOCUMENT.
ROUTINE SERVICES PERFORMED BY PHYSICIANS THAT DO NOT PARTICIPATE IN YOUR NETWORK
COF ARE NOT COVERED. PLEASE REFER TO YOUR BENEFIT PLAN DOCUMENT.
SERVICES RELATED TO THE TREATMENT OF INFERTILITY ARE NOT COVERED. PLEASE REFER TO
COG YOUR BENEFIT PLAN DOCUMENT.
YOUR ROUTINE CARE BENEFIT DOES NOT COVER IMMUNIZATIONS. PLEASE REFER TO YOUR
COH BENEFIT PLAN DOCUMENT.
TAXES APPLIED TO MEDICAL SERVICES ARE NOT COVERED. PLEASE REFER TO YOUR BENEFIT
COJ PLAN DOCUMENT.
EMERGENCY ROOM CHARGES FOR NON-EMERGENCY SERVICES ARE NOT COVERED. PLEASE
COK REFER TO YOUR BENEFIT PLAN DOCUMENT.
COL THIS AMOUNT EXCEEDS THE PLAN'S MAXIMUM BENEFIT FOR TRANSPLANT SERVICES.
COM SERVICES HAVE BEEN ROLLED TO APPROPRIATE SERVICE CODE FOR ADJUDICATION.

THIS CLAIM HAS BEEN FORWARDED TO HEALTH MANAGEMENTCENTER, YOUR DESIGNATED
MENTAL HEALTH CARRIER. TO EXPEDITE FUTURE CLAIM CONSIDERATIONS, PLEASE SEND
CON DIRECTLY TO: HEALTH MANAGEMENT CENTER PO BOX 14621, LEXINGTON, KENTUCKY 40512-4621

THIS AMOUNT EXCEEDS THE PAYMENT AGREEMENT FOR PROVIDER SELECT. ANY QUESTIONS
COP REGARDING NETWORK SAVINGS, CONTACT COALITION AMERICA, INC. AT 404-459-7201.
COZ GAMMA GLOBULIN COVERED ONLY FOR HYPOGAMMAGLOBULINEMIA AND HEPATITIS.
THIS PROVIDER IS NO LONGER PARTICIPATING IN OUR NETWORK. FUTURE CLAIMS WILL NOT BE
CO1 PAID AS NETWORK.
CO2 THIS IS A FABOH DISCOUNT. THE MEMBER IS NOT RESPONSIBLE FOR THIS AMOUNT.
CO3 REPAIR OR REPLACEMENT OF DURABLE MEDICAL EQUIPMENT IS NOT COVERED.
CO6 HYPNOSIS IS NOT A COVERED EXPENSE.
CO7 STANDARD STOCK ORTHOPEDIC SHOES ARE NOT COVERED UNDER THE PLAN.
CO8 THIS PYSCHIATRIC SERVICE IS ONLY ALLOWED ONCE PER DAY
Humana Remittance Advice Codes

The following codes are updated on a monthly basis. Some codes may have changed since last update.

Last Update: 12/5/07
Code Description

THIS AMOUNT EXCEEDS THE PAYMENT AGREEMENT FOR MEDICAL RESOURCE. ANY QUESTIONS
CO9 REGARDING NETWORK SAVINGS, CONTACT COALITION AMERICA, INC. AT 404-459-7201.
CP( ALPHA-FETOPROTEIN SERUM IS NOT A COVERED BENEFIT.
THE DIAGNOSIS CODE PROVIDED IS CONSIDERED INVALID. THIS MEANS IT MAY BE TERMED,
INVALID OR REQUIRE A 4TH OR 5TH DIGIT. WE RELIED ON INTERNAL CRITERIA TO MAKE THIS
CP& DETERMINATION.
TEAM SURGERY SERVICES NOT WARRANTED FOR THIS PROCEDURE. REVIEW HAS BEEN
CP! COMPLETED BY ORTHONET,LLC.
CP* THE YEARLY MAXIMUM BENEFIT FOR LENSES/CONTACTS HAS BEEN MET.
CP/ SCRATCH COATING AND/OR TINTING IS NOT A COVERABLE BENEFIT.
A CODE HAS BEEN ADDED AND SUBMITTED CHARGES HAVE BEEN REDISTRIBUTED TO MORE
CP? ACCURATELY REFLECT THE SERVICES THAT WERE PERFORMED DUE TO MULTIPLE BIRTHS.
INFERTILITY TREATMENT AND RELATED DRUG CHARGES ARE NOT COVERED UNDER THE BASIC
CP# MEDICAL PLAN.
CPA BENEFITS REDUCED DUE TO NO PRE-AUTHORIZATION.
THIS PROVIDER IS A MEMBER OF YOUR PARTICIPATING PROVIDER ORGANIZATION NETWORK.
CPC SERVICES ARE DISCOUNTED ACCORDING TO THE NEGOTIATED RATE.
CPG PAID ACCORDING TO IPA'S CONTRACTED RATE AS DIRECTED BY IPA.
CPH SERVICES PROVIDED BY THE CHOICECARE PROVIDER NETWORK.
CPJ PER TEXAS PROMPT PAY LEGISLATION, THIS LINE ITEM ADJUSTMENT IS BEING PAID AT 100%.
DEPO-PROVERA FOR CONTRACEPTION IS ALLOWED EVERY THREE MONTHS. THIS INJECTION
CPL EXCEEDS SERVICES PREVIOUSLY RENDERED WITHIN THE THREE MONTH PERIOD.
AUTHORIZATION REQUIRED FOR THIS SERVICE WAS NOT OBTAINED. MEMBER IS NOT
RESPONSIBLE FOR BALANCE UNLESS PROVIDER OBTAINED THE MEMBER'S SIGNED STATEMENT
CPS OF FINANCIAL RESPONSIBILITY FOR NON COVERED SERVICES.
CPX NO DESCRIPTION AVAILABLE
THIS SERVICE/PROCEDURE EXCEEDS FREQUENCY FOR THE DIAGNOSIS SUBMITTED. THE
PROVIDER OF SERVICE IS RESPONSIBLE FOR SUBMITTING SUPPORTING MEDICAL
CP1 DOCUMENTATION FOR RECONSIDERATION.
CHARGES SUBMITTED HAVE BEEN REDISTRIBUTED TO PROVIDE A MORE ACCURATE BENEFIT.
THIS SERVICE/PROCEDURE EXCEEDS THE EXPECTED FREQUENCY FOR THE DIAGNOSIS
SUBMITTED. THE PROVIDER OF SERVICE IS RESPONSIBLE FOR SUBMITTING SUPPORTING
CP2 MEDICAL DOCUMENTATION FOR RECONSIDERATION.
CHARGES INCLUDE MEDICAL VISIT PERFORMED ON THE SAME DAY. THIS SERVICE/PROCEDURE
EXCEEDS THE EXPECTED FREQUENCY FOR THE DIAGNOSIS SUBMITTED. THE PROVIDER OF
SERVICE IS RESPONSIBLE FOR SUBMITTING SUPPORTING DOCUMENTATION FOR
CP3 RECONSIDERATION.
CODE CHANGED TO MORE ACCURATELY REFLECT THE PROCEDURE PERFORMED. THIS
SERVICE/PROCEDURE EXCEEDS THE EXPECTED FREQUENCY FOR THE DIAGNOSIS SUBMITTED.
THE PROVIDER OF SERVICE IS RESPONSIBLE FOR SUBMITTING SUPPORTING MEDICAL
CP4 DOCUMENTATION FOR RECONSIDERATION.
CP5 NO DESCRIPTION AVAILABLE
CP7 PHYSICIAN INTERPRETATION CHARGE NOT ALLOWED SEPARATELY FROM LAB CHARGE.
CQ( HAIR PROSTHESIS, HAIR TRANSPLANTS OR IMPLANTS AND WIGS ARE NOT COVERED.
THE DIAGNOSIS CODE BILLED IS NOT COMPATIBLE WITH THE AGE OF THE PATIENT. WE RELIED
CQ& ON INTERNAL CRITERIA TO MAKE THIS DETERMINATION.
CQ$ MEDICARE PART B DEDUCTIBLE IS NOT PAYABLE UNDER THE PLAN.
CQ* MAXIMUM BENEFIT FOR THIS TYPE OF SERVICE IS $200.00 (U.S.) PER PATIENT.
Humana Remittance Advice Codes

The following codes are updated on a monthly basis. Some codes may have changed since last update.

Last Update: 12/5/07
Code Description
CQ/ MAXIMUM ORTHOTIC BENEFIT HAS BEEN MET.
SKILLED NURSING HAS BEEN PAID IN ACCORDANCE WITH THE RESOURCE UTILIZATION GROUP
CQ% (RUG) PAYMENT RATE.
DUE TO MULTIPLE BIRTHS, THIS CODE WAS ADDED IN ORDER TO MORE ACCURATELY DISTRIBUTE
CQ? CHARGES FOR THE SERVICES RENDERED.
CQA NO DESCRIPTION AVAILABLE
CQB NO DESCRIPTION AVAILABLE
CQC NO DESCRIPTION AVAILABLE
CQD NO DESCRIPTION AVAILABLE
CQE NO DESCRIPTION AVAILABLE
CQF NO DESCRIPTION AVAILABLE
CQG NO DESCRIPTION AVAILABLE
CQH NO DESCRIPTION AVAILABLE
CQI NO DESCRIPTION AVAILABLE
CQJ NO DESCRIPTION AVAILABLE
CQK NO DESCRIPTION AVAILABLE
CQL NO DESCRIPTION AVAILABLE
CQM NO DESCRIPTION AVAILABLE
CQN NO DESCRIPTION AVAILABLE
CQP NO DESCRIPTION AVAILABLE
CQQ NO DESCRIPTION AVAILABLE
CQR NO DESCRIPTION AVAILABLE
CQS NO DESCRIPTION AVAILABLE
CQT NO DESCRIPTION AVAILABLE
CQU NO DESCRIPTION AVAILABLE
CQV NO DESCRIPTION AVAILABLE
CQW NO DESCRIPTION AVAILABLE
CQX NO DESCRIPTION AVAILABLE
CQY NO DESCRIPTION AVAILABLE
CQZ NO DESCRIPTION AVAILABLE
EFFECTIVE 1-1-02, I-CARE CLAIMS, REGARDLESS OF DATES OF SERVICE, SHOULD BE SUBMITTED
TO OUR NEW CLAIMS PROCESSING VENDOR. PLEASE SUBMIT TO I-CARE CLAIMS IN C/O DORAL
CQ1 U.S.A., 1017 WEST GLEN OAKS LANE, MEQUON WI 53092.
THIS IS A PREFERRED ONE DISCOUNT. MEMBER NOT RESPONSIBLE FOR THIS DISCOUNTED
CQ2 AMOUNT.
PER TEXAS PROMPT PAY LEGISLATION, THIS CLAIM IS BEING PAID AT 100% OF BILLED CHARGES
CQ3 MINUS ANY MEMBER'S RESPONSIBILITY.
PER TEXAS LEGISLATION, THIS CLAIM IS BEING PAID AT 100% OF CONTRACTED AMOUNT AND WILL
BE AUDITED. AT THE END OF THE AUDIT PERIOD, YOU WILL RECEIVE NOTIFICATION OF THE
CQ4 RESULTS.
THE AUDIT PERIOD DETERMINED THAT AN ADDITIONAL 15% OF CONTRACTED RATES IS BEING
CQ5 REIMBURSED MINUS ANY MEMBER'S RESPONSIBILITY.
CQ7 PLEASE SUBMIT CLAIM TO KAISER PERMANENTE FOR CONSIDERATION.
CQ8 EXPENSES ARE DENIED BY INDEPENDENT PRACTICE ASSOCIATION (IPA).
EXPENSES ARE DENIED BY INDEPENDENT PRACTICE ASSOCIATION (IPA) PER THEIR ELIGIBILITY
CQ9 RECORDS.
NON-PARTICIPATING PROVIDER SERVICES ARE NOT COVERED WITHOUT AN APPROVED
CR( REFERRAL.
Humana Remittance Advice Codes

The following codes are updated on a monthly basis. Some codes may have changed since last update.

Last Update: 12/5/07
Code Description
THE DIAGNOSIS CODE BILLED IS NOT COMPATIBLE WITH THE SEX OF THE PATIENT. WE RELIED
CR& ON INTERNAL CRITERIA TO MAKE THIS DETERMINATION.
CR! MEMBER COPAY/COINSURANCE IS WAIVED FOR THIS SERVICE.
CR$ PAYMENT IS BASED ON AN 80% ESTIMATION OF MEDICARE BENEFITS.
CR* THE YEARLY MAXIMUM NON-NETWORK PHYSICAL THERAPY BENEFIT HAS BEEN MET.
CR/ COSMETIC SERVICES/SUPPLIES ARE NOT A COVERED BENEFIT UNDER THE PLAN.
CR? THIS AMOUNT EXCEEDS THE MAXIMUM ALLOWABLE FEE.
CR# VERIFICATION OF MODIFIER USED OR REQUIRED.
CRF NO DESCRIPTION AVAILABLE
CRG NO DESCRIPTION AVAILABLE
CRH NO DESCRIPTION AVAILABLE
CRI NO DESCRIPTION AVAILABLE

THE CHIROPRACTIC MAXIMUM PAYABLE BENEFIT HAS BEEN MET FOR THIS DATE OF SERVICE,
CRK THEREFORE, THIS AMOUNT IS NOT COVERED. REFER TO THE BENEFIT PLAN DOCUMENT.
CRQ NO DESCRIPTION AVAILABLE
CRS NO DESCRIPTION AVAILABLE
CRT NO DESCRIPTION AVAILABLE
CRU NO DESCRIPTION AVAILABLE
CRX NO DESCRIPTION AVAILABLE
CRY NO DESCRIPTION AVAILABLE
CRZ NO DESCRIPTION AVAILABLE
THIS AMOUNT REPRESENTS A PROMPT PAYMENT DISCOUNT AND IS EXCLUDED FROM THE
CR1 PATIENT RESPONSIBILITY
CR2 SERVICES DENIED PER ABHS. CALL 414-345-6057 WITH DENIAL QUESTIONS.
CR3 CLAIM MUST BE SUBMITTED BY THE ACTUAL PROVIDER OF SERVICE
THIS CLAIM HAS BEEN FORWARDED TO THE DESIGNATED MENTAL HEALTH CARRIER. TO
EXPEDITE FUTURE CLAIMS PROCESSING, PLEASE SEND CLAIMS DIRECTLY TO THE MENTAL
CR5 HEALTH CARRIER FOR THIS MEMBER.
CR6 LETTER OF EXPLANATION BEING SENT UNDER SEPARATE COVER
ALL BILLS WITH INJURY DATE PRIOR TO 2/1/97 SHOULD BE SENT TO: SEDGWICK JAMES GE
CR7 APPLIANCE PARK, AP70 LOUISVILLE, KY 40225
THIS CLAIM WAS SUBMITTED TO HUMANA IN ERROR. WE ARE NOT THE PHARMACY CARRIER.
PLEASE SUBMIT THIS CLAIM TO: ADVANCED PHARMACY CARRIER SYSTEM (PCS), P. O. BOX 52116,
CR8 PHOENIX, AZ 85072-2116
THIS CLAIM HAS BEEN FORWARDED TO PROFESSIONAL VISION CARE FOR PROCESSING. TO
EXPEDITE FUTURE CONSIDERATIONS, PLEASE SEND DIRECTLY TO: PVC 2106PLANTSIDE
CR9 DRIVE SUITE 1 & 2 JEFFERSONTOWN, KY 40299-1924
THIS HCPCS CODE IS NOT CONSIDERED TO BE A VALID CODE. WE RELIED ON INTERNAL CRITERIA
CS& TO MAKE THIS DETERMINATION.
CS! SERVICES DENIED, LIFETIME MAXIMUM HAS BEEN MET FOR FIRST STEPS BENEFIT.
CS* THE YEARLY MAXIMUM NON-NETWORK OCCUPATIONAL BENEFIT HAS BEEN MET.
REPAIR AND MAINTENANCE OF AN APPLIANCE, ORTHOTIC OR MEDICAL EQUIPMENT IS NOT
CS/ COVERED BY THE PLAN.
CLAIMS FOR CHIROPRACTIC SERVICES SHOULD BE FORWARDED TO: AXIA WHOLEHEALTH
CS? NETWORKS, PO BOX 3192 MILWAUKEE, WI 53201-3192
CS# INFORMATION RECEIVED ILLEGIBLE, RESUBMIT A LEGIBLE COPY.
CSA ANNUAL BENEFIT ALLOWANCE APPLIED.
CSC INFERTILITY SERVICES ARE NOT A COVERED BENEFIT UNDER THE PLAN.
Humana Remittance Advice Codes

The following codes are updated on a monthly basis. Some codes may have changed since last update.

Last Update: 12/5/07
Code Description
THIS AMOUNT EXCEEDS THE WISCONSIN PREFERRED PROVIDER NETWORK (WPPN) PAYMENT
CSG AGREEMENT.
CSJ PRESCRIPTION COPAYMENT REFUND REEMBOLSO DEL COPAGO POR MEDICINAS
CSM PLEASE SUBMIT THE OPERATIVE REPORT.
CSO OUTPATIENT CLAIM PAYMENT HAS BEEN ADJUSTED TO ACCOUNT FOR INPATIENT CHARGES.
A NON-LICENSED PROVIDER/ FACILITY/ PHARMACY IS NOT COVERED UNDER YOUR PLAN. REFER
CSQ TO YOUR BENEFIT PLAN DOCUMENT.
CSU INVITRO FERTILIZATION IS NOT A BENEFIT COVERED BY MEMBER'S HEALTH PLAN.
THE CHEMICAL DEPENDENCY LIFETIME MAXIMUM PAYABLE BENEFIT HAS BEEN EXHAUSTED. NO
CSV ADDITIONAL BENEFITSWILL BE PAID. REFER TO THE BENEFIT PLAN DOCUMENT.
CSW TMJ AND/OR CRANIOMANDIBULAR JAW DISORDERS ARE NOT COVERED.
CSX CUSTODIAL CARE IS NOT COVERED BY MEMBER'S HEALTH PLAN.
CHARGES FOR ENVIRONMENTAL CONTROL OR ENHANCEMENT INCLUDING AIR CONDITIONERS,
PURIFIERS, VACUUM CLEANERS, MOTORIZED TRANSPORTATION OTHER THAN WHEELCHAIRS,
ESCALATORS, ELEVATORS, RAMPS, PILLOWS OR MATTRESSES, SWIMMING POOLS, SAUNAS,
WHIRLPOOLS, SPAS, EXERCISE EQUIPMENT, ETC., ARE NOT COVERED BY YOUR HEALTH PLAN.
CSY REFER TO THE BENEFIT PLAN DOCUMENT.
CSZ ACUPUNCTURE IS NOT COVERED BY MEMBER'S HEALTH PLAN.
CS1 INPATIENT CLAIM PAYMENT HAS BEEN ADJUSTED TO ACCOUNT FOR OUTPATIENT CHARGES.
CS2 OUTPATIENT CLAIM PAYMENT HAS BEEN ADJUSTED TO ACCOUNT FOR INPATIENT CHARGES.

WE ARE UNABLE TO PROCESS THIS CLAIM BECAUSE WE HAVE NOT RECEIVED A HMO
OUTPATIENT AUTHORIZATION MATCHING THE SERVICE(S) RENDERED ON THE DATE(S) OF
SERVICE. PLEASE CONTACT THE HMO OUTPATIENT AUTHORIZATION SOURCE (E.G., MEMBER'S
CS3 PCP). UPON RECEIPT OF THE AUTHORIZATION, WE WILL EXPEDITE PROCESSING OF YOUR CLAIM.
WE ARE UNABLE TO PROCESS THIS CLAIM BECAUSE THE AUTHORIZATION NUMBER IS INVALID
AND NO HMO OUTPATIENT AUTHORIZATION WAS RECEIVED MATCHING THE SERVICE(S)
RENDERED ON THE DATE(S) OF SERVICE. PLEASE CONTACT THE HMO OUTPATIENT
AUTHORIZATION SOURCE (E.G., MEMBER'S PCP). UPON RECEIPT OF THE AUTHORIZATION, WE
CS4 WILL EXPEDITE PROCESSING OF YOUR CLAIM.
PLEASE SUBMIT A CURRENT/CORRECT NDC# FOR EACH APPLICABLE DRUG AS SHOWN ON THE
CS5 CLAIM.
CS6 CLAIM HAS BEEN PENDED FOR REVIEW. NO ACTION IS NECESSARY.
CS8 SURCHARGE PAID THROUGH POOL ELECTION. REMOVE GROUP FROM SURCHARGE BILLING.
THE PROCEDURE CODE BILLED IS NOT COMPATIBLE WITH TEH AGE OF THE PATIENT. WE RELIED
CT& ON INTERNAL CRITERIA TO MAKE THIS DETERMINATION.
CT! THIS SERVICE IS NOT COVERED BY MEDICARE DUE TO A STATUTORY EXCLUSION.
CT* THE YEARLY MAXIMUM NON-NETWORK SPEECH THERAPY BENEFIT HAS BEEN MET.
CT% THIS AMOUNT WAS PAID PREVIOUSLY BY HUMANA.
CHARGES BILLED SHOULD BE CONSIDERED OVERHEAD AND NOT BILLABLE TO THE CARRIER OR
CT? THE PATIENT.
PRESCRIPTION FOR THERAPY PROVIDED (INCLUDING TREATMENT PLAN AND EXPECTED
CT# DURATION).
CHARGES FOR TREATMENT FOR MENTAL RETARDATION AND/OR MENTAL DEFICIENCY ARE NOT
CTB COVERED BY THE HEALTH PLAN. REFER TO THE BENEFIT PLAN DOCUMENT.

CTC REPLACEMENT OF WHOLE BLOOD OR PLASMA IS NOT COVERED BY MEMBER'S HEALTH PLAN.
CTE COINSURANCE AMOUNT.
CTG NO DESCRIPTION AVAILABLE
Humana Remittance Advice Codes

The following codes are updated on a monthly basis. Some codes may have changed since last update.

Last Update: 12/5/07
Code Description
CTH SEX CHANGE SERVICES ARE NOT COVERED BY MEMBER'S HEALTH PLAN.
CHARGES FOR THE DIAGNOSIS OR CARE AND TREATMENT OF WEAK, STRAINED, UNSTABLE OR
FLAT FEET OR TOENAILSARE NOT COVERED BY THE HEALTH PLAN. REFER TO THE BENEFIT PLAN
CTI DOCUMENT.
CHARGES FOR ENROLLMENT IN HEALTH, ATHLETIC, OR SIMILAR CLUBS ARE NOT COVERED BY
CTJ THE HEALTH PLAN. REFER TO THE BENEFIT PLAN DOCUMENT.
CTK HOMEOPATHIC DRUGS ARE NOT COVERED BY MEMBER'S HEALTH PLAN.
CTL METHADONE TREATMENT IS NOT COVERED BY MEMBER'S HEALTH PLAN.
CHARGES FOR COURT ORDERED TREATMENTS FOR PSYCHIATRIC DISORDERS, ALCOHOLISM AND
DRUG DEPENDENCY ARE NOT COVERED BY THE PLAN. REFER TO THE BENEFIT PLAN
CTM DOCUMENT.
CTN WEIGHT LOSS PROGRAMS ARE NOT COVERED BY MEMBER'S PLAN.
PLAN BENEFITS ARE LIMITED TO SPECIFIC ROUTINE DENTAL CARE SERVICES. THEREFORE, THIS
CTO SERVICE IS NOT COVERED. REFER TO THE BENEFIT PLAN DOCUMENT.
CTQ THIS AMOUNT EXCEEDS THE CORPHEALTH PAYMENT AGREEMENT.

THIS CLAIM WAS DENIED BECAUSE THE ITEMIZED BILL REQUESTED FROM THE PROVIDER WAS
CTR NOT RECEIVED. UPON RECEIPT OF AN ITEMIZED BILL, CLAIM WILL BE CONSIDERED FOR PAYMENT.
THIS CLAIM WAS DENIED BECAUSE THE EMERGENCY ROOM REPORT REQUESTED FROM THE
PROVIDER WAS NOT RECEIVED. UPON RECEIPT OF THE EMERGENCY ROOM REPORT, CLAIM WILL
CTS BE CONSIDERED FOR PAYMENT.
THIS CLAIM WAS DENIED BECAUSE THE OPERATIVE REPORT REQUESTED FROM THE PROVIDER
WAS NOT RECEIVED. UPON RECEIPT OF THE OPERATIVE REPORT, CLAIM WILL BE CONSIDERED
CTT FOR PAYMENT.

THIS CLAIM WAS DENIED BECAUSE A COPY OF THE ADMISSION HISTORY AND/OR DISCHARGE
SUMMARY REQUESTED FROM THE PROVIDER WAS NOT RECEIVED. UPON RECEIPT OF THE
CTU ADMISSION HISTORY AND/OR DISCHARGE SUMMARY,CLAIM WILL BE CONSIDERED FOR PAYMENT.
THIS CLAIM WAS DENIED BECAUSE THE ORIGINAL PHARMACY/DRUG INFORMATION REQUESTED
FROM YOU WAS NOT RECEIVED. ONCE THE ORIGINAL PHARMACY/DRUG INFORMATION OR AN
ITEMIZED PHARMACY STATEMENT SIGNED BY THE PHARMACIST IS RECEIVED, CLAIM WILL BE
CTV CONSIDERED FOR PAYMENT.
THIS CLAIM WAS DENIED BECAUSE THE ACCIDENT INFORMATION REQUESTED FROM YOU WAS
NOT RECEIVED. UPON RECEIPT OF THE ACCIDENT DETAILS, CLAIM WILL BE CONSIDERED FOR
CTW PAYMENT.
THIS CLAIM WAS DENIED BECAUSE THE ATTENDING PHYSICIAN'S STATEMENT FOR THIS
EQUIPMENT REQUESTED FROM THE PROVIDER WAS NOT RECEIVED. WHEN WE RECEIVE THIS
CTX STATEMENT, CLAIM WILL BE CONSIDERED FOR PAYMENT.
THIS CLAIM WAS DENIED BECAUSE PRIOR HEALTH INFORMATION REQUESTED FROM YOUR
PROVIDER WAS NOT RECEIVED. WHEN WE RECEIVE THIS INFORMATION, CLAIM WILL BE
CTY CONSIDERED FOR PAYMENT.
THIS CLAIM WAS DENIED BECAUSE THE STUDENT/HANDICAPPED STATUS INFORMATION
REQUESTED FROM YOU WAS NOT RECEIVED. WHEN WE RECEIVE THIS INFORMATION, CLAIM WILL
CTZ BE CONSIDERED FOR PAYMENT.
THIS CLAIM HAS BEEN FORWARDED TO CORPHEALTH FOR PROCESSING. THEIR ADDRESS AND
PHONE NUMBER ARE: 1300 SUMMITT AVENUE; SUITE 600 FORT WORTH, TEXAS 76102 AND (800)
CT3 410-5999. THANK YOU.
Humana Remittance Advice Codes

The following codes are updated on a monthly basis. Some codes may have changed since last update.

Last Update: 12/5/07
Code Description
THIS INJURY/ILLNESS IS DETERMINED TO BE WORK RELATED. SUBMIT THESE CHARGES TO THE
WORKERS COMPENSATION INSURANCE CARRIER FOR CONSIDERATION. REFER TO THE BENEFIT
CT5 PLAN DOCUMENT.
CT6 NO PCP REFERRAL ON FILE. REDUCED BENEFITS HAVE BEEN APPLIED.
CT7 THE PROVIDER OF SERVICE IS NOT COVERED UNDER YOUR PLAN.
THE EXPENSES SUBMITTED ARE NOT BEING CONSIDERED BY HUMANA. THE LIABILITY CARRIER
CT8 HAS REACHED A SETTLEMENT FOR THESE EXPENSES.
PLEASE SUBMIT THESE CHARGES TO AUTO, HOMEOWNERS OR OTHER LIABILITY INSURANCE
CT9 CARRIER FOR PRIMARY BENEFIT CONSIDERATION.
THE PROCEDURE CODE BILLED IS NOT COMPATIBLE WITH THE SEX OF THE PATIENT. WE RELIED
CU& ON INTERNAL CRITERIA TO MAKE THIS DETERMINATION.
CU* AMOUNT OVER ACCEPTED FEE SCHEDULE.
YEARLY MAXIMUM NON-NETWORK RESIDENTIAL, DAY/EVENING, OR INTENSIVE OUTPATIENT
CU/ TREATMENT HAS BEEN MET.
CU? STERILIZATION IS NOT COVERED BY THIS PLAN. REVIEW THE BENEFIT PLAN DOCUMENT.
CU# NAME OF THE REFERRING PHYSICIAN.
THIS LINE WAS PAID IN ACCORDANCE WITH THE INPATIENT PSYCHIATRIC FACILITIES
CU PROSPECTIVE PAYMENT SYSTEM.
THIS CLAIM WAS DENIED BECAUSE THE ATTENDING PHYSICIAN'S STATEMENT FOR PHYSICAL
THERAPY REQUESTED FROM THE PROVIDER WAS NOT RECEIVED. ONCE WE RECEIVE THE
CUA STATEMENT, CLAIM WILL BE CONSIDERED FOR PAYMENT.
THIS CLAIM WAS DENIED BECAUSE THE ATTENDING PHYSICIAN'S STATEMENT FOR PRIVATE DUTY
NURSING REQUESTEDFROM THE PROVIDER WAS NOT RECEIVED. ONCE WE RECEIVE THIS
CUB STATEMENT, CLAIM WILL BE CONSIDERED FOR PAYMENT.
CUC THIS AMOUNT EXCEEDS THE ALLOWABLE CHARGE
THIS CLAIM WAS DENIED BECAUSE THE ATTENDING PHYSICIAN'S STATEMENT FOR PRIVATE DUTY
NURSING REQUESTED FROM THE PROVIDER WAS NOT RECEIVED. ONCE WE RECEIVE THIS
CUD STATEMENT, CLAIM WILL BE CONSIDERED FOR PAYMENT.
THIS CLAIM WAS DENIED BECAUSE THE ATTENDING PHYSICIAN'S STATEMENT FOR THE TENS UNIT
FROM THE PROVIDER WAS NOT RECEIVED. ONCE WE RECEIVE THIS STATEMENT, CLAIM WILL BE
CUE CONSIDERED FOR PAYMENT.
THIS CLAIM WAS DENIED BECAUSE THE OFFICE NOTES AND PATHOLOGY REPORT REQUESTED
FROM YOUR PROVIDER WAS NOT RECEIVED. ONCE WE RECEIVE THE NOTES AND REPORT, CLAIM
CUF WILL BE CONSIDERED FOR PAYMENT.
THIS CLAIM WAS DENIED BECAUSE THE ATTENDING PHYSICIAN'S STATEMENT FOR SPEECH
THERAPY REQUESTED FROM THE PROVIDER WAS NOT RECEIVED. ONCE WE RECEIVE THE
CUG STATEMENT, CLAIM WILL BE CONSIDERED FOR PAYMENT.
THIS CLAIM WAS DENIED BECAUSE THE ATTENDING PHYSICIAN'S STATEMENT FOR MEDICAL
NECESSITY REQUESTED FROM THE PROVIDER WAS NOT RECEIVED. ONCE WE RECEIVE THE
CUH STATEMENT, CLAIM WILL BE CONSIDERED FOR PAYMENT.
THIS CLAIM WAS DENIED BECAUSE AUTHORIZATION FOR THIS SERVICE REQUESTED FROM THE
PROVIDER WAS NOT RECEIVED. ONCE WE RECEIVE APPROVED AUTHORIZATION, CLAIM WILL BE
CUJ CONSIDERED FOR PAYMENT.
THIS CLAIM WAS DENIED BECAUSE AUTHORIZATION FOR SKILLED NURSING SERVICES
REQUESTED FROM THE PROVIDER WAS NOT RECEIVED. ONCE WE RECEIVE APPROVED
CUK AUTHORIZATION, CLAIM WILL BE CONSIDERED FOR PAYMENT.
THIS CLAIM WAS DENIED BECAUSE THE MEDICAL RECORDS REQUESTED FROM THE PROVIDER
AND NECESSARY TO DETERMINE MEMBER ELIGIBILITY WERE NOT RECEIVED. ONCE WE RECEIVE
CUL THE MEDICAL RECORDS, CLAIM WILL BE CONSIDERED FOR PAYMENT.
Humana Remittance Advice Codes

The following codes are updated on a monthly basis. Some codes may have changed since last update.

Last Update: 12/5/07
Code Description
THIS CLAIM WAS DENIED BECAUSE AN APPROVED AUTHORIZATION WAS NOT OBTAINED. ONCE
CUN WE RECEIVE APPROVED AUTHORIZATION, THE CLAIM WILL BE RECONSIDERED.
THIS CLAIM WAS DENIED BECAUSE THE ANESTHESIA MINUTES REQUESTED FROM THE PROVIDER
WERE NOT RECEIVED. ONCE WE RECEIVE THE ANESTHESIA MINUTES, CLAIM WILL BE
CUS CONSIDERED FOR PAYMENT.
TO PREVENT PAYMENT DELAYS, PLEASE RESUBMIT THIS CLAIM AND ANY FUTURE CLAIMS TO:
UNITED TEACHERS ASSOCIATES INSURANCE COMPANY P.O. BOX 29010 AUSTIN, TEXAS 78755-
CUT 6010 1-888-577-1887

THIS CLAIM WAS DENIED BECAUSE THE ATTENDING PHYSICIAN'S STATEMENT FOR MEDICAL
NECESSITY FOR CHIROPRACTIC SERVICES REQUESTED FROM THE PROVIDER WAS NOT
CUU RECEIVED. ONCE WE RECEIVE THE STATEMENT, CLAIM WILL BE CONSIDERED FOR PAYMENT.
THIS CLAIM WAS DENIED BECAUSE FACILITY'S UB92 AND CORRESPONDING ITEMIZED BILL
REQUESTED FROM THE PROVIDER WAS NOT RECEIVED. ONCE WE RECEIVE THE UB92 AND
CUV CORRESPONDING ITEMIZATION STATEMENT, CLAIM WILL BE CONSIDERED FOR PAYMENT.

CUW THIS LINE WAS PAID IN ACCORDANCE WITH THE DIAGNOSTIC RELATED GROUP PAYMENT RATE.
CUX DEDUCTIBLE AMOUNT
CUY DEPENDENT ELIGIBILITY INFORMATION REQUESTED FROM MEMBER.
THIS CLAIM HAS BEEN FORWARDED TO PPOM FOR REPRICING. TO EXPEDITE FUTURE CLAIM
CONSIDERATIONS, PLEASE SEND DIRECTLY TO: PPOM PO BOX 2720 FARMINGTON HILLS, MI 48333-
CU0 2720
CU7 NO COVERAGE FOR SERVICES NOT RENDERED.
CU8 ROOM RATE REDUCED, HOSPITAL CONFINEMENT PROVISION STATES 15 HOURS.
CV( GENETIC TESTING IS NOT COVERED ON YOUR PLAN. PLEASE REVIEW YOUR BENEFIT PLAN.
THIS PROCEDURE CODE IS CONSIDERED AN INTEGRAL PART OF THE PRIMARY PROCEDURE AND
SHOULD NOT BE BILLED SEPARATELY. WE RELIED ON INTERNAL CRITERIA TO MAKE THIS
CV& DETERMINATION.
THIS SERVICE IS CONSIDERED PART OF THE GENERAL FEE OR DAILY RATE AND IS NOT
CV! SEPARATELY PAYABLE. SERVICES HAVE BEEN REVIEWED BY ORTHONET, LLC.
A PORTION OF YOUR BENEFITS ARE NOT COVERED DUE TO A PRE-EXISTING CONDITON. PLEASE
CV* REFER TO THE LETTER UNDER SEPARATE COVER.
CV/ YOUR YEARLY MAXIMUM NON-NETWORK INPATIENT HOSPITAL BENEFIT HAS BEEN MET.
THIS POLICY IS FOR PHARMACY COVERAGE ONLY. PLEASE SUBMIT MEDICAL EXPENSES TO YOUR
CV? MEDICAL CARRIER.
CV# THE PERFORMING PROVIDER'S TAX IDENTIFICATION NUMBER.
A PORTION OF YOUR BENEFITS IS NOT COVERED BECAUSE OF A PRE-EXISTING CONDITION.
CVE PLEASE REFER TO THE LETTER SENT TO YOU SEPARATELY.
CLAIMS WITH DATE OF SERVICE PRIOR TO 08/01/02 ARE BEING FORWARDED TO ARC/ARIA FOR
CLAIMS PROCESSING.TO EXPEDITE FUTURE CLAIMS CONSIDERATIONS FOR DATES OF SERVICE
PRIOR TO 08/01/02 PLEASE SEND DIRECTLYTO: ARC/ARIA, 6937 N. IH35, SUITE 500, AUSTIN, TX
CVF 78752
THIS CLAIM HAS BEEN FORWARDED TO MENTAL HEALTH NETWORK, OUR DESIGNATED CARRIER.
TO EXPEDITE FUTURE CLAIM CONSIDERATIONS PLEASE SEND DIRECTLY TO: MENTAL HEALTH
CVG NETWORK, MH NET PO BOX 209010, AUSTIN, TX, 78720
THIS CLAIM HAS BEEN FORWARDED TO HORIZON BEHAVIORAL SERVICES, OUR DESIGNATED
CARRIER. TO EXPEDITE FUTURE CLAIM CONSIDERATIONS PLEASE SEND DIRECTLY TO: HORIZON
CVH BEHAVIORAL SERVICES, PO BOX 953309, LAKE MARY, FL 32795-3309
Humana Remittance Advice Codes

The following codes are updated on a monthly basis. Some codes may have changed since last update.

Last Update: 12/5/07
Code Description
THIS CLAIM WAS SUBMITTED WITH INCOMPLETE CHARGE AMOUNT(S). SUBMIT A CORRECTED
CVI CLAIM FOR PAYMENT CONSIDERATION.
THIS CLAIM WAS SUBMITTED WITH INCOMPLETE DATE(S) OF SERVICE. SUBMIT A CORRECTED
CVJ CLAIM FOR PAYMENT CONSIDERATION.
THE HOME HEALTH MAXIMUM PAYABLE BENEFIT HAS BEEN REACHED FOR THE YEAR.
CVK THEREFORE, THIS SERVICE IS NOT COVERED. REFER TO THE BENEFIT PLAN DOCUMENT.
WE ARE UNABLE TO VERIFY PHYSICIAN/FACILITY'S NAME,ADDRESS, AND PHONE NUMBER.
PLEASE SUBMIT A CORRECTED CLAIM TO INCLUDE CORRECT PHYSICIAN/FACILITY NAME,
CVL ADDRESS, AND PHONE NUMBER FOR PAYMENT CONSIDERATION.
THIS SURGERY IS NOT MEDICALLY NECESSARY AND THEREFORE IS NOT COVERED. REFER TO
CVM THE BENEFIT PLAN DOCUMENT.
THIS VACCINE HAS NOT BEEN APPROVED BY THE FDA AND THEREFORE IS NOT COVERED. REFER
CVN TO THE BENEFIT PLAN DOCUMENT.
THIS VACCINE IS NO LONGER BEING MANUFACTURED AND THEREFORE IS NOT COVERED. REFER
CVO TO THE BENEFIT PLAN DOCUMENT.
TRAVEL CHARGES, WHICH ARE NOT MEDICALLY NECESSARY, ARE NOT COVERED UNLESS
CVP RELATED TO A TRANSPLANT. REFER TO THE BENEFIT PLAN DOCUMENT.

CVQ VACCINES FOR HEPATITIS A & B ARE NOT COVERED. REFER TO THE BENEFIT PLAN DOCUMENT.
VACCINES REQUIRED FOR TRAVEL ABROAD ARE NOT COVERED. REFER TO THE BENEFIT PLAN
CVR DOCUMENT.
PATERNITY TESTS ARE NOT MEDICALLY NECESSARY AND THEREFORE NOT COVERED. REFER TO
CVS THE BENEFIT PLAN DOCUMENT.
CVT SPECT SCANS ARE NOT A COVERED BENEFIT. REFER TO THE BENEFIT PLAN DOCUMENT.
CHARGES FOR TELEPHONE CONSULTATIONS ARE NOT COVERED. REFER TO THE BENEFIT PLAN
CVU DOCUMENT.
THIS PROCEDURE HAS NOT BEEN APPROVED BY THE FDA AND THEREFORE IS NOT A COVERED
CVW PROCEDURE. REFER TO THE BENEFIT PLAN DOCUMENT.
THE HOSPICE MAXIMUM PAYABLE BENEFIT HAS BEEN REACHED FOR THE YEAR. THEREFORE,
CVX THIS SERVICE IS NOT COVERED. REFER TO THE BENEFIT PLAN DOCUMENT.
AMBULANCE CHARGES RELATED TO MILEAGE ARE NOT COVERED. REFER TO YOUR BENEFIT PLAN
CVY DOCUMENT.
LAB TESTS RELATED TO INFERTILITY ARE NOT MEDICALLY NECESSARY AND THEREFORE NOT
CVZ COVERED. REFER TO THE BENEFIT PLAN DOCUMENT.
THIS CLAIM WAS SUBMITTED TO HUMANA IN ERROR. WE ARE NOT THE VISION CARRIER. PLEASE
SUBMIT THIS CLAIM TO: EYE CARE OF WISCONSIN, 8705 N.PT. WASHINGTON RD STE.303, FOX
CV1 POINT, WI 53217.
THIS CLAIM WAS SUBMITTED TO HUMANA IN ERROR. WE ARE NOT THE CHIROPRACTIC CARRIER.
PLEASE SUBMIT THIS CLAIM TO: CHIROTECH AT N.14 W23833 STONERIDGE DR. #330, WAUKESHA,
CV2 WI 53188.
CV3 ONLY CHARGES INCURRED FOR THE DISABLING CONDITION ARE COVERED.
CV5 THIS PAYMENT REFLECTS A RATE AGREED UPON BY HUMANA AND THE PROVIDER.
CV6 PAID ACCORDING TO CHOICECARE PROVIDER NETWORK AGREEMENT.
CV7 PPO ADJUSTMENT - HPO AND AFFILIATED NETWORKS.
CV8 THIS PAYMENT REFLECTS A RATE NEGOTIATED BY HUMANA AND BCE EMERGIS.
CV9 TMJ MAXIMUM PAYABLE BENEFIT HAS BEEN MET. THIS SERVICE IS NOT COVERED.
CW( SUPPLIES USED DURING AMBULANCE TRANSPORT ARE NOT COVERED.
THIS PROVIDER HAS REQUESTED THIS DENIAL OF COVERAGE NOTICE AS THE CLAIM CONTAINS
CW& ALL NON COVERED SERVICES.
Humana Remittance Advice Codes

The following codes are updated on a monthly basis. Some codes may have changed since last update.

Last Update: 12/5/07
Code Description
THIS PROVIDER IS A MEMBER OF THE DELL NETWORK. SERVICES ARE DISCOUNTED ACCORDING
CW! TO THE NEGOTIATED RATE.
CW$ MAINTENANCE THERAPY IS NOT A MEDICARE COVERED BENEFIT.
THIS AMOUNT HAS BEEN COORDINATED WITH THE WORKER'S COMPENSATION BENEFIT YOU
CW* HAVE RECEIVED THROUGH YOUR EMPLOYER. REFER TO YOUR BENEFIT PLAN DOCUMENT.
CW/ THE 90 DAY COURSE OF TREATMENT LIMIT FOR THIS BENEFIT HAS BEEN MET.
THE SERVICE BEING BILLED IS NOT SUPPORTED BY THE DIAGNOSIS BILLED AND/OR
CW? DOCUMENTATION RECEIVED.

CW# PAID AMOUNT EXCEEDING CHARGE IS BASED ON THE PROVIDER CONTRACTUAL AGREEMENT.
CWB CLAIM DEFICIENT. PLEASE RESUBMIT WITH INFORMATION IN FIELD 50.
CWD DEFICIENT CLAIM. PLEASE RESUBMIT WITH INFORMATION IN FIELD 58-89.
CWE SERVICES HAVE BEEN DENIED BY MENTAL HEALTH VENDOR.
CWF THIS SERVICE IS NOT COVERED DUE TO THE BENEFIT WAITING PERIOD.
CWG THIS CONDITION IS EXCLUDED FROM COVERAGE.
CWH SERVICES ARE DENIED DUE TO NO ACTIVE COVERAGE.
THE INFERTILITY MAXIMUM PAYABLE BENEFIT HAS BEEN REACHED FOR THE YEAR. THEREFORE,
CWI THIS SERVICE IS NOT COVERED. REFER TO THE BENEFIT PLAN DOCUMENT.
THE SKILLED NURSING MAXIMUM PAYABLE BENEFIT HAS BEEN REACHED FOR THE YEAR.
CWJ THEREFORE, THIS SERVICE IS NOT COVERED. REFER TO THE BENEFIT PLAN DOCUMENT.
THE DIALYSIS MAXIMUM PAYABLE BENEFIT HAS BEEN REACHED FOR THE YEAR. THEREFORE,
CWK THIS SERVICE IS NOT COVERED. REFER TO THE BENEFIT PLAN DOCUMENT.
THE ALLERGY MAXIMUM PAYABLE BENEFIT HAS BEEN REACHED FOR THE YEAR. THEREFORE,
CWL THIS SERVICE IS NOT COVERED. REFER TO THE BENEFIT PLAN DOCUMENT.
THE DENTAL MAXIMUM PAYABLE BENEFIT HAS BEEN REACHED FOR THE YEAR. THEREFORE, THIS
CWM SERVICE IS NOT COVERED. REFER TO THE BENEFIT PLAN DOCUMENT.
CWN SERVICES HAVE BEEN ROLLED TO THE APPROPRIATE CODE FOR CLAIM ADJUDICATION.
MEDICAL TESTS AND/OR EXAMINATIONS REQUIRED BY LAW ENFORCEMENT ARE NOT COVERED.
CWO REFER TO THE BENEFIT PLAN DOCUMENT.
SKILLED NURSING CARE IS NOT COVERED BY YOUR HEALTH PLAN. REFER TO YOUR BENEFIT
CWS PLAN DOCUMENT.
AUTOMATED PAP TEST (PAPNET) IS NOT ANY MORE RELIABLE THAN THE STANDARD PHYSICIAN
REVIEW OF A SLIDE. THEREFORE, THIS SERVICE IS CONSIDERED NOT MEDICALLY NECESSARY.
CWT REFER TO THE BENEFIT PLAN DOCUMENT.

CWU AUTOPSIES ARE NOT A COVERED EXPENSE. PLEASE REFER TO THE BENEFIT PLAN DOCUMENT.
CHARGES FOR SERVICES RELATED TO MEDICAL PAPERWORK, UNLESS RELATED TO
CWV TRANSPLANTS, ARE NOT COVERED. REFER TO THE BENEFIT PLAN DOCUMENT.
COURT-RELATED MEDICAL TESTIMONY IS NOT A COVERED SERVICE. REFER TO THE BENEFIT
CWX PLAN DOCUMENT.
CHEST COMPRESSION GENERATORS AND HOSES ARE NOT A COVERED BENEFIT UNLESS
TREATMENT IS FOR A PATIENT WITH CYSTIC FIBROSIS. WE RELIED ON INTERNAL CRITERIA TO
MAKE THIS DETERMINATION. THIS INFORMATION WILL BE SUPPLIED TO YOU UPON REQUEST,
CWY FREE OF CHARGE.
CHARGES FOR HOME MODIFICATION SERVICES ARE NOT COVERED. REFER TO THE BENEFIT PLAN
CWZ DOCUMENT.
CW1 THIS CODE IS OBSOLETE. PLEASE RESUBMIT WITH A CURRENT HCPCS AND/OR CPT CODE.

CW2 CHARGE WILL BE CONSIDERED WHEN A CURRENT HCPCS OR CPT CODE HAS BEEN RECEIVED.
Humana Remittance Advice Codes

The following codes are updated on a monthly basis. Some codes may have changed since last update.

Last Update: 12/5/07
Code Description
THIS PAYMENT REFLECTS A RATE NEGOTIATED BY HUMANA AND NATIONAL HEALTH BENEFITS
CW4 CORPORATION.
YOUR CLAIM HAS BEEN REVIEWED AND DENIED. A LETTER OF MEDICAL NECESSITY
CW7 DETERMINATION WILL FOLLOW.
CLAIM HAS BEEN CLINICALLY REVIEWED AND FINAL DETERMINATION IS THAT CHARGES WILL NOT
CW8 BE ALLOWED; NO FURTHER PAYMENT WILL BE MADE.
THIS SERVICE WAS REVIEWED AT THE REQUEST OF THE PROVIDER AND DETERMINDED TO BE
CX& NOT COVERED. WE USED MEDICARE GUIDELINES TO MAKE THIS DETERMINATION.
CX* PAYMENT IS 50% OF ELIGIBLE CHARGES
THIS SERVICE/PROCEDURE IS INCIDENTAL, AND THEREFORE NOT REIMBURSED SEPARATELY. WE
CX? RELIED ON INTERNAL CRITERIA TO MAKE THIS DETERMINATION.
CX ADDITIONAL AMOUNT OF DRG OR APC OVER BILLED CHARGE.
CXA PLEASE SUBMIT THE EMERGENCY ROOM REPORT.
CXB NO DESCRIPTION AVAILABLE
CXC NO DESCRIPTION AVAILABLE
CXI NO DESCRIPTION AVAILABLE
THIS CLAIM HAS BEEN FORWARDED TO NEW DIRECTIONS BEHAVIORAL HEALTH, OUR
DESIGNATED MENTAL HEALTH CARRIER. TO EXPEDITE FUTURE CLAIM CONSIDERATIONS PLEASE
SEND DIRECTLY TO: NEW DIRECTIONS BEHAVIORAL HEALTH, EPOCH, PO BOX 399, SHAWNEE
CXJ MISSION,KS 66201

THIS CLAIM HAS BEEN FORWARDED TO LANDMARK HEALTHCARE SERVICES, OUR DESIGNATED
CARRIER. TO EXPEDITE FUTURE CLAIM CONSIDERATIONS PLEASE SUBMIT DIRECTLY TO:
CXK LANDMARK HEALTHCARE SERVICES, 1750 HOWE AVE SUITE 300, SACRAMENTO, CA., 95825
THIS CLAIM WAS DENIED BECAUSE THE ATTENDING PHYSICIAN'S NAME AND ADDRESS
REQUESTED FROM YOU WAS NOT RECEIVED. ONCE WE RECEIVE THE NAME AND ADDRESS, THE
CXL CLAIM WILL BE CONSIDERED FOR PAYMENT.
CXM PLEASE SUBMIT THE ATTENDING PHYSICIAN STATEMENT FOR SPEECH THERAPY.
CXN PLEASE SUBMIT THE ATTENDING PHYSICIAN STATEMENT FOR PHYSICAL THERAPY.
CXO PLEASE SUBMIT THE ATTENDING PHYSICIAN STATEMENT FOR TENS UNIT.
CXP PLEASE SUBMIT THE ATTENDING PHYSICIAN STATEMENT FOR EQUIPMENT.
CXQ PLEASE SUBMIT THE ATTENDING PHYSICIAN STATEMENT FOR CHIRO SERVICES.
CXR PLEASE SUBMIT THE ATTENDING PHYSICIAN STATEMENT FOR PRIVATE DUTY NURSING.
CXS THIS AMOUNT EXCEEDS THE AMOUNT REPRICED WITH PHOEBE HEALTH SYSTEMS.
ROUTINE HEARING/TESTING SERVICES ARE NOT A COVERABLE EXPENSE. PLEASE REFER TO
CXU BENEFIT PLAN DOCUMENT.
THE PHYSICAL THERAPY MAXIMUM PAYABLE BENEFIT HAS BEEN REACHED FOR THE YEAR.
CXV THEREFORE, THIS SERVICE IS NOT COVERED. REFER TO THE BENEFIT PLAN DOCUMENT.
THE ROUTINE CARE MAXIMUM PAYABLE BENEFIT HAS BEEN REACHED FOR THE YEAR.
CXW THEREFORE, THIS SERVICE IS NOT COVERED. REFER TO THE BENEFIT PLAN DOCUMENT.
THE VISION MAXIMUM PAYABLE BENEFIT HAS BEEN REACHED FOR THE YEAR. THEREFORE, THIS
CXY SERVICE IS NOT COVERED. REFER TO THE BENEFIT PLAN DOCUMENT.
THE SPEECH THERAPY MAXIMUM PAYABLE BENEFIT HAS BEEN REACHED FOR THE YEAR.
CXZ THEREFORE, THIS SERVICE IS NOT COVERED. REFER TO THE BENEFIT PLAN DOCUMENT.
ORTHOTICS THAT ARE NOT CUSTOM-MOLDED ARE NOT A COVERABLE EXPENSE. PLEASE REFER
CX0 TO THE BENEFIT PLAN DOCUMENT.
CX2 TRANSPLANT BENEFITS ARE NOT COVERED UNDER THIS POLICY.
PER ARIZONA REGULATION. HB2600 SECTION 34, THIS REQUEST FOR ADJUSTMENT EXCEEDS 12
CX6 MONTHS AND CANNOT BE RECONSIDERED.
Humana Remittance Advice Codes

The following codes are updated on a monthly basis. Some codes may have changed since last update.

Last Update: 12/5/07
Code Description
NOT APPROVED BY MENTAL HEALTH NETWORK/FORT WALTON MARKET AREA, PHYSICIAN MUST
CX7 SUBMIT OUTPATIENT CERTIFICATION FORM

CX8 THESE EXPENSES HAVE NOT BEEN CONSIDERED FOR PAYMENT AT THE MEMBER'S REQUEST.
THE PAYMENT REPRESENTS DOLLARS PREVIOUSLY APPLIED TO THE DEDUCTIBLE AND/OR OUT-
CY( OF-POCKET IN ERROR.
THE SERVICE PROCEDURE WAS REVIEWED AND DETERMINED TO BE NOT MEDICALLY
CY& NECESSARY. WE USED MEDICARE GUIDELINES TO MAKE THIS DETERMINATION.
THERAPY, SUPPLIES, OR COUNSELING SERVICES RELATED TO SEXUAL DYSFUNCTION ARE NOT
COVERED BY YOUR PLAN. PLEASE REVIEW THE WHAT IS NOT COVERED (MEDICAL PLANS)
CY! SECTION OF YOUR BENEFIT PLAN DOCUMENT.
CY$ LETTER OF EXPLANATION BEING SENT UNDER SEPARATE COVER FROM CORPHEALTH.
CY* HOME CARE DEVICE NOT COVERED
CY/ THIS SERVICE REQUIRES CALLCARE PRE-APPROVAL FOR COVERAGE.
CY VALID AUTHORIZATION NOT ON FILE. MEMBER IS NOT LIABLE FOR THIS AMOUNT.
COMPLEXITY OF THE ESAM CODE IS UNEXPECTED BASED UPON THE DIAGNOSIS SUBMITTED. THE
PROVIDER OF SERVICE IS RESPONSIBLE FOR SUBMITTING SUPPORTING MEDICAL
CYB DOCUMENATION FOR RECONSIDERATION.
THE SERVICE WAS NOT EXPECTED WITH THE DIAGNOSIS SUBMITTED ON THE CLAIM AND IS NOT
COVERED AS BILLED. THE PROVIDER OF SERVICE IS RESPONSIBLE FOR SUBMITTING
CYD SUPPORTING MEDICAL DOCUMENTATION FOR RECONSIDERATION.
CHARGES SUBMITTED HAVE BEEN REDISTRIBUTED TO PROVIDE A MORE ACCURATE BENEFIT. THE
SERVICE WAS NOT EXPECTED WITH THE DIAGNOSIS SUBMITTED AND IS NOT COVERED AS
BILLED. THE PROVIDER OF SERVICE IS RESPONSIBLE FOR SUBMITTING MEDICAL
CYE DOCUMENTATION FOR RECONSIDERATION.

CHARGES INCLUDE MEDICAL VISIT PERFORMED ON THE SAME DAY. THE SERVICE WAS NOT
EXPECTED WITH THE DIAGNOSIS SUBMITTED AND IS NOT COVERED AS BILLED. THE PROVIDER OF
CYF SERVICE IS RESPONSIBLE FOR SUBMITTING MEDICAL DOCUMENTATION FOR RECONSIDERATION.
CODE CHANGED TO MORE ACCURATELY REFLECT THE PROCEDURE PERFORMED. THE SERVICE
WAS NOT EXPECTED WITH THE DIAGNOSIS SUBMITTED AND IS NOT COVERED AS BILLED. THE
PROVIDER OF SERVICE IS RESPONSIBLE FOR SUBMITTING MEDICAL DOCUMENTATION FOR
CYG RECONSIDERATION.

CYH NO PRECERTIFICATION ON FILE. PENALTY APPLIED. MEMBER IS RESPONSIBLE FOR AMOUNT.

CYN NS, THE DESIGNATED PROVIDER. THIS CLAIM WAS SENT TO NEW DIRECTIONS COMMUNICATION
CYO THIS AMOUNT EXCEEDS THE PAYMENT AGREEMENT FOR MULTIPLAN NETWORK.

CYP ADDITIONAL PROVIDER INFORMATION NEEDED TO PROCESS CLAIM. PLEASE RESUBMIT CLAIM.
THIS CLAIM HAS BEEN FORWARDED TO MAGELLEN, OUR DESIGNATED MENTAL HEALTH CARRIER.
TO EXPEDITE FUTURE CLAIM CONSIDERATIONS PLEASE SEND DIRECTLY TO: MAGELLEN
CYR BEHAVIORAL HEALTH, PO BOX 13000, TALLAHASEE, FL 32317
CYY PLEASE SUBMIT OFFICE NOTES AND PATHOLOGY REPORT.
THE WELL BABY MAXIMUM PAYABLE BENEFIT HAS BEEN REACHED FOR THE YEAR. THEREFORE,
CYZ THIS SERVICE IS NOTCOVERED. REFER TO THE BENEFIT PLAN DOCUMENT.
Humana Remittance Advice Codes

The following codes are updated on a monthly basis. Some codes may have changed since last update.

Last Update: 12/5/07
Code Description
WE HAVE RECEIVED AND REVIEWED DOCUMENTATION FOR A REDUCED SERVICE LEVEL ON A
PREVIOUSLY SUBMITTED CLAIM. THE ORIGINAL DECISION REGARDING THE SERVICE LEVEL HAS
BEEN UPHELD. WE RELIED ON INTERNAL GUIDELINES TO MAKE THIS DECISION. THIS
CY0 INFORMATION WILL BE SUPPLIED TO YOU UPON REQUEST, FREE OF CHARGE.
CY1 CLAIMS FOR SSI MEDICAID MEMBER. PLEASE SUBMIT TO NHIC.
CY2 PATIENT UNDER 21 YEARS-PLEASE USE STATE STAR IMMUNIZATION
CY3 SERVICES MUST BE FILED WITH NHIC PROCESSING
CY4 MEDICAID DESCRIPTIVE CODES ONLY. NO PAYMENT DUE
CY5 INCOMPLETE EPSDT SCREEN. PLEASE PROVIDE REASON FOR TEST NOT DONE.
CY6 INCOMPLETE EPSDT SCREEN. PHYSICIAN SIGNATURE NOT PROVIDED.
CY7 SERVICES DENIED; COPY OF SIGNED CONSENT NECESSARY
CY8 SERVICES NOT COVERED PER CONTRACT. BILL PATIENT IF WAIVER SIGNED.
CY9 PAYMENT ON THIS CLAIM WAS INCLUDED IN SETTLEMENT FROM PCA.
THIS SERVICE(S) PROCEDURE IS CONSIDERED TO BE MUTUALLY EXCLUSIVE TO THE PRIMARY
PROCEDURE AND SHOULD NOT HAVE BEEN BILLED SEPARATELY. WE RELIED ON INTERNAL
CZ& CRITERIA TO MAKE THIS DETERMINATION.
CZ$ MATERNITY SERVICES ARE INELIGIBLE FOR PAYMENT.
THIS AMOUNT EXCEEDS THE PYMT AGREEMENT FOR PRIME HEALTH/HCD. ANY QUESTIONS
CZ% REGARDING NETWORK SAVINGS, CONTACT COALITION AMERICA INC. AT 404-459-7201.
AMOUNT ALLOWED IS THE HFN ALLOWABLE FEE. YOU ARE NOT REQUIRED TO PAY THE PROVIDER
CZ? ADJUSTMENT.
CZ# NEED MEDICARE IDENTIFICATION NUMBER TO ADJUDICATE CLAIM.
CZ VALID AUTHORIZATION IS NOT ON FILE. MEMBER IS NOT LIABLE FOR THIS AMOUNT.

CZA THE DOCUMENTATION SUBMITTED FOR THESE CHARGES SUPPORTS THE SERVICE LEVEL BILLED.
WE HAVE RECEIVED AND REVIEWED DOCUMENTATION THAT SUPPORTS A PREVIOUSLY
SUBMITTED CLAIM. WE HAVE OVERTURNED THE ORIGINAL DECISION AND HAVE THEREFORE
CZB INCREASED THE ALLOWED AMOUNT FOR THIS SERVICE.
WE HAVE RECEIVED AND REVIEWED DOCUMENTATION THAT SUPPORTS A PREVIOUSLY
SUBMITTED CLAIM. BASED ON THIS DOCUMENTATION, WE HAVE INCREASED THE ALLOWED
CZC AMOUNT FOR THIS SERVICE.
THE HEARING MAXIMUM PAYABLE BENEFIT HAS BEEN REACHED FOR THE YEAR. THEREFORE,
CZG THIS SERVICE IS NOT COVERED. REFER TO THE BENEFIT PLAN DOCUMENT.

THE OCCUPATIONAL THERAPY MAXIMUM PAYABLE BENEFIT HAS BEEN REACHED FOR THE YEAR.
CZH THEREFORE, THIS SERVICE IS NOT COVERED. REFER TO THE BENEFIT PLAN DOCUMENT.
THE PODIATRY MAXIMUM PAYABLE BENEFIT HAS BEEN REACHED FOR THE YEAR. THEREFORE,
CZI THIS SERVICE IS NOT COVERED. REFER TO THE BENEFIT PLAN DOCUMENT.
THE CHIROPRACTIC MAXIMUM PAYABLE BENEFIT FOR THIS SERVICE HAS BEEN REACHED FOR
THE YEAR. THEREFORE, THIS SERVICE IS NOT COVERED. REFER TO THE BENEFIT PLAN
CZJ DOCUMENT.
CLAIM HAS BEEN DENIED DUE TO PENDING TRANSPLANT CONTRACT NEGOTIATIONS.UPON
COMPLETION OF TRANSPLANTCONTRACT NEGOTIATIONS, CLAIM(S) WILL BE PROMPTLY
CONSIDERED ACCORDING TO CONTRACT AND PLAN BENEFITS.RESUBMISSION OF CLAIM(S) IS
CZK NOT REQUIRED.
CZL CLAIM DEFICIENT. RESUBMIT WITH INFO IN BOX 23 OF HCFA1500 OR FIELD 63 OF UB92.

CZN THIS CLAIM WAS DETERMINED TO BE DEFICIENT. PLEASE SUBMIT REQUIRED ATTACHMENT(S).
CZP CLAIM DEFICIENT. PLEASE RESUBMIT WITH THE INFORMATION IN FIELD 54.
Humana Remittance Advice Codes

The following codes are updated on a monthly basis. Some codes may have changed since last update.

Last Update: 12/5/07
Code Description
CZQ CLAIM DEFICIENT. PLEASE SUBMIT WITH THE INFORMATION IN FIELD(S) 11A-D.
CZR CLAIM DEFICIENT. PLEASE RESUBMIT WITH INFORMATION IN FIELD(S) 9A-D.
CZS CLAIM DEFICIENT. PLEASE RESUBMIT WITH INFORMATION IN FIELD 29 AND/OR 30.
THESE CHARGES SHOULD BE SUBMITTED TO: CNR/INOVATED HEALTH SERVICES P.O. BOX 27905
CZT MILWAUKEE WISCONSIN 53227-0905
CZU THIS AMOUNT EXCEEDS THE MULTIPLAN PAYMENT AGREEMENT.
CZV THIS AMOUNT EXCEEDS THE HEALTH PAYORS ORGANIZATION PAYMENT AGREEMENT.
CZW THIS AMOUNT EXCEEDS THE BCE EMERGIS PAYMENT AGREEMENT.

CZX THIS AMOUNT EXCEEDS THE NATIONAL HEALTH BENEFITS CORPORATION PAYMENT AGREEMENT.
THE NERVOUS MENTAL DAILY MAXIMUM PAYABLE BENEFIT HAS BEEN REACHED. THEREFORE,
CZ0 THIS SERVICE IS NOT COVERED. REFER TO THE BENEFIT PLAN DOCUMENT.

CZ4 THIS IS A LEASED NETWORK DISCOUNT. MEMBER NOT RESPONSIBLE FOR DISCOUNTED AMOUNT.
CZ8 ADDITIONAL CONSUMER CHOICE OPTION COPAYMENT FOR SPECIALIST SERVICES
THIS CLAIM HAS BEEN FORWARDED TO APS, OUR DESIGNATED MENTAL HEALTH CARRIER.TO
EXPEDITE FUTURE CLAIM CONSIDERATIONS, PLEASE SEND DIRECTLY TO: APS, PO BOX 10897,
CZ9 ROCKVILLE, MD 20849
C0* NON-EMERGENT SERVICES IN THE EMERGENCY ROOM ARE NOT A COVERED BENEFIT.
MULTIPLE CODES DESCRIBING SIMILAR SERVICES ARE NOT TO BE BILLED TOGETHER. WE RELIED
C0? ON INTERNAL CRITERIA TO MAKE THIS DETERMINATION.
IMPLANTABLE DEFIBRILLATORS ARE PAYABLE BY TRADITIONAL MEDICARE. PLEASE SUBMIT THE
C0Z CHARGES FOR IMPLANTABLE DEFIBRILLATOR TO TRADITIONAL MEDICARE.
C08 CHARGES ARE BEING REVIEWED BY YOUR THIRD PARTY ADMINISTRATOR
THIS CLAIM WAS SUBMITTED TO HUMANA IN ERROR. WE ARE NOT THE VISION CARRIER. PLEASE
C1& SUBMIT THIS CLAIM TO: VSP, P.O.BOX 997105, SACRAMENTO, CA. 95899-7105.
C1$ THIS IS AWH DISCOUNT. MEMBER NOT RESPONSIBLE FOR THIS DISCOUNTED AMOUNT.
SERVICES WERE RENDERED BY A NON-NETWORK PROVIDER. BENEFITS REDUCED TO 50% OF
C1/ THE ALLOWABLE.
CLINICAL TRIAL REQUIRES THAT DIAGNOSIS CODE BEING BILLED PRIMARY CAN NOT BE BILLED AS
C1? PRIMARY. WE RELIED ON INTERNAL CRITERIA TO MAKE THIS DETERMINATION.
C1# PAYMENT IS CALCULATED BASED ON YOUR CONTRACT WITH PPOM.
DISCOUNT TAKEN THROUGH PPO NEXT. PLEASE CALL CONCENTRA AT 800-854-3986 FOR
C1 QUESTIONS REGARDING THIS DISCOUNT.
C1B LETTER OF EXPLANATION TO FOLLOW
PLEASE CALL THE 1-800 NUMBER NOTED ON THIS FORM WITH YOUR EMPLOYMENT STATUS. THIS
C1E INFORMATION IS NEEDED SO WE CAN PROCESS YOUR CLAIM.
YOU SHOULD SUBMIT THESE CHARGES TO: MCC MANAGED BEHAVIORAL CARE, INC. MEMBER
C1G SERVICES 11095 VIKING DRIVE, SUITE 350 EDEN PRAIRIE, MN 55344
C1H EXPENSES HAVE BEEN PAID BASED ON THE MEDICARE PART B ESTIMATE.
YOU SHOULD SUBMIT THESE CHARGES TO: MCC MANAGED BEHAVIORAL CARE, INC. MEMBER
C1O SERVICES 11095 VIKING DRIVE, SUITE 350, EDEN PRAIRIE, MN 55344
C1R CHARGES PENDING AUDIT OF HOSPITAL BILL.
THIS AMOUNT EXCEEDS THE PAYMENT AGREEMENT FOR HEALTH COALITION PARTNERS. ANY
QUESTIONS REGARDING NETWORK SAVINGS, CONTACT COALITION AMERICA, INC. AT 404-459-
C1S 7201.
THIS AMOUNT EXCEEDS THE PAYMENT AGREEMENT FOR INTEGRATED HEALTH PLAN/NHP. ANY
QUESTIONS REGARDING NETWORK SAVINGS, CONTACT COALITION AMERICA, INC. AT 404-459-
C1T 7201.
Humana Remittance Advice Codes

The following codes are updated on a monthly basis. Some codes may have changed since last update.

Last Update: 12/5/07
Code Description
THIS AMOUNT EXCEEDS THE PAYMENT AGREEMENT FOR GALAXY HEALTH NETWORK. ANY
QUESTIONS REGARDING NETWORK SAVINGS, CONTACT COALITION AMERICA, INC. AT 404-459-
C1Y 7201.
C14 EXPENSES THE MEMBER IS NOT REQUIRED TO PAY ARE NOT COVERED.
C15 THIS CHARGE IS CONSIDERED AS PART OF THE PRIMARY PROCEDURE
C2( PAYMENT MADE IN FULL. TEXAS PROVIDER CONTRACTED CLEAN CLAIM PENALTY APPLIED.
THIS CLAIM WAS SUBMITTED TO HUMANA IN ERROR. WE ARE NOT THE BEHAVIORAL HEALTH
CARRIER. PLEASE SUBMIT THIS CLAIM TO: APS HEALTHCARE INC., P.O.BOX 99, LINTHICUM, MD.
C2& 21090-0099.
C2% SERVICES FOR THIS DIAGNOSIS ARE EXCLUDED FROM THE MEMBER'S PLAN.
ICD-9 E-CODES ARE NOT ACCEPTABLE AS THE PRIMARY DIAGNOSIS. RESUBMIT WITH CORRECTED
C2? ICD-9 CODE. WE RELIED ON INTERNAL CRITERIA TO MAKE THIS DETERMINATION.
C2# CANCELLED/MISSED APPOINTMENT NOT COVERED.
THIS AMOUNT EXCEEDS THE PAYMENT AGREEMENT FOR PPONEXT PHN/HEALTHSTAR. ANY
QUESTIONS REGARDING NETWORK SAVINGS, CONTACT COALITION AMERICA, INC. AT 404-459-
C2C 7201.
THIS AMOUNT EXCEEDS THE PAYMENT AGREEMENT FOR PRIMARY HEALTH SERVICES (PHS). ANY
QUESTIONS REGARDING NETWORK SAVINGS, CONTACT COALITION AMERICA, INC AT 404-459-
C2D 7201.
C2E THIS AMOUNT EXCEEDS THE CONCENTRA PAYMENT AGREEMENT.
THIS AMOUNT EXCEEDS THE PAYMENT AGREEMENT FOR HFNID. ANY QUESTIONS REGARDING
C2F NETWORK SAVINGS, CONTACT COALITION AMERICA, INC. AT 404-459-7201.
C2G THIS AMOUNT EXCEEDS THE ALLOWABLE CHARGE.
THIS AMOUNT EXCEEDS THE PAYMENT AGREEMENT FOR NOVANET. ANY QUESTIONS REGARDING
C2I NETWORK SAVINGS, CONTACT COALITION AMERICA, INC. AT 404-459-7201.
THIS AMOUNT EXCEEDS THE PAYMENT AGREEMENT FOR INTERGROUP. ANY QUESTIONS
C2K REGARDING NETWORK SAVINGS, CONTACT COALITION AMERICA, INC. AT 404-459-7201.
C2Q EXCEEDS AUTHORIZED NUMBER OF SERVICES.
C2R SERVICES PROVIDED DURING UNAUTHORIZED HOSPITAL DAYS ARE NOT COVERED.
C2S EXPLANATION OF THIS DETERMINATION IS IN LETTER FORM
THIS AMOUNT EXCEEDS THE PAYMENT AGREEMENT FOR INTERWEST TRADITIONAL. ANY
QUESTIONS REGARDING NETWORK SAVINGS, CONTACT COALITION AMERICA, INC. AT 404-459-
C2T 7201
C2U THE HOSPITAL/EMERGENCY AUTHORIZATION HAS BEEN DENIED
C2W EXPLANATION OF THIS DETERMINATION IS IN LETTER FORM

THIS AMOUNT EXCEEDS THE PAYMENT AGREEMENT FOR PREFERRED CARE. ANY QUESTIONS
C2X REGARDING NETWORK SAVINGS, CONTACT COALITION AMERICA, INC. AT 404-459-7201.
THIS AMOUNT EXCEEDS THE PAYMENT AGREEMENT FOR HMN/RAN/AMN. ANY QUESTIONS
C2Y REGARDING NETWORK SAVINGS,CONTACT COALITION AMERICA, INC. AT 404-459-7201.
C2Z LETTER OF EXPLANATION TO FOLLOW
THIS AMOUNT EXCEEDS THE PAYMENT AGREEMENT FOR PHS/HEALTH PAYORS ORGANIZATION,
LTD. ANY QUESTIONS REGARDING NETWORK SAVINGS, CONTACT COALITION AMERICA, INC. AT
C23 404-459-7201.
C25 CLAIM PENDING RECEIPT OF ADDITIONAL INFORMATION.
THIS MEDICATION WAS PREVIOUSLY PROCESSED BY YOUR PLAN'S PHARMACY CLAIMS
C3( ADMINISTRATOR.
Humana Remittance Advice Codes

The following codes are updated on a monthly basis. Some codes may have changed since last update.

Last Update: 12/5/07
Code Description
THIS CLAIM WAS SUBMITTED TO HUMANA IN ERROR. WE ARE NOT THE HEARING CARRIER
PLEASE SUBMIT THIS CLAIM TO: NECP/HEARUSA, 6825 E. TENNESSEE AVE. #415, DENVER, CO.
C3& 80224-1632.
C3! SERVICE IS ON SAME DATE AS INPATIENT PROCDURE.
THE FOREIGN TRAVEL MAXIMUM PAYABLE BENEFIT HAS BEEN REACHED FOR THE YEAR.
C3% THEREFORE, THIS SERVICE IS NOT COVERED
AMOUNT EXCEEDS THE PAYMENT AGREEMENT FOR CAI & MEDLINK HEALTHCARE. ANY
QUESTIONS REGARDING NETWORK SAVINGS, CONTACT COALITION AMERICA INC. AT 404-459-
C3? 7201.
DURABLE MEDICAL EQUIPMENT INCLUDING RELATED SUPPLIES AND/OR REPAIR IS NOT COVERED.
C3 REFER TO YOUR BENEFIT PLAN DOCUMENT.
C3A PAYMENT FOR THE NEWBORN WAS INCLUDED IN THE MOTHER'S MATERNITY PAYMENT.
THIS AMOUNT EXCEEDS THE PAYMENT AGREEMENT FOR FORTIFIED PROVIDER NETWORK. ANY
QUESTIONS REGARDING NETWORK SAVINGS, CONTACT COALITION AMERICA, INC. AT 404-459-
C3C 7201.
THIS AMOUNT EXCEEDS THE PAYMENT AGREEMENT FOR THREE RIVERS PROVIDER NETWORK.
ANY QUESTIONS REGARDING NETWORK SAVINGS, CONTACT COALITION AMERICA, INC. AT 404-459-
C3D 7201.
C3H MEDICAL RECORDS NEEDED, MEMBER CANNOT BE BILLED.
C3J NO VALID AUTHORIZATION ON FILE FOR SERVICES RENDERED.
C3K A HCFA 1500 FORM IS NEEDED TO PROCESS THIS ELECTRONIC SUBMISSION.
C3L SUBMIT PROOF OF DISINCENTIVE PAYMENT
C3N PLEASE SUBMIT A VALID CHARGE AMOUNT FOR SERVICE.
C3P BENEFITS ARE NOT PROVIDED UNDER THIS PLAN FOR PHYSICIAN SERVICES.
THIS WAS SUBMITTED TO HUMANA IN ERROR. WE ARE NOT THE PHARMACY CARRIER. PLEASE
SUBMIT THIS CLAIM TO: ADVANCED PHARMACY CARRIER SYSTEM (PCS), P.O.BOX 52116, PHOENIX,
C3Q AZ 85072-2116.
C3R NO ADDL PMT DUE ON LATE INPAT CHGS UNLESS ADDL DAY(S) BILLED
C3S OUTPT LATE CHGS W/ BENEFIT PMT DUE OF LESS THAN $50 - WRITE-OFF
THIS AMOUNT EXCEEDS THE PAYMENT AGREEMENT FOR AMERICAN PPO. ANY QUESTIONS
C3X REGARDING NETWORK SAVINGS, CONTACT COALITION AMERICA, INC. AT 404-459-7201.
C3Z PRICE DIFFERENCE BETWEEN THE BRAND NAME DRUG AND THE GENERIC DRUG.
C31 OFFICE VISITS ARE NOT COVERED WHEN A NON PARTICIPATING PROVIDER IS UTILIZED.
THIS IS A DUPLICATE OF A CLAIM PREVIOUSLY PROCESSED. THIS CLAIM WAS RECEIVED
ELECTRONICALLY FROM MEDICARE THROUGH AUTOMATED CLAIMS PROCESSING. IT WAS ALSO
RECEIVED FROM THE PROVIDER OF SERVICE/MEMBER. IT IS NOT NECESSARY TO SUBMIT MOST
CLAIMSFOR MEMBERS WHO HAVE CHOSEN AUTOMATED CLAIMS PROCESSING, AS THEY ARE
C35 SENT DIRECTLY FROM MEDICARE TO HUMANA.
C38 PROMPT PAY DISCOUNT. EXPENSE NOT THE RESPONSIBILITY OF MEMBER.
C39 CHARGES DISALLOWED AFTER AUDIT OF HOSPITAL BILL.
NON-PAR EMERGENCY ROOM SERVICES AND ADMISSIONS ARE PAID AT A USUAL AND
CUSTOMARY RATE AS ALLOWED BY FLORIDA STATUTE 641.513(5) (B). BALANCE BILLING OF
C4& MEMBERS IS PROHIBITED BY FLORIDA STATUTE 641.3155(8).
THIS IS A BEECHSTREET NETWORK DISCOUNT. MEMBER IS NOT RESPONSIBLE FOR THIS
C4$ DISCOUNTED AMOUNT.
C4/ THIS AMOUNT WAS PAID BY YOUR PRIMARY INSURANCE CARRIER.
C4% NO DESCRIPTION AVAILABLE
C4# THE PATIENT IS NOT RESPONSIBLE FOR THESE CHARGES.
Humana Remittance Advice Codes

The following codes are updated on a monthly basis. Some codes may have changed since last update.

Last Update: 12/5/07
Code Description
THIS AMOUNT EXCEEDS THE PAYMENT AGREEMENT FOR MEDICAL RESOURCE/NATNL PRVDR
NTWK. ANY QUESTIONS REGARDING NETWORK SAVINGS, CONTACT COALITION AMERICA, INC. AT
C4C 404-459-7201.
C4D BILL HOSPICE FOR CLAIMS. IF NON-TERMINAL ILLNESS, BILL ORIGINAL MEDICARE.
THIS IS NOT A COVERED SERVICE. CHARGES SHOULD BE SUBMITTED TO MEDICAID FOR
C4E CONSIDERATION.
C4F SERVICES NOT COVERED UNDER WORKERS' COMPENSATION.
YOU SHOULD SUBMIT THESE CHARGES TO: BEHAVIORAL HEALTH DEPARTMENT. CLAIMS
C4G DEPARTMENT 222 SOUTH RIVERSIDE PLAZA, SUITE 1045 CHICAGO, IL 60606
C4I SUBMIT TO PREFERRED HEALTH CARE, RYDER CLAIMS REPRESENTATIVE
C4J FILE PRESCRIPTION CHARGES WITH PAID PRESCRIPTION PLAN CARRIER
THIS AMOUNT EXCEEDS THE PAYMENT AGREEMENT FOR MEDICAL RESOURCE/NATNL HOSPITAL
NTWK. ANY QUESTIONS REGARDING NETWORK SAVINGS, CONTACT COALITION AMERICA, INC. AT
C4L 404-459-7201.
THIS CLAIM WAS RECEIVED BY THE MEDICARE CARRIERS. PLEASE SUBMIT AN ITEMIZED HCFA-
C4M 1500 CLAIM FORM.
SERVICES FOR A MEDICARE BENEFICIARY MUST BE PROVIDED BY A MEDICARE CERTIFIED
C4P NURSING FACILITY. THE MEMBER SHOULD NOT BE BILLED.
C4Q AMOUNT OVER WORKERS' COMPENSATION APPROVED PROVIDER DISCOUNT.
C4R AMOUNT OVER WORKERS' COMPENSATION REIMBURSEMENT FEE SCHEDULE.
C4S THIS SERVICE SHOULD BE RENDERED BY THE DESIGNATED LABORATORY
C4T THESE SERVICES HAVE BEEN CONSIDERED BY THE PRIOR CARRIER
THIS AMOUNT EXCEEDS THE PAYMENT AGREEMENT FOR PHS/HPO/INTEGRATED HLTH PLAN, INC.
ANY QUESTIONS REGARDING NETWORK SAVINGS, CONTACT COALITION AMERICA, INC. AT 404-459-
C42 7201.
THIS AMOUNT EXCEEDS THE PAYMENT AGREEMENT FOR HEALTH PAYORS ORGANIZATION. ANY
QUESTIONS REGARDING NETWORK SAVINGS, CONTACT COALITION AMERICA, INC. AT 404-459-
C44 7201.
C45 THIS SERVICE HAS BEEN DENIED BY TRANSPLANT MANAGEMENT
THE DME MAXIMUM PAYABLE BENEFIT HAS BEEN REACHED FOR THE YEAR. THEREFORE, THIS
C46 SERVICE IS NOT COVERED. REFER TO THE BENEFIT PLAN DOCUMENT.
C47 TYPE OF DRUG NOT COVERED
C48 PAYMENT REDUCED BY ADMAR NEGOTIATED AMOUNT
THESE CHARGES ARE INCLUDED IN THE CONTRACTED FEE FOR THE TRANSPLANT SERVICES. THE
C49 MEMBER CANNOT BE BILLED FOR THESE CHARGES.
C5& UNIT PREVIOUSLY RENTED; RENTAL FEES ARE APPLIED TO THE PURCHASE PRICE.
C5! THIS SERVICE/PROCEDURE IS ONLY BILLED AS INPATIENT.
THE AMOUNT EXCEEDS THE PYMT AGREEMENT FOR PHS/COMP CARE OF OZARKS. ANY
QUESTIONS REGARDING NETWORK SAVINGS, CONTACT COALITION AMERICA INC. AT 404-459-
C5% 7201.
INAPPROPRIATE SPECIFICATION OF BILATERAL PROCEDURES. WE RELIED ON INTERNAL CRITERIA
C5? TO MAKE THIS DETERMINATION.

C5# EXPENSES ARISING FROM OR RELATED TO ANY NON COVERED TREATMENT ARE NOT COVERED.
C5A MEMBER ADVISED TO CONTACT BILLING OFFICE DUE TO INCOMPLETE RECORDS
C5B EXPENSES FOR HEARING AIDS ARE NOT COVERED
C5C RESUBMIT CLAIM FOR BENEFIT DETERMINATION AFTER DELIVERY
C5D EXCEEDS TIMELY FILING LIMITATIONS: EXPENSES NOT COVERED.
C5E EXPENSES NOT COVERED-24 MONTHS ALLOWED FOR FILING OF CLAIM
Humana Remittance Advice Codes

The following codes are updated on a monthly basis. Some codes may have changed since last update.

Last Update: 12/5/07
Code Description
C5F MISSED APPOINTMENTS OR COMPLETION OF FORMS ARE NOT COVERED
C5G SERVICE DETERMINED AS NOT MEDICALLY NECESSARY
C5H PLAN EXCLUDES COVERAGE FOR ABORTION EXCEPT TO SAVE THE LIFE OF THE MOTHER.
C5I EXPENSES FOR REPLACEMENT DUE TO LOSS, ETC ARE NOT COVERED
C5J PHYSICIAN NOT RECOGNIZED UNDER PLAN PROVISIONS.
C5K THIS AMOUNT IS NOT COVERED DUE TO MEDICARE PROSPECTIVE PAYMENT SYSTEM.
C5L DIAGNOSIS IS NOT A COVERED NERVOUS AND MENTAL BENEFIT
C5M FACILITY NOT A RECOGNIZED AMBULATORY SURGICAL/BIRTHING CTR
C5N BENEFITS ARE NOT PROVIDED FOR PRE-EXISTING CONDITIONS
C5O BENEFITS ARE NOT PROVIDED FOR ROOM EXPENSE AFTER DISCHARGE
C5P PRESCRIPTION DRUGS ARE NOT COVERED UNDER THIS POLICY.
C5Q NO ADDITIONAL BENEFIT FOR PHYSICIAN VISITS FOLLOWING SURGERY
C5R CALENDAR YEAR PRESCRIPTION DRUG MAXIMUM HAS BEEN MET
C5S REPLACEMENTS COVERED ONLY IF PHYSICAL CHANGE IN AREA
C5T COPAYMENT AND/OR COINSURANCE
C5U ORTHOTICS ARE NOT COVERED UNDER THIS POLICY
C5V RESUBMIT CLAIM FOR BENEFIT DETERMINATION AFTER TREATMENT COMPLETED
C5W ICD-9 DOES NOT WARRANT SPEECH/PHYSICAL THERAPY BENEFITS
C5Y SUBMIT THESE CHARGES TO MANAGED CARE PROGRAMS.
CLAIM WAS SUBMITTED TO HUMANA IN ERROR. SUBMIT CLAIM TO MEMBER'S PRIMARY CARE
C5Z PHYSICIAN'S CENTER OFTHE INDEPENDENT PRACTICE ASSOCIATION (IPA).
C50 PERSONAL ITEMS (TV, TELEPHONE, ETC.) ARE NOT COVERED.
C51 NO DESCRIPTION AVAILABLE
C52 PRIVATE ROOM BENEFITS ARE LIMITED TO THE AVERAGE SEMI-PRIVATE RATE.
C53 TREATMENT COVERED BY WORKER'S COMPENSATION IS NOT COVERED.
C54 INSTITUTION NOT RECOGNIZED AS A HOSPITAL
C55 DENTAL SERVICES ARE NOT COVERED, EXCEPT FOR ACCIDENTAL INJURY.
C56 SERVICES/SUPPLIES NOT ORDERED BY PHYSICIAN ARE NOT COVERED
C57 VITAMINS, MINERALS, & NUTRITIONAL SUPPLEMENTS NOT COVERED
C58 ROUTINE SERVICES ARE NOT COVERED BY THIS POLICY.
C59 BENEFITS FOR THIS SERVICE HAVE BEEN EXHAUSTED
C6& REFERRING PHYSICIAN IS INELIGIBLE TO ORDER DME AND/OR TESTING.
C6* THE YEARLY MAXIMUM PSYCHIATRIC VISITS HAS BEEN MET.
THE CLAIM WAS PAID IN ACCORDANCE WITH THE AMBULATORY PAYMENT CLASSIFICATION
PAYMENT RATE, HOWEVER, NOT ALL PROCEDURES/SERVICES WERE ALLOWED. FOR
EXPLANATION OF THE PROCEDURES/SERVICES THAT WERE NOT ALLOWED, PLEASE REVIEW
C6% SUBSEQUENT REJECTED LINE(S).
C6? CODE IS NOT RECOGNIZED BY MEDICARE.
C6# BENEFIT DETERMINATION PER CONSULTANT REVIEW
C6B THIS AMOUNT HAS BEEN PAID BY THE PRIMARY INSURANCE CARRIER
C6D CLAIM HAS BEEN PENDED FOR REVIEW. NO ACTION IS NECESSARY.
YOU SHOULD SUBMIT THESE CHARGES TO: METROPOLITAN CLINICS OF COUNSELING 1720 SOUTH
C6E BELLAIRE SUITE #106 DENVER, CO 80222 PHONE: (303) 759-5292
YOU SHOULD SUBMIT THESE CHARGES TO: PSYCHOLOGICAL RESOURCE ORGANIZATION 3700
C6F EAST ALAMEDA SUITE #300 DENVER, CO 80209
SUBMITTED CHARGES WERE REDISTRIBUTED FOR A MORE ACCURATE BENEFIT. THE PROVIDER
OF SERVICE IS RESPONSIBLE FOR SUBMITTING SUPPORTING MEDICAL DOCUMENTATION FOR
C6H RECONSIDERATION.
C6I CHARGES INCLUDE MEDICAL VISITS PERFORMED ON THE SAME DAY
Humana Remittance Advice Codes

The following codes are updated on a monthly basis. Some codes may have changed since last update.

Last Update: 12/5/07
Code Description
C6J COSMETIC PROCEDURE ONLY COVERED IF DUE TO ACC WHILE INSURED
THIS CLAIM HAS BEEN PENDED FOR FURTHER REVIEW. WE ARE NOT REQUESTING ANY
INFORMATION FROM YOU AT THIS TIME, BUT REVIEW IS NECESSARY BEFORE BENEFITS CAN BE
C6K DETERMINED.
CHARGES HAVE BEEN COMBINED WITH PRIMARY PROCEDURE TO PROVIDE A MORE ACCURATE
C6L BENEFIT. NO ADDITIONAL PAYMENT WILL BE MADE.
THIS SERVICE WAS DENIED BECAUSE IT WAS PART OF ANOTHER SERVICE PROVIDED AT THE
C6M SAME TIME. NO ADDITIONAL PAYMENT WILL BE MADE.

C6N SERVICE WILL NOT BE REIMBURSED ON SAME DATE AS ANOTHER COMPREHENSIVE SERVICE.
C6O PATIENT RESPONSIBLE FOR COPAY UNDER PHYS. PANEL PRODUCT
C6P PROCEDURE INVALID FOR PATIENT'S SEX/AGE. REPLACED CODE WITH ALTERNATE CODE.
C6Q THIS CHARGE APPEARS TO BE A DUPLICATE
CODE CHANGED TO MORE ACCURATELY REFLECT THE PROCEDURE PERFORMED. THE PROVIDER
OF SERVICE IS RESPONSIBLE FOR SUBMITTING SUPPORTING MEDICAL DOCUMENTATION FOR
C6S RECONSIDERATION.

C6V CODE SUBMITTED WAS CHANGED TO MORE ACCURATELY REFLECT THE SERVICE PERFORMED.

C6W CODE SUBMITTED WAS CHANGED TO MORE ACCURATELY REFLECT THE SERVICE PERFORMED.
C6X MEDICAL VISIT NOT ALLOWED FOR SEPARATE REIMBURSEMENT
C6Y SERVICE DOES NOT REQUIRE AN ASSISTANT SURGEON.
THIS CLAIM HAS BEEN FORWARDED TO THE DESIGNATED MENTAL HEALTH CARRIER. TO
EXPEDITE FUTURE CLAIMS PROCESSING, PLEASE SEND CLAIMS DIRECTLY TO THE MENTAL
C6Z HEALTH CARRIER FOR THIS MEMBER.
C60 CHARGES INCURRED AFTER COVERAGE TERMINATED ARE NOT COVERED
C61 CHARGES INCURRED PRIOR TO EFFECTIVE DATE OF COVERAGE
C62 ROUTINE FOOT CARE IS NOT COVERED
C63 EYE REFRACTIONS ARE NOT COVERED
C64 EYE GLASSES, CONTACT LENSES AND/OR EYE EXAMS ARE NOT COVERED.
C65 ORTHOPTIC OR VISUAL TRAINING IS NOT COVERED
THIS IS A DUPLICATE OF A CLAIM WE ARE CURRENTLY CONSIDERING. NO ACTION IS NECESSARY
C66 FROM YOU AT THIS TIME.
C67 SUBLUXATION/MISPLACEMENTS OF VERTEBRAE TREATMENT NOT COVERED
C68 EDUCATIONAL MATERIALS, TESTING OR TRAINING IS NOT COVERED
C69 CUSTODIAL CARE IS NOT COVERED
C7( CLAIM PAID IN ACCORDANCE WITH THE "FIRST STEPS" BENEFIT ENHANCEMENT.
PLEASE SUBMIT MEDICAL NOTES WHICH ARE NEEDED TO REVIEW THE CLAIM FOR MEDICAL
C7! NECESSITY.
C7$ PROPER AUTHORIZATION IS NOT ON FILE FOR THIS SERVICE.
C7? NO DESCRIPTION AVAILABLE
WEIGHT CONTROL TREATMENT AND RELATED PROCEDURES ARE NOT COVERED UNDER THIS
C7# PLAN.
C7A AMOUNT OVER THE ACCEPTED FEE SCHEDULE
C7B ANCILLARY SERVICES ADJUSTED. LETTER OF EXPLANATION TO FOLLOW
C7C CHARGE IS PART OF ANOTHER SERVICE PROVIDED AT THE SAME TIME.
C7D LETTER OF EXPLANATION BEING SENT UNDER SEPARATE COVER.
C7E THIS AMOUNT EXCEEDS THE SAGAMORE NETWORK PAYMENT AGREEMENT.
Humana Remittance Advice Codes

The following codes are updated on a monthly basis. Some codes may have changed since last update.

Last Update: 12/5/07
Code Description
PRESCRIPTION TAKE HOME DRUGS DISPENSED FROM A FACILITY OR PHYSICIAN OFFICE FOR
C7F MEMBER CONSUMPTION AFTER DISCHARGE ARE NOT COVERED.
C7G PRIOR APPROVAL NOT ON FILE FOR THIS NON-PAR PROVIDER
C7H SCHOOL, SPORT, OR WORK EXAMS ARE NOT COVERED
SERVICES PROVIDED AT A NON-PARTICIPATING FACILITY ARE NOT COVERED WITHOUT PRIOR
C7I APPROVAL.
C7J PRIOR-AUTHORIZATION NOT OBTAINED
C7K SUBMIT THESE CHARGES TO UNITED BEHAVIORAL COUNSELING
C7L HOSPITAL CHARGES NOT COVERED-ADMITTING PHYSICIAN NON-PAR
C7M CHARGES REDUCED BY CONTRACTED ARRANGEMENT
YOU SHOULD SUBMIT THESE CHARGES TO: ASSOCIATED COUNSELING & THERAPY 3150 CUSTER
C7O DR SUITE #300 LEXINGTON, KY 40502
C7P BENEFITS ARE ALLOWED TO ONE PHYSICIAN PER DAY FOR EACH DIAGNOSIS
C7Q ORAL SURGERY IS NOT COVERED. REFER TO YOUR BENEFIT PLAN DOCUMENT.
C7R FUTURE SERVICES WILL BE SUBJECT TO MEDICAL NECESSITY REVIEW
C7T HOSPITAL MEDICAL RECORDS NEEDED
C7U TRANSPORTATION RELATING TO UNAUTHORIZED TREATMENT IS NOT PAYABLE
C7V PROFESSIONAL COMPONENT MUST BE BILLED ON CMS 1500 FORM
C7W CHARGES EXCEED THE FEE ALLOWANCE APPROVED BY THE CENTER
C7X PROVIDER CONTRACT TERMS FOR THIS CLAIM PREVIOUSLY PAID IN FULL.
C7Y PAID AS MEDICARE CONTRACTED PROVIDER-MEMBER NOT RESPONSIBLE
C7Z REFERRAL PROCESS INCOMPLETE
C70 COSMETIC PROCEDURE ONLY COVERED IF DUE TO ACCIDENT WHILE INSURED.
C71 SERVICES TO REVERSE VOLUNTARY STERILIZATION ARE NOT COVERED
C72 EXPERIMENTAL PROCEDURES ARE NOT COVERED.
LIMITATIONS FOR THIS PRE-EXISTING CONDITION HAVE BEEN REACHED AND THE BENEFITS HAVE
C73 BEEN EXHAUSTED ACCORDING TO THE BENEFIT PLAN DOCUMENT.
C74 DEPENDENT CHILD MATERNITY CHARGES ARE NOT COVERED.
C75 CHARGES FOR SURGICAL PROCEDURES FOR OBESITY ARE NOT COVERED.
THIS SERVICE IS NOT COVERED. THE PROVIDER/FACILITY IS NOT RECOGNIZED AS
C76 PARTICIPATING. REFER TO YOURBENEFIT PLAN DOCUMENT.
C77 TYPE OF EXPENSE IS NOT COVERED
C78 TYPE OF EXPENSE NOT RECOGNIZED AS DURABLE MEDICAL EQUIPMENT
C79 OBESITY TREATMENT/WEIGHT CONTROL METHODS ARE NOT COVERED
AMNIOCENTESIS IS NOT COVERED BY YOUR PLAN. PLEASE REVIEW YOUR BENEFIT PLAN
C8( DOCUMENT.
C8? THIS SERVICE EXCEEDS THE PLAN BENEFIT MAXIMUM.
C8# COSMETIC SURGERY IS NOT COVERED BY THIS PLAN.
THE AMOUNT EXCEEDS YOUR PLAN'S MAXIMUM FOR LABS/XRAYS, THEREFORE THIS SERVICE IS
C8 NOT COVERED. REFER TO YOUR PLAN BENEFIT DOCUMENT.
C8A MEDICARE EXPLANATION OF BENEFITS NEEDED BEFORE PAYMENT CAN BE MADE.
C8B EXPLANATION OF BENEFITS FROM OTHER CARRIER IS NEEDED
C8C PHYSICIAN IS NOT LISTED AS THE PRIMARY CARE PHYSICIAN
C8D POLICY DOES NOT CONTAIN PARTICIPATING PHARMACY BENEFITS
C8E OTHER PARTY/CARRIER INFORMATION REQUESTED WAS NOT RECEIVED
C8F ROOM AND BOARD EXPENSES DETERMINED NOT MEDICALLY NECESSARY
C8G THESE CHARGES HAVE BEEN CONSIDERED BY UNITED BEHAVIORAL HEALTH SERVICES.
C8I BILLED SERVICES EXCEED THOSE AUTHORIZED
C8J THE HOSPITAL/EMERGENCY AUTHORIZATION HAS BEEN DENIED
Humana Remittance Advice Codes

The following codes are updated on a monthly basis. Some codes may have changed since last update.

Last Update: 12/5/07
Code Description
C8K REFERRAL PROCESS INCOMPLETE-CONTACT MEMBER'S CENTER
C8L SERVICES RENDERED BY FAMILY MEMBERS ARE NOT A COVERED EXPENSE

C8M NOT APPROVED BY MERIT BEHAVIORAL SERVICES, SUBMIT OUTPATIENT CERTIFICATION FORM
C8N TREATMENT NOT AUTHORIZED BY A HUMANA HEALTH CARE PLAN PHYSICIAN
THIS CLAIM HAS BEEN FORWARDED TO CONTACT BEHAVIORAL HEALTH SYSTEMS, OUR
DESIGNATED MENTAL HEALTH CARRIER. TO EXPEDITE FUTURE CLAIMS CONSIDERATIONS PLEASE
SEND DIRECTLY TO: CONTACT BEHAVIORAL HEALTH SYSTEMS, 1400 E. SOUTHERN STE 800,
C8O TEMPE, AZ 85282.
C8P APPROVED HMO OUTPATIENT AUTHORIZATION IS NOT ON FILE. CLAIM IS REJECTED.
C8Q THIS EXPENSE HAS BEEN APPLIED TO A PRIOR YEAR'S DEDUCTIBLE
C8R PLEASE SEE PRIOR LETTER OF EXPLANATION REGARDING THESE SERVICES
C8S LETTER OF EXPLANATION BEING SENT UNDER SEPARATE COVER.
C8T ON CALL SERVICES ARE NOT PAYABLE; PLEASE SEE PCP FOR PAYMENT.
C8U PRIMARY CARE PHYSICIAN UNIDENTIFIED
THIS DISCOUNT WAS OBTAINED BY HUMANA THROUGH A ONE TIME NEGOTIATION BETWEEN
HUMANA AND YOUR ORGANIZATION. THIS DISCOUNT AMOUNT IS NOT THE RESPONSIBILITY OF
C8V THE MEMBER OR INSURER.
C8W SERVICES PERFORMED EXCEEDS THE REFERRAL AUTHORIZATION
C8X REJECTED-REFERRAL NOT APPROVED BY MARKET OFFICE
C8Y THIS CHARGE IS CONSIDERED AS PART OF THE PRIMARY PROCEDURE
WE CANNOT CONSIDER PAYMENT BECAUSE THESE SERVICES WERE NOT URGENT/EMERGENT,
C8Z NOR WERE THEY APPROVED IN ADVANCE.
C80 LEARNING AND BEHAVIOR DISORDERS ARE NOT COVERED
C81 DEPENDENT NOT ELIGIBLE FOR COVERAGE DUE TO AGE LIMITATIONS ON PLAN
C82 EXPENSES SUBSCRIBER IS NOT REQUIRED TO PAY ARE NOT COVERED
C83 BIRTH CONTROL MEDICATION OR DEVICES ARE NOT COVERED
C84 OVER-THE-COUNTER DRUGS AND MEDICINES ARE NOT COVERED.
C85 THIS AMOUNT EXCEEDS THE PLAN'S MAXIMUM BENEFIT.
C86 THIS AMOUNT EXCEEDS THE ALLOWABLE CHARGE
C87 LIFETIME MAXIMUM MET; NO ADDITIONAL BENEFITS DUE.
C88 THIS APPEARS TO BE A DUPLICATE OF A CHARGE PREVIOUSLY CONSIDERED.
C89 NO ADDITIONAL PAYMENT FOR DME THAT HAS BEEN PURCHASED.
C9( ROUTINE CARE BENEFITS DO NOT COVER LAB AND X-RAYS.

THE AMOUNT EXCEEDS THE PYMT AGREEMENT FOR APB ADMINISTRATORS. ANY QUESTIONS
C9? REGARDING NETWORK SAVINGS, CONTACT COALITION AMERICA INC. AT 404-459-7201.
C9# COSMETIC SERVICES/SUPPLIES ARE NOT A COVERED BENEFIT UNDER THIS PLAN.
SERVICES RECEIVED FROM A COMPSYCH PROVIDER. CHARGES DISCOUNTED ACCORDING TO
C9 THE COMPSYCH CONTRACTEDRATE.
THESE EXPENSES HAVE BEEN PAID BY MEDICARE AND ARE NOT ELIGIBLE FOR ADDITIONAL
C9A REIMBURSEMENT.
C9B ONLY THE AMOUNT APPROVED BY MEDICARE IS COVERED
C9C THIS AMOUNT WAS PAID BY AUTOMOBILE INSURANCE.
C9D THIS MEDICARE HMO POLICY DOES NOT COVER PART A EXPENSES
C9E PART B EXPENSES NOT COVERED BY MEDICARE REPLACEMENT
C9F MEDICARE DEDUCTIBLE REIMBURSEMENT NOT PROVIDED BY PLAN
C9G PRESCRIPTION CHARGES MUST BE SUBMITTED BY PARTICIPATING PHARMACY.
C9H SERVICES PROVIDED WITHOUT AUTHORIZATION ARE NOT COVERED.
Humana Remittance Advice Codes

The following codes are updated on a monthly basis. Some codes may have changed since last update.

Last Update: 12/5/07
Code Description
THIS SERVICE IS NOT A COVERED BENEFIT AND EXCLUDED FROM COVERAGE. PLEASE REFER TO
C9I YOUR MEMBER MATERIALS FOR BENEFIT GUIDELINES.
C9J BILL HCFA INTERMEDIARY AS PRIMARY CARRIER FOR INPATIENT CHARGES
C9K THE HOSPITAL SHOULD SUBMIT THESE PART B CHARGES
C9L MEDICARE PART A DEDUCTIBLE SATISFIED WITHIN 60 DAY PERIOD
C9M EXPENSES HAVE BEEN PAID BY MEDICARE
PLEASE REFILE CLAIM INCLUDING NURSES NOTES, PATIENT CARE PLAN, DR. ORDERS AND
C9O TREATMENT SHEETS
C9P AMOUNT REPRESENTS ADJUSTMENT ON PREVIOUSLY PROCESSED CLAIM
C9Q SERVICES DENIED BY MEDICARE ARE NOT COVERED BY SUPPLEMENT
C9R THE MEDICARE PART A DEDUCTIBLE HAS BEEN SATISFIED FOR THE YEAR
C9S SUBMIT PAGE 1 OF MEDICARE EXPLANATION OF BENEFITS STATEMENT
C9T SUBMIT PAGE 2 OF MEDICARE EXPLANATION OF BENEFITS STATEMENT
C9U SUBMIT PAGE 3 OF MEDICARE EXPLANATION OF BENEFITS STATEMENT
C9V SUBMIT PAGE 4 OF MEDICARE EXPLANATION OF BENEFITS STATEMENT
C9W SUBMIT PAGE 5 OF MEDICARE EXPLANATION OF BENEFITS STATEMENT
C9X SUBMIT MEDICARE EXPLANATION OF BENEFITS STATEMENT FOR PART B
C9Y NO BENEFITS AVAILABLE FOR THE FIRST 30 DAYS OF PATIENT'S CONTRACT
C9Z PATIENT MUST BE DISCHARGED FROM HOSPITAL 7 DAYS FOR BENEFITS.
C90 THIS AMOUNT EXCEEDS THE ALLOWABLE CHARGE
C92 PATIENT NOT A FULL-TIME STUDENT AT TIME OF EXPENSE.
C93 LETTER OF EXPLANATION BEING SENT UNDER SEPARATE COVER
C94 BENEFITS PAYABLE BY "NO FAULT", SUBMIT TO AUTO INSURANCE CARRIER
C95 NERVOUS/MENTAL MAXIMUM MET; NO ADDITIONAL BENEFITS DUE.
C96 HOSPICE SERVICES ARE NOT COVERED UNDER THIS PLAN.
C97 ASSIGNMENT ACCEPTED-DIFFERENCE NOT COVERED
CONFINEMENT MUST BEGIN WITHIN 14 DAYS AFTER A 3 DAY HOSPITAL STAY FOR THE SAME
C98 DIAGNOSIS.
C99 DENIED DUE TO NO RESPONSE FOR THE REQUESTED INFORMATION
MA0 PATIENT REFUND AMOUNT.
MA1 CLAIM DENIED CHARGED.
MA2 CONTRACTUAL ADJUSTMENT.
MA4 MEDICARE CLAIM PPS CAPITAL DAY OUTLIER AMOUNT.
MA5 MEDICARE CLAIM PPS CAPITAL COST OUTLIER AMOUNT.
MA6 PRIOR HOSPITALIZATION OR 30 DAY TRANSFER REQUIREMENT NOT MET.
MA7 PRESUMPTIVE PAYMENT ADJUSTMENT.
MA8 CLAIM DENIED; UNGROUPABLE DRG.
THE DIAGNOSTIC PROCEDURE REIMBURSEMENT IS INCLUDED IN A SURGICAL CONFINEMENT
MBD1 THAT HAS ALREADY BEEN PAID.
MB1 NON-COVERED VISITS.
ALLOWED AMOUNT REDUCED BECAUSE A COMPONENT OF THE BASIC PROCEDURE/TEST WAS
MB10 PAID.
THE CLAIM/SERVICE HAS BEEN TRANSFERRED TO THE PROPER PAYER/PROCESSOR FOR
MB11 PROCESSING. CLAIM/SERVICE NOT COVERED BY THIS P
MB12 SERVICES NOT DOCUMENTED IN PATIENTS' MEDICAL RECORDS.
PREVIOUSLY PAID. PAYMENT FOR THIS CLAIM/SERVICE MAY HAVE BEEN PROVIDED IN PREVIOUS
MB13 PAYMENT.
PAYMENT DENIED BECAUSE ONLY ONE VISIT OR CONSULTATION PER PHYSICIAN PER DAY IS
MB14 COVERED.
Humana Remittance Advice Codes

The following codes are updated on a monthly basis. Some codes may have changed since last update.

Last Update: 12/5/07
Code Description
PAYMENT ADJUSTED BECAUSE THIS SERVICE/PROCEDURE REQUIRES THAT A QUALIFYING
MB15 SERVICE/PROCEDURE BE RECEIVED AND COVERED. TH
MB16 PAYMENT ADJUSTED BECAUSE ¶NEW PATIENT' QUALIFICATIONS WERE NOT MET.
MB17 PAYMENT ADJUSTED BECAUSE THIS SERVICE WAS NOT PRESCRIBED BY A PHYSICIAN.
MB19 CLAIM/SERVICE ADJUSTED BECAUSE OF THE FINDING OF A REVIEW ORGANIZATION.
PAYMENT ADJUSTED BECAUSE PROCEDURE/SERVICE WAS PARTIALLY OR FULLY FURNISHED BY
MB20 ANOTHER PROVIDER.
THE CHARGES WERE REDUCED BECAUSE THE SERVICE/CARE WAS PARTIALLY FURNISHED BY
MB21 ANOTHER PHYSICIAN.
MB22 THIS PAYMENT IS ADJUSTED BASED ON THE DIAGNOSIS.
PAYMENT DENIED BECAUSE THIS PROVIDER HAS FAILED AN ASPECT OF A PROFICIENCY TESTING
MB23 PROGRAM.
MB3 COVERED CHARGES.
MB4 LATE FILING PENALTY.
PAYMENT ADJUSTED BECAUSE COVERAGE/PROGRAM GUIDELINES WERE NOT MET OR WERE
MB5 EXCEEDED.
PROVIDER WAS NOT CERTIFIED/ELIGIBLE TO BE PAID FOR THIS PROCEDURE ON THIS DATE OF
MB7 SERVICE.
CLAIM/SERVICE NOT COVERED/REDUCED BECAUSE ALTERNATIVE SERVICES WERE AVAILABLE,
MB8 AND SHOULD HAVE BEEN UTILIZED.
MB9 SERVICES NOT COVERED BECAUSE THE PATIENT ENROLLED IN A HOSPICE.
THE ADMITTING DIAGNOSIS CODE IS INVALID FOR THE DATE OF SERVICE BILLED. WE RELIED ON
MDDA INTERNAL CRITERIA TO MAKE THIS DETERMINATION,
THE DIAGNOSIS BILLED FOR THIS SERVICE IS INVALID FOR THE DATE OF SERVICE BILLED. WE
MDDB RELIED ON INTERNAL CRITERIA TO MAKE THIS DETERMINATION.
THE DIAGNOSIS BILLED FOR THIS SERVICE IS INVALID FOR THE DATE OF SERVICE BILLED. WE
MDDC RELIED ON INTERNAL CRITERIA TO MAKE THIS DETERMINATION.
THE DIAGNOSIS BILLED FOR THIS SERVICE IS INVALID FOR THE DATE OF SERVICE BILLED. WE
MDDD RELIED ON INTERNAL CRITERIA TO MAKE THIS DETERMINATION.
THE DIAGNOSIS BILLED FOR THIS SERVICE IS INVALID FOR THE DATE OF SERVICE BILLED. WE
MDDE RELIED ON INTERNAL CRITERIA TO MAKE THIS DETERMINATION.
THE DIAGNOSIS BILLED FOR THIS SERVICE IS INVALID FOR THE DATE OF SERVICE BILLED. WE
MDD0 RELIED ON INTERNAL CRITERIA TO MAKE THIS DETERMINATION.
THE DIAGNOSIS BILLED FOR THIS SERVICE IS INVALID FOR THE DATE OF SERVICE BILLED. WE
MDD1 RELIED ON INTERNAL CRITERIA TO MAKE THIS DETERMINATION.
THE DIAGNOSIS BILLED FOR THIS SERVICE IS INVALID FOR THE DATE OF SERVICE BILLED. WE
MDD2 RELIED ON INTERNAL CRITERIA TO MAKE THIS DETERMINATION.
THE DIAGNOSIS BILLED FOR THIS SERVICE IS INVALID FOR THE DATE OF SERVICE BILLED. WE
MDD3 RELIED ON INTERNAL CRITERIA TO MAKE THIS DETERMINATION.
THE DIAGNOSIS BILLED FOR THIS SERVICE IS INVALID FOR THE DATE OF SERVICE BILLED. WE
MDD4 RELIED ON INTERNAL CRITERIA TO MAKE THIS DETERMINATION.
THE DIAGNOSIS BILLED FOR THIS SERVICE IS INVALID FOR THE DATE OF SERVICE BILLED. WE
MDD5 RELIED ON INTERNAL CRITERIA TO MAKE THIS DETERMINATION.
THE DIAGNOSIS BILLED FOR THIS SERVICE IS INVALID FOR THE DATE OF SERVICE BILLED. WE
MDD6 RELIED ON INTERNAL CRITERIA TO MAKE THIS DETERMINATION.
THE DIAGNOSIS BILLED FOR THIS SERVICE IS INVALID FOR THE DATE OF SERVICE BILLED. WE
MDD7 RELIED ON INTERNAL CRITERIA TO MAKE THIS DETERMINATION.
THE DIAGNOSIS BILLED FOR THIS SERVICE IS INVALID FOR THE DATE OF SERVICE BILLED. WE
MDD8 RELIED ON INTERNAL CRITERIA TO MAKE THIS DETERMINATION.
Humana Remittance Advice Codes

The following codes are updated on a monthly basis. Some codes may have changed since last update.

Last Update: 12/5/07
Code Description
THE DIAGNOSIS BILLED FOR THIS SERVICE IS INVALID FOR THE DATE OF SERVICE BILLED. WE
MDD9 RELIED ON INTERNAL CRITERIA TO MAKE THIS DETERMINATION.
MDFH MESSAGE TEXT DESCRIPTION IS NOT AVAILABLE FOR THIS HIPAA CODE.
MDFT MESSAGE TEXT DESCRIPTION IS NOT AVAILABLE FOR THIS EX CODE.
THE CLAIM HAS BEEN DENIED AS THE CHARGES WERE NOT SUBMITTED WITHIN THE REQUIRED
MD01 TIME PERIOD. PLEASE REFER TO YOUR BENEFIT PLAN DOCUMENT.
WE DETECTED A CODING ERROR. THE DIAGNOSIS BILLED IS NOT COMPATIBLE WITH THE AGE OF
MD03 THE PATIENT. WE RELIED ON INTERNAL CRITERIA TO MAKE THIS DETERMINATION.
WE DETECTED A CODING ERROR. THE PROCEDURE BILLED IS NOT COMPATIBLE WITH THE AGE
MD04 OF THE PATIENT. WE RELIED ON INTERNAL CRITERIA TO MAKE THIS DETERMINATION.
WE DETECTED A CODING ERROR. THE MODIFIER BILLED IS NOT COMPATIBLE WITH THE
MD13 PROCEDURE BILLED. WE RELIED ON INTERNAL CRITERIA TO MAKE THIS DETERMINATION.
MD21 THIS (THESE) DIAGNOSIS(ES) IS (ARE) MISSING OR ARE INVALID.
WE DETECTED A CODING ERROR. THE PROCEDURE BILLED IS NOT VALID FOR THE DATE OF
MD34 SERVICE. WE RELIED ON INTERNAL CRITERIA TO MAKE THIS DETERMINATION.
WE DETECTED A CODING ERROR. THE HCPC CODE BILLED IS NOT VALID FOR DATE OF SERVICE.
MD35 WE RELIED ON INTERNAL CRITERIA TO MAKE THIS DETERMINATION.

WE DETECTED A CODING ERROR. THE PROCEDURE CODE BILLED IS NOT COMPATIBLE WITH THE
MD37 GENDER OF THE PATIENT. WE RELIED ON INTERNAL CRITERIA TO MAKE THIS DETERMINATION
WE DETECTED A CODING ERROR. THE HCPC CODE BILLED IS NOT COMPATIBLE WITH THE AGE OF
MD38 THE PATIENT. WE RELIED ON INTERNAL CRITERIA TO MAKE THIS DETERMINATION.
ME46 TIMELY PAYMENT PENALTY AMOUNT (INFORMATIONAL ONLY)
ME47 TIMELY PAYMENT DISCOUNT AMOUNT (INFORMATIONAL ONLY)
THIS IS A DUPLICATE CHARGE OR BILLING ERROR. THE MEMBER IS NOT RESPONSIBLE FOR THIS
MFED CHARGE.
MFLK SEALANTS ARE COVERED ON THE OCCLUSAL SURFACE OF PERMANENT MOLARS ONLY.
SEALANTS ARE ONLY COVERED ON THE OCCLUSAL SURFACE OF DECAY/RESTORATION FREE
MFLL PERMANENT MOLARS.
THIS CHARGE WILL BE CONSIDERED UPON COMPLETION OF THE PERMANENT SERVICE. PLEASE
MFLM RESUBMIT.
MFLN SEALANTS COVERED ONE PER TOOTH PER LIFETIME.
MFLO THIS CHARGE WAS COORDINATED WITH THE OTHER DENTAL CARRIER.
MFLR COVERAGE NOT FOUND FOR THIS PROCEDURE CATEGORY.
MFLU CHARGES DISTRIBUTED WITH THE COVERED SERVICES.
MFLW ACTIVE PERIO NOT EVIDENT, OPTIONAL TREATMENT APPLIED.
MFLX THIS PROCEDURE IS NOT COVERED BECAUSE THE PRIMARY PROCEDURE IS NOT COVERED.
SPACE MAINTAINERS ARE ONLY COVERED IN ORDER TO RETAIN SPACE FOR THE PREMATURE
MFLY LOSS OF PRIMARY TEETH.
ADJUSTMENTS PERFORMED WITHIN THE FIRST 6 MONTHS ARE INELIGIBLE FOR SEPARATE
MFMQ BENEFITS ARE THEREFORE COMBINED WITH THE PRIMARY PROCEDURE.
MFMR THIS CHARGE WAS COMBINED WITH THE COMPLETED SERVICE.
MFMS THIS SERVICE IS COVERED ONLY ON PERMANENT TEETH.
THIS SERVICE IS CONSIDERED AN INTEGRAL PART OF A MORE COMPREHENSIVE SERVICE AND
MFMT BENEFITS ARE NOT AVAILABLE.
MFMU CONSULTATION BY THE TREATING DENTIST IS NOT A COVERED BENEFIT
THE MED/DENT NECESSITY FOR THIS PROCEDURE IS NOT EVIDENT; PATIENT MANAGEMENT/
MFMV APPREHENSION DOES NOT CONSTITUTE NECESSITY.
MFMW PLAN EXCLUDES BENEFITS FOR SPLINTING PROCEDURES.
Humana Remittance Advice Codes

The following codes are updated on a monthly basis. Some codes may have changed since last update.

Last Update: 12/5/07
Code Description
MFMX BENEFITS FOR PROPHYLAXIS INCLUDES AN ALLOWANCE FOR SCALING AND POLISHING.
THIS SERVICE IS NOT COVERED BY THE DENTAL PLAN. IT HAS BEEN REFERRED TO THE MEDICAL
MFMY PLAN FOR REVIEW.
MFMZ VITAL PULPOTOMY IS A COVERED BENEFIT ON DECIDUOUS TEETH ONLY.

MFNA THIS PLAN DOES NOT PROVIDE BENEFITS FOR DENTAL IMPLANTS OR RELATED PROCEDURES.
BENEFITS ARE CONSIDERED WHEN ACTUAL TREATMENT IS RENDERED. STERILIZATION
MFNB TECHNIQUES ARE NOT TREATMENT OF THE PATIENT, NO BENEFITS ARE AVAILABLE.
THIS PLAN DOES NOT PROVIDE BENEFITS FOR REPLACING AN APPLIANCE THAT HAS BEEN LOST,
MFNC BROKEN OR STOLEN.
DOCUMENTATION OR CLAIM INFORMATION INDICATES THIS TOOTH IS NOT PRESENT OR
MFND EXTRACTED. NO BENEFIT IS AVAILABLE.
BENEFITS ARE AVAILABLE ONLY WHEN PERFORMED AT LEAST 3 MONTHS FOLLOWING ACTIVE
MFNE PERIODONTAL THERAPY.
THIS SERVICE CAN ONLY BE CONSIDERED WHEN PERFORMED IN CONJUNCTION WITH
MFNF PERIODONTAL SURGERY.
THE FREQUENCY LIMIT HAS BEEN EXCEEDED FOR THIS SERVICE. PLEASE REFER TO YOUR
MFNG DENTAL PLAN.
ADDITIONAL FILMS, INCLUDING BITEWINGS, TAKEN WITH A FULL MOUTH SET OF X-RAYS IS PART
MFNH OF A COMPLETE SERIES. ALLOWANCE BASED ON COMPLETE SERIES.

OCCLUSAL ADJUSTMENTS ARE LIMITED TO A MAXIMUM OF FOUR QUADRANTS IN A CALENDAR
MFNI YEAR, ONLY WHEN PERFORMED IN CONJUNCTION WITH PERIODONTAL SURGERY.
SUBMITTED DOCUMENTATION OR PRIOR CLAIM INFORMATION INDICATED CROWN/BRIDGE/
MFNJ PARTIAL HAS ALREADY BEEN PLACED, THEREFORE, NO BENEFITS AVAILABLE.
BENEFITS PROVIDED INCLUDE ALL RELATED SERVICES AND ARE BASED ON THE MAXIMUM FEE
MFNK ALLOWABLE BY THE PLAN.
THIS SERVICE IS CONSIDERED A COMPONENT OF THE PRIMARY PROCEDURE, THEREFORE A
MFNL SEPARATE BENEFIT IS NOT AVAILABLE.
MFNM ONLY THE INITIAL APPLIANCE IS COVERED BY YOUR PLAN.
MFNN THIS SERVICE IS NOT A COVERED EXPENSE UNDER YOUR DENTAL PLAN.
THIS SERVICE CAN ONLY BE CONSIDERED WHEN PERFORMED IN CONJUNCTION WITH
MFNO PERIODONTAL SERVICES.
BENEFITS FOR THIS PROCEDURE ARE AVAILABLE ONLY WHEN PERFORMED AT LEAST FOUR
MFNP WEEKS FOLLOWING COMPLETION OF PERIODONTAL THERAPY.

MFNQ REMOVAL OF POSTS ARE NOT TO BE USED IN CONJUNCTION WITH ENDODONTIC TREATMENT.
PAYMENTS FOR ORTHO CASES IN PROGRESS ARE ISSUED AUTOMATICALLY BASED ON
MFNR ELIGIBILITY. PLEASE DO NOT SUBMIT MONTHLY/QUARTERLY CLAIMS TO OUR OFFICE.

GINGIVECTOMY/CROWN LENGTHENING IS NOT COVERED WHEN BILLED SEPARATELY FROM THE
PRIMARY PROCEDURE. THE BENEFIT FOR A RESTORATION INCLUDES AN ALLOWANCE FOR
MFNS TISSUE PREPARATION ASSOCIATED WITH THE IMPRESSION/PLACEMENT OF THERESTORATION.
BENEFITS ARE BASED ON THE ALTERNATE SERVICE PROVISION OF THE PLAN. BENEFITS MAY BE
MFNT APPLIED TO THE TREATMENT PLAN CHOSEN BY THE PATIENT/PROVIDER.
MFNU THIS CHARGE AND THE BENEFITS AVAILABLE REFLECT ALL RELATED SERVICES.
ACTIVE PERIODONTAL DISEASE IS NOT EVIDENT, ALTERNATE SERVICE BENEFITS HAVE BEEN
MFNV APPLIED.
Humana Remittance Advice Codes

The following codes are updated on a monthly basis. Some codes may have changed since last update.

Last Update: 12/5/07
Code Description
SERVICES PERFORMED WITH A MORE COMPREHENSIVE PERIODONTAL PROCEDURE ARE
MFNX CONSIDERED COMPONENTS AND ARE COMBINED.
THIS PORCELAIN FACING OF THE RESTORATION ON THIS TOOTH IS CONSIDERED COSMETIC.
MFNY THEREFORE, AN ALLOWANCE WAS MADE FOR A FULL CAST RESTORATION.
RESIN RESTORATIONS ON PRE-MOLARS AND MOLARS ARE NOT COVERED EXCEPT ON BUCCAL
MFNZ SURFACES. AN ALLOWANCE HAS BEEN MADE FOR AN AMALGAM RESTORATION.
MFN0 THE SUBMITTED CODE HAS BEEN SUBSTITUTED WITH THE APPROPRIATE CODE.
SCALING AND ROOT DEBRIDEMENT PROCEDURES ARE CONSIDERED AS SCALING AND ROOT
MFN1 PLANING, PROCEDURE D4341.
BENEFITS ARE BASED ON PRIOR PERIODONTAL TREATMENT. CURRENT PROCEDURE ALLOW FOR
MFN2 PERIODONTAL MAINTENANCE.
ADA CODE HAS BEEN CHANGED TO REFLECT DESCRIPTION SUBMITTED, QUESTIONS CALL 1-800-
MFN3 233-4013.
CONSULTATION BY THE TREATING DENTIST IS NOT A COVERED BENEFIT, A BENEFIT FOR AN EXAM
MFN4 HAS BEEN ALLOWED.
CHARGES HAVE BEEN COMBINED WITH PRIOR CHARGES SUBMITTED. TOTAL AMOUNT REFLECTS
MFN5 PRIOR AND CURRENT SUBMITTED CHARGES FOR THIS PROCEDURE.
SERVICE IS NOT COVERED, REFER TO THE SCHEDULE OF BENEFITS. VISITS TO PARTICIPATING
DENTISTS HAVE COST SAVING FEATURES, THE MEMBER IS ONLY RESPONSIBLE FOR CHARGES UP
MFN6 TO THE DENTIST'S CONTRACTED AMOUNT.
MFN7 PROCEDURE CODE WAS CHANGED TO REFLECT THE AGE OF THE PATIENT.
MFN8 DUE TO AGE LIMITS, NO BENEFITS ARE AVAILABLE. REFER TO PLAN BOOKLET.
IF MORE THAN ONE SURGICAL SERVICE IS PERFORMED ON THE SAME DAY, ONLY THE MOST
MFN9 INCLUSIVE SERVICE IS A COVERED EXPENSE.
THE ELIGIBLE EXPENSE REFLECTS THE PROVIDER'S CONTRACTED AGREEMENT FOR THE
MF41 MOTHER AND BABY. THE MEMBER IS NOT RESPONSIBLE FOR THE CHARGE.

WE DETECTED A CODING ERROR. THE PROCEDURE BILLED IS NOT COMPATIBLE WITH THE
MJ03 GENDER OF THE PATIENT. WE RELIED ON INTERNAL CRITERIA TO MAKE THIS DETERMINATION
WE DETECTED A CODING ERROR. THE PROCEDURE BILLED IS NOT COMPATIBLE WITH THE AGE
MJ05 OF THE PATIENT. WE RELIED ON INTERNAL CRITERIA TO MAKE THIS DETERMINATION.

WE DETECTED A CODING ERROR. THE PROCEDURE BILLED IS NOT COMPATIBLE WITH GENDER
MJ07 OF THE PATIENT. WE RELIED ON INTERNAL CRITERIA TO MAKE THIS DETERMINATION.
THIS PROCEDURE IS NOT ALLOWED SEPARATELY, AS IT IS PART OF A MORE GLOBAL CODE. WE
MJ09 RELIED ON INTERNAL CRITERIA TO MAKE THIS DETERMINATION.
THIS PROCEDURE IN NOT ALLOWED SEPARATELY, AS IT IS PART OF A MORE GLOBAL CODE. WE
MJ11 RELIED ON INTERNAL CRITERIA TO MAKE THIS DETERMINATION.
THIS SERVICE IS A PRE-OPERATIVE VISIT AND IS INCLUDED IN THE GLOBAL SURGICAL FEE. WE
MJ13 RELIED ON INTERNAL CRITERIA TO MAKE THIS DETERMINATION.
THE FOLLOW UP EXAM IS INCLUDED IN THE GLOBAL SURGICAL FEE. WE RELIED ON INTERNAL
MJ15 CRITERIA TO MAKE THIS DETERMINATION.
THIS PROCEDURE IS NOT ALLOWED SEPARATELY, AS IT IS PART OF A MORE GLOBAL CODE. WE
MJ17 RELIED ON INTERNAL CRITERIA TO MAKE THIS DETERMINATION.

THE CODE(S) SUBMITTED WAS REPLACED WITH A CODE THAT MORE ACCURATELY REPRESENTS
MJ21 THE SERVICE(S) RENDERED. WE RELIED ON INTERNAL CRITERIA TO MAKE THIS DETERMINATION.
Humana Remittance Advice Codes

The following codes are updated on a monthly basis. Some codes may have changed since last update.

Last Update: 12/5/07
Code Description

THE CODE(S) SUBMITTED WAS REPLACED WITH A CODE THAT MORE ACCURATELY REPRESENTS
MJ22 THE SERVICE(S) RENDERED. WE RELIED ON INTERNAL CRITERIA TO MAKE THIS DETERMINATION.

THE CODE(S) SUBMITTED WAS REPLACED WITH A CODE THAT MORE ACCURATELY REPRESENTS
MJ25 THE SERVICE(S) RENDERED. WE RELIED ON INTERNAL CRITERIA TO MAKE THIS DETERMINATION.
THIS PROCEDURE IS NOT ALLOWED SEPARATELY AS IT IS PART OF A MORE GLOBAL CODE. WE
MJ27 RELIED ON INTERNAL CRITERIA TO MAKE THIS DETERMINATION.
THIS PROCEDURE IS NOT ALLOWED SEPARATELY AS IT IS PART OF A MORE GLOBAL CODE. WE
MJ29 RELIED ON INTERNAL CRITERIA TO MAKE THIS DETERMINATION.
MJ35 ALLOWANCE IS FOR MULTIPLE PROCEDURE, REFER TO YOUR BENEFIT PLAN DOCUMENT.

THE CODE(S) SUBMITTED WAS REPLACED WITH A CODE THAT MORE ACCURATELY REPRESENTS
MJ36 THE SERVICE(S) RENDERED. WE RELIED ON INTERNAL CRITERIA TO MAKE THIS DETERMINATION.

THE CODE(S) SUBMITTED WAS REPLACED WITH A CODE THAT MORE ACCURATELY REPRESENTS
MJ37 THE SERVICE(S) RENDERED. WE RELIED ON INTERNAL CRITERIA TO MAKE THIS DETERMINATION.

THE CODE(S) SUBMITTED WAS REPLACED WITH A CODE THAT MORE ACCURATELY REPRESENTS
MJ38 THE SERVICE(S) RENDERED. WE RELIED ON INTERNAL CRITERIA TO MAKE THIS DETERMINATION.
THIS PROCEDURE IS NOT ALLOWED AS IT HAS BEEN IDENTIFIED AS EXPERIMENTAL. WE RELIED
MJ41 ON INTERNAL CRITERIA TO MAKE THIS DETERMINATION.
MJ42 PROCEDURE IDENTIFIED AS OBSOLETE - CURRENT LINE
PHYSICIAN INTERPRETATION/INTERVENTION CHARGE IS NOT ALLOWED SEPARATELY. CHARGES
SHOULD BE INCLUDED IN THE PRIMARY FEE. WE RELIED ON INTERNAL CRITERIA TO MAKE THIS
MJ43 DETERMINATION.

OUR CLAIMS HISTORY INDICATES WE PROCESSED A NEW PATIENT EXAM FROM THIS PROVIDER
MJ44 WITHIN THE LAST THREE YEARS. PAYMENT ALLOWED AS AN ESTABLISHED PATIENT.
THIS IS A DUPLICATE CHARGE OR BILLING ERROR. THE MEMBER IS NOT LIABLE FOR THIS
MJ48 CHARGE.
THIS IS A DUPLICATE CHARGE OR BILLING ERROR. WE RELIED ON INTERNAL CRITERIA TO MAKE
MJ50 THIS DETERMINATION.
THE SERVICE WAS NOT COMPATIBLE WITH THE DIAGNOSIS SUBMITTED ON THE CLAIM FORM. WE
MJ52 RELIED ON INTERNAL CRITERIA TO MAKE THIS DETERMINATION.
THIS IS A DUPLICATE CHARGE OR BILLING ERROR. THE MEMBER IS NOT LIABLE FOR THIS
MJ56 CHARGE.
THIS IS A DUPLICATE CHARGE OR BILLING ERROR. THE MEMBER IS NOT LIABLE FOR THIS
MJ78 CHARGE.
THE SERVICE BILLED DOES NOT CORRESPOND TO THE AGE OF THE PATIENT. WE RELIED ON
MJ82 INTERNAL CRITERIA TO MAKE THIS DETERMINATION.

ASSISTANT SURGEON/SURGICAL ASSISTANT SERVICES ARE NOT WARRANTED FOR THE
MJ90 PROCEDURE PERFORMED. WE RELIED ON INTERNAL CRITERIA TO MAKE THIS DETERMINATION.
THIS PROCEDURE IS NOT ALLOWED SEPARATELY AS IT IS PART OF A MORE GLOBAL CODE. WE
MJ94 RELIED ON INTERNAL CRITERIA TO MAKE THIS DETERMINATION.
THIS PROCEDURE IS NOT ALLOWED SEPARATELY AS IT IS PART OF A MORE GLOBAL CODE. WE
MJ95 RELIED ON INTERNAL CRITERIA TO MAKE THIS DETERMINATION.
Humana Remittance Advice Codes

The following codes are updated on a monthly basis. Some codes may have changed since last update.

Last Update: 12/5/07
Code Description
WE DETECTED A CODING ERROR. THE DIAGNOSIS AND PROCEDURE CODES ON THE CLAIM DO
MJ99 NOT MATCH. WE RELIED ON INTERNAL CRITERIA TO MAKE THIS DETERMINATION.
MPBQ FACILITY PROVIDER HAS AN INVALID COS.
MPL1 PAY IN -PLAN BENEFIT.
MPL2 PAY IN-PLAN/ OVERRIDE LOGIC
MPPE PCP IS NOT ASSOCIATED WITH MEMBER'S NETWORK
MPSE PROVIDER SPECIALTY INDICATES THIS IS A POTENTIAL APG CLAIM
MPSQ SERVICE PROVIDER HAS INVALID COS.
MPSU SERVICE PROVIDER IS NOT AN INPLAN PROVIDER.
MW1 WORKERS COMPENSATION STATE FEE SCHEDULE ADJUSTMENT.
MXYZ ADJUSTMENT TO DEDUCTIBLE, COINSURANCE, COPAYMENT OR EXCLUDED AMOUNT
SERVICE IS NOT COVERED, REFER TO THE SCHEDULE OF BENEFITS. VISITS TO PARTICIPATING
DENTISTS HAVE COST SAVING FEATURES, THE MEMBER IS ONLY RESPONSIBLE FOR CHARGES UP
MX00 TO THE DENTIST'S CONTRACTED AMOUNT.
PLAN DOES NOT ALLOW BENEFITS FOR AN ADULT FLOURIDE. AMOUNT ALLOWED REFLECTS THE
MX01 ALLOWANCE FOR AN ADULT PROPHYLAXIS.
MYYY ADJUSTMENT TO PREVIOUSLY PAID CLAIM #
M1 DEDUCTIBLE AMOUNT
M1CD SUBMIT A DESCRIPTION OF SERVICE AND/OR CPT OR A VALID HCPC CODE.
YOUR CHARGES WERE NOT FILED WITHIN THE TIME DESCRIBED IN THE PLAN. PLEASE SUBMIT
M1D1 PROOF OF TIMELY FILING FOR RECONSIDERATION.
M1D9 LATE CHARGES WERE ADDED TO THE ORIGINAL CLAIM FOR PROCESSING.
THE GRACE PERIOD FOR PREMIUM PAYMENT HAS EXPIRED. EXPENSES WERE INCURRED AFTER
COVERAGE TERMINATED. PLEASE CONTACT BILLING AND ENROLLMENT AT THE NUMBER LISTED
M1HP ON YOUR ID CARD WITH ANY QUESTIONS.

CLAIM HAS BEEN DENIED, TO PROCESS THIS CLAIM THE PROVIDER OF SERVICE MUST RESUBMIT
M1IB USING THE APPROPRIATE CMS (HFCA) 1500 OR UB-92 FORM AS DEFINED BY THEIR CONTRACT.
INVOICE NEEDED TO DETERMINE THE CORRECT PAYMENT OF THIS CLAIM. CLAIM WILL BE
M1IN RECONSIDERED WHEN INVOICE IS RECEIVED.
M1IS THE DIAGNOSIS BILLED IS NOT COMPATIBLE WITH THE GENDER OF THE PATIENT.
M1P2 CHARGES PRIOR TO EFFECTIVE DATE OF POLICY.
M1P3 THIS CHARGE WAS INCURRED AFTER THE TERMINATION DATE OF COVERAGE.
CLAIM HAS BEEN DENIED AS THE REQUESTED INFORMATION RECEIVED IS INCOMPLETE OR NOT
M1RX LEGIBLE.
M10 THE DIAGNOSIS IS INCONSISTENT WITH THE PATIENT'S GENDER.
M100 PAYMENT MADE TO PATIENT/INSURED/RESPONSIBLE PARTY.
PREDETERMINATION: ANTICIPATED PAYMENT UPON COMPLETION OF SERVICES OR CLAIM
M101 ADJUDICATION.
M102 MAJOR MEDICAL ADJUSTMENT.
M103 PROVIDER PROMOTIONAL DISCOUNT (E.G., SENIOR CITIZEN DISCOUNT).
M104 MANAGED CARE WITH HOLDING.
M105 TAX WITHOLDING.
M106 PATIENT PAYMENT OPTION/ELECTION NOT IN EFFECT.
CLAIM/SERVICE ADJUSTED BECAUSE THE RELATED OR QUALIFYING CLAIM/SERVICE WAS NOT
M107 IDENTIFIED ON THIS CLAIM.
M108 PAYMENT ADJUSTED BECAUSE RENT/PURCHASE GUIDELINES WERE NOT MET.
CLAIM NOT COVERED BY THIS PAYER/CONTRACTOR. YOU MUST SEND THE CLAIM TO THE
M109 CORRECT PAYER/CONTRACTOR.
Humana Remittance Advice Codes

The following codes are updated on a monthly basis. Some codes may have changed since last update.

Last Update: 12/5/07
Code Description
M11 THE DIAGNOSIS IS INCONSISTENT WITH THE PROCEDURE.
M111 NOT COVERED UNLESS THE PROVIDER ACCEPTS ASSIGNMENT.
SERVICES WHICH ARE NOT RENDERED OR SUBSTANTIATED IN THE PROVIDERS MEDICAL
RECORDS ARE NOT A COVERED EXPENSE. REFER TO YOUR BENEFIT PLAN DOCUMENT FOR
M112 MORE INFORMATION.
PAYMENT DENIED BECAUSE SERVICE/PROCEDURE WAS PROVIDED OUTSIDE THE UNITED STATES
M113 OR AS A RESULT OF WAR.
M114 PROCEDURE/PRODUCT NOT APPROVED BY THE FOOD AND DRUG ADMINISTRATION.
M115 PAYMENT ADJUSTED AS PROCEDURE POSTPONED OR CANCELED.
PAYMENT DENIED. THE ADVANCE INDEMNIFICATION NOTICE SIGNED BY THE PATIENT DID NOT
M116 COMPLY WITH REQUIREMENTS.
PAYMENT ADJUSTED BECAUSE TRANSPORTATION IS ONLY COVERED TO THE CLOSEST FACILITY
M117 THAT CAN PROVIDE THE NECESSARY CARE.
M118 CHARGES REDUCED FOR ESRD NETWORK SUPPORT.
M119 BENEFIT MAXIMUM FOR THIS TIME PERIOD OR OCCURRENCE HAS BEEN REACHED.
M12 THE DIAGNOSIS IS INCONSISTENT WITH THE PROVIDER TYPE.
M121 INDEMNIFICATION ADJUSTMENT.
M122 PSYCHIATRIC REDUCTION.
M123 PAYER REFUND DUE TO OVERPAYMENT.
M125 PAYMENT ADJUSTED DUE TO A SUBMISSION/BILLING ERROR(S).
M126 DEDUCTIBLE -- MAJOR MEDICAL.
M127 COINSURANCE -- MAJOR MEDICAL.
M128 NEWBORN'S SERVICES ARE COVERED IN THE MOTHER'S ALLOWANCE.
M129 PAYMENT DENIED - PRIOR PROCESSING INFORMATION APPEARS INCORRECT.
M13 THE DATE OF DEATH PRECEDES THE DATE OF SERVICE.
M130 CLAIM SUBMISSION FEE.
M131 CLAIM SPECIFIC NEGOTIATED DISCOUNT.
M132 PREARRANGED DEMONSTRATION PROJECT ADJUSTMENT.
M133 THE DISPOSITION OF THIS CLAIM/SERVICE IS PENDING FURTHER REVIEW.
M134 TECHNICAL FEES REMOVED FROM CHARGES.
M135 CLAIM DENIED. INTERIM BILLS CANNOT BE PROCESSED.
M136 CLAIM ADJUSTED. PLAN PROCEDURES OF A PRIOR PAYER WERE NOT FOLLOWED.
M138 CLAIM/SERVICES DENIED. APPEAL PROCEDURES NOT FOLLOWED OR TIME LIMITS NOT MET.
CONTRACTED FUNDING AGREEMENT - SUBSCRIBER IS EMPLOYED BY THE PROVIDER OF
M139 SERVICES.
M14 THE DATE OF BIRTH FOLLOWS THE DATE OF SERVICE.
M140 PATIENT/INSURED HEALTH IDENTIFICATION NUMBER AND NAME DO NOT MATCH.
CLAIM ADJUSTMENT BECAUSE THE CLAIM SPANS ELIGIBLE AND INELIGIBLE PERIODS OF
M141 COVERAGE.
M142 CLAIM ADJUSTED BY THE MONTHLY MEDICAID PATIENT LIABILITY AMOUNT.
M143 PORTION OF PAYMENT DEFERRED.
M144 INCENTIVE ADJUSTMENT, E.G. PREFERRED PRODUCT/SERVICE.
M149 LIFETIME BENEFIT MAXIMUM HAS BEEN REACHED FOR THIS SERVICE/BENEFIT CATEGORY.
PAYMENT ADJUSTED AS THE SUBMITTED AUTHORIZATION NUMBER IS MISSING, INVALID, OR DOES
M15 NOT APPLY.
PAYMENT ADJUSTED BECAUSE THE PAYER DEEMS THE INFORMATION SUBMITTED DOES NOT
M150 SUPPORT THIS LEVEL OF SERVICE
M16 CLAIM/SERVICE LACKS INFORMATION WHICH IS NEEDED FOR ADJUDICATION.
Humana Remittance Advice Codes

The following codes are updated on a monthly basis. Some codes may have changed since last update.

Last Update: 12/5/07
Code Description
PAYMENT ADJUSTED BECAUSE REQUESTED INFORMATION WAS NOT PROVIDED OR WAS
M17 INSUFFICIENT/INCOMPLETE.
M18 DUPLICATE CLAIM/SERVICE.
CLAIM DENIED BECAUSE THIS IS A WORK-RELATED INJURY/ILLNESS AND THUS THE LIABILITY OF
M19 THE WORKER'S COMPENSATION CARRIER.
M2 COINSURANCE AMOUNT
SERVICES FOR WHICH NO CHARGE IS MADE, OR FOR WHICH YOU WOULD NOT BE REQUIRED TO
PAY IF YOU DID NOT HAVE THIS INSURANCE ARE NOT A COVERED EXPENSE. REFER TO YOUR
M2FR BENEFIT PLAN DOCUMENT FOR MORE INFORMATION.
M2HR NO BENEFITS ARE AVAILABLE AS THE ELIGIBILITY REQUIREMENTS WERE NOT MET.
M2IN MEDICAL ONLY - ITEMIZATION NEEDED
M2ME NO BENEFITS ARE AVAILABLE AS THE ELIGIBILITY REQUIREMENTS WERE NOT MET.
YOUR CLAIM HAS BEEN DENIED BECAUSE THE OFFICE OF GROUP BENEFITS HAS NOT RECEIVED
PREMIUM ON YOUR BEHALF FROM THE LOCAL AGENCY. PLEASE CONTACT YOUR AGENCY'S H.R.
M2MP REPRESENTATIVE FOR FURTHER DETAILS.
MEDICAL MANAGEMENT NEGOTIATED DISCOUNT. MEMBER IS NOT RESPONSIBLE FOR DISCOUNT
M2NP AMOUNT.
HUMANA IS NO LONGER THE GROUP ADMINISTRATOR. PLEASE FORWARD ALL CLAIMS TO THE
M2RN NEW CARRIER.
HUMANA IS NO LONGER GROUP ADMINISTRATOR. CLAIM HAS BEEN DENIED AND SENT TO NEW
M2TM CARRIER.
M2WD DUE TO A WAITING PERIOD, THIS SERVICE IS NOT COVERED AT THIS TIME.
WAITING PERIOD FOR THIS SERVICE IS 12 MONTHS FROM YOUR EFFECTIVE DATE. INSURED NOT
M2WM ELIGIBLE FOR SERVICE PERFORMED.
THERE IS NO COVERAGE FOR THIS PHASE OF ORTHODONTIC TREATMENT AS SERVICES WERE
M2WO RENDERED DURING A WAITING PERIOD.
DUE TO WAITING PERIOD, THIS SERVICE IS NOT COVERED AT THIS TIME. PATIENT IS NOT
M2WP ELIGIBLE FOR PROCEDURE ON DATE INDICATED.
THIS SERVICE IS NOT COVERED DUE TO ROUTINE MAMMOGRAM BENEFIT WAITING PERIOD NOT
M2W1 BEING MET.
THIS SERVICE IS NOT COVERED DUE TO THE ROUTINE PAP BENEFIT WAITING PERIOD NOT BEING
M2W2 MET.
THIS SERVICE IS NOT COVERED DUE TO THE MATERNITY BENEFIT WAITING PERIOD NOT BEING
M2W3 MET.
THIS SERVICE IS NOT COVERED DUE TO THE NERVOUS MENTAL BENEFIT WAITING PERIOD NOT
M2W4 BEING MET.
THIS SERVICE IS NOT COVERED DUE TO THE ROUTINE PROSTATE SCREENING BENEFIT WAITING
M2W5 PERIOD NOT BEING MET.
THIS SERVICE IS NOT COVERED DUE TO ROUTINE ENDSCOPIC SERVICE WAITING PERIOD NOT
M2W6 MET.
M2W7 THIS SERVICE IS NOT COVERED DUE TO ROUTINE CARE WAITING PERIOD NOT BEING MET.
M20 CLAIM DENIED BECAUSE THIS INJURY/ILLNESS IS COVERED BY THE LIABILITY CARRIER.
M203 PAYMENT ADJUSTED FOR DISCONTINUED OR REDUCED SERVICE.
M207 THIS IS AN ADJUSTMENT OF A PREVIOUSLY PROCESSED CLAIM.
M21 CLAIM DENIED BECAUSE THIS INJURY/ILLNESS IS THE LIABILITY OF THE NO-FAULT CARRIER.
M214 DUE TO LATE APPLICANT PROVISION, THIS SERVICE IS NOT COVERED AT THIS TIME.
PAYMENT ADJUSTED BECAUSE THIS CARE MAY BE COVERED BY ANOTHER PAYER PER
M22 COORDINATION OF BENEFITS.
Humana Remittance Advice Codes

The following codes are updated on a monthly basis. Some codes may have changed since last update.

Last Update: 12/5/07
Code Description
PAYMENT ADJUSTED DUE TO THE IMPACT OF PRIOR PAYER(S) ADJUDICATION INCLUDING
M23 PAYMENTS AND/OR ADJUSTMENTS
PAYMENT FOR CHARGES ADJUSTED. CHARGES ARE COVERED UNDER A CAPITATION
M24 AGREEMENT/MANAGED CARE PLAN.
M25 PAYMENT DENIED. YOUR STOP LOSS DEDUCTIBLE HAS NOT BEEN MET.
M26 EXPENSES INCURRED PRIOR TO COVERAGE.
M27 EXPENSES INCURRED AFTER COVERAGE TERMINATED.
M29 THE TIME LIMIT FOR FILING HAS EXPIRED.
M3 CO-PAYMENT AMOUNT
THE CODE(S) SUBMITTED WAS REPLACED WITH A CODE THAT ACCURATELY REPRESENTS THE
M3DC SERVICE(S) RENDERED. WE RELIED ON INTERNAL CRITERIA FOR THIS DECISION.
THE PROCEDURE CODE SUBMITTED IS MISSING OR INVALID. PLEASE RESUBMIT WITH A VALID
M3IV PROCEDURE CODE.
THE CODE YOU ARE BILLING IS NOT REFLECTED AS BEING RENDERED ACCORDING TO THE
RECORDS WE REVIEWED. PLEASE REVIEW YOUR RECORDS AND BILLING FOR THE APPROPRIATE
M3MC SERVICES BEING RENDERED.
WE CANNOT PROCESS THIS CLAIM WITHOUT A TAX ID NUMBER. WE WILL PROCESS THE CLAIM
M3TX WHEN WE RECEIVE THE TAX ID.
PAYMENT ADJUSTED THE PATIENT HAS NOT MET THE REQUIRED ELIGIBILITY, SPEND DOWN,
M30 WAITING, OR RESIDENCY REQUIREMENTS.
M31 CLAIM DENIED AS PATIENT CANNOT BE IDENTIFIED AS OUR INSURED.

M32 OUR RECORDS INDICATE THAT THIS DEPENDENT IS NOT AN ELIGIBLE DEPENDENT AS DEFINED.
M33 CLAIM DENIED. INSURED HAS NO DEPENDENT COVERAGE.
M34 CLAIM DENIED. INSURED HAS NO COVERAGE FOR NEWBORNS.
M35 BENEFIT MAXIMUM HAS BEEN REACHED.
SERVICES NOT PROVIDED OR AUTHORIZED BY DESIGNATED (NETWORK/PRIMARY CARE)
M38 PROVIDERS.
M39 SERVICES DENIED AT TIME AUTHORIZATION/PRE-CERTIFICATION WAS REQUESTED.
THE PROCEDURE CODE IS INCONSISTENT WITH THE MODIFIER USED OR A REQUIRED MODIFIER
M4 IS MISSING.
THIS CHARGE IS A DUPLICATE. PLEASE REFER TO THE ORIGINAL EXPLANATION OF BENEFITS FOR
M4D1 PAYMENT INFORMATION.
THIS CHARGE IS A DUPLICATE OF A PREVIOUSLY PROCESSED CLAIM. PLEASE REFER TO THE
M4P1 ORIGINAL EXPLANATION OF BENEFITS FOR PAYMENT INFORMATION.
THIS CHARGE IS A DUPLICATE. THE MAXIMUM BENEFIT HAS BEEN ISSUED. PLEASE REFER TO
M4P5 THE ORIGINAL EXPLANATION OF BENEFITS FOR PAYMENT INFORMATION.
M40 CHARGES DO NOT MEET QUALIFICATIONS FOR EMERGENT/URGENT CARE.
M41 OPENED IN ERROR
M42 CHARGES EXCEED OR FEE SCHEDULE OR MAXIMUM ALLOWABLE AMOUNT.
M43 GRAMM-RUDMAN REDUCTION.
M44 PROMPT-PAY DISCOUNT.
CHARGE EXCEEDS FEE SCHEDULE/MAXIMUM ALLOWABLE OR CONTRACTED/LEGISLATED FEE
M45 ARRANGEMENT.
M46 THIS (THESE) SERVICE(S) IS (ARE) NOT COVERED.
M47 THIS (THESE) DIAGNOSIS(ES) IS (ARE) NOT COVERED, MISSING, OR ARE INVALID.
M48 THIS (THESE) PROCEDURE(S) IS (ARE) NOT COVERED.
NON-COVERED SERVICES BECAUSE THIS IS A ROUTINE EXAM OR SCREENING PROCEDURE DONE
M49 IN CONJUNCTION WITH ROUTINE EXAM.
Humana Remittance Advice Codes

The following codes are updated on a monthly basis. Some codes may have changed since last update.

Last Update: 12/5/07
Code Description
M5 THE PROCEDURE CODE/BILL TYPE IS INCONSISTENT WITH THE PLACE OF SERVICE.
THIS CHARGE IS DENIED BECAUSE COSMETIC SURGERIES AS PLAN DEFINED ARE NOT COVERED.
REFER TO THE LIMITATIONS AND EXCLUSIONS SECTION OF THE MEMBER'S BENEFIT PLAN
M5CN DOCUMENT.
M5DT ORGAN DONOR CHARGES ARE NOT COVERED.
M5D1 SERVICES EXCEEDED AUTHORIZED DAYS APPROVED FOR STAY.
M5D2 THE DIAGNOSIS BILLED IS NOT COVERED UNDER THE MEMBER'S EXTENSION OF BENEFITS.
QUARTERLY PAYMENTS WILL BE ISSUED AUTOMATICALLY FOR ORTHODONTICS BASED ON
M5D4 ELIGIBILITY. MONTHLY SUBMISSION IS NOT NECESSARY.
M5D5 ORTHODONTIC CHARGES ARE PROCESSED ON A MONTHLY BASIS.
QUARTERLY PAYMENTS WILL BE ISSUED AUTOMATICALLY BASED ON ELIGIBILITY. MONTHLY
M5D8 SUBMISSION IS NOT NECESSARY.
SERVICES THAT ARE EXPERIMENTAL, INVESTIGATIONAL, OR FOR RESEARCH PURPOSES ARE NOT
M5EN A COVERED BENEFIT.
THIS SERVICE IS NOT COVERED UNDER THE MEMBER'S PLAN. PLEASE REFER TO THE
M5MC LIMITATIONS AND EXCLUSIONS PORTION OF THE MEMBER'S BENEFIT PLAN DOCUMENT.
THIS TREATMENT IS NOT MEDICALLY NECESSARY AS DEFINED BY THE MEMBER'S PLAN AND IS
M5MN NOT ELIGIBLE FOR COVERAGE. PLEASE REFER TO LETTER UNDER SEPARATE COVER.

THE MEMBER'S CONDITION IS PRE-EXISTING AND NOT COVERED UNDER THEIR PLAN PROVISIONS.
M5PX THE PLAN MAY ALLOW FOR CREDIT FROM A PRIOR MEDICAL PLAN, IF PROOF IS SUBMITTED.
THESE SERVICES REQUIRE PRIOR AUTHORIZATION FOR COVERAGE. THE REQUESTED
AUTHORIZATION WAS DENIED. PLEASE REFER TO THE BENEFIT PLAN DOCUMENT FOR FURTHER
M5SD INFORMATION.
SERVICES DENIED. STAGE III TRANSPLANT-RELATED SERVICES MUST BE PACKAGED BILLED.
RESUBMIT BILLS TO: NTN; TRANSPLANT CLAIMS DEPT; WATERSIDE BUILDING 12 FLOOR; 101 E
M5S3 MAIN ST; LOUISVILLE, KY 40201
TO PROCESS THIS CLAIM THE PROVIDER MUST SUBMIT BILLS TO: NATIONAL TRANSPLANT
NETWORK; ATTN TRANSPLANT CLAIMS DEPARTMENT; WATERSIDE BUILDING 12TH FLOOR; 101
M5TE EAST MAIN STREET; LOUISVILLE, KENTUCKY 40201
M5TP THESE SERVICES WERE PAID IN ACCORDANCE TO TRANSPLANT CONTRACT.
M5VM LOWER BENEFIT, NO VMC REFERRAL RECEIVED.
THESE ARE NON-COVERED SERVICES BECAUSE THIS IS NOT DEEMED A ¶MEDICAL NECESSITY' BY
M50 THE PAYER.
M51 THESE ARE NON-COVERED SERVICES BECAUSE THIS IS A PRE-EXISTING CONDITION.
THE REFERRING/PRESCRIBING/RENDERING PROVIDER IS NOT ELIGIBLE TO
M52 REFER/PRESCRIBE/ORDER/PERFORM THE SERVICE BILLED.
PROFESSIONAL INTERPRETATION CHARGE IS NOT ALLOWED SEPARATELY FOR AUTOMATED LAB
M522 TESTS.
THERE IS NO TECHNICAL COMPONENT FOR THIS CHARGE. WE RELIED ON INTERNAL CRITERIA TO
M523 MAKE THIS DETERMINATION.
THIS PROCEDURE IS NOT ALLOWED SEPARATELY AS THE PAYMENT FOR THE TECHNICAL
COMPONENT IS INCLUDED WITH THE FACILITY ALLOWANCE. WE RELIED ON INTERNAL CRITERIA
M524 TO MAKE THIS DETERMINATION.
THIS PROCEDURE IS NOT ALLOWED SEPERATELY, AS PART OF A MORE GLOBAL CODE. WE
M525 RELIED ON INTERNAL CRITERIA TO MAKE THIS DECISION.
SERVICES BY AN IMMEDIATE RELATIVE OR A MEMBER OF THE SAME HOUSEHOLD ARE NOT
M53 COVERED.
M54 MULTIPLE PHYSICIANS/ASSISTANTS ARE NOT COVERED IN THIS CASE.
Humana Remittance Advice Codes

The following codes are updated on a monthly basis. Some codes may have changed since last update.

Last Update: 12/5/07
Code Description
CLAIM/SERVICE DENIED BECAUSE PROCEDURE/TREATMENT IS DEEMED
M55 EXPERIMENTAL/INVESTIGATIONAL BY THE PAYER.
M55E BENEFIT AMOUNT ADJUSTED DUE TO PAYMENT ON A PREVIOUSLY PROCESSED CLAIM.
CLAIM/SERVICE DENIED BECAUSE PROCEDURE/TREATMENT HAS NOT BEEN DEEMED "PROVEN TO
M56 BE EFFECTIVE" BY THE PAYER.
PAYMENT DENIED/REDUCED BECAUSE THE PAYER DEEMS THE INFORMATION SUBMITTED DOES
M57 NOT SUPPORT THIS LEVEL OF SERVICE, THIS MA
PAYMENT ADJUSTED BECAUSE TREATMENT WAS DEEMED BY THE PAYER TO HAVE BEEN
M58 RENDERED IN AN INAPPROPRIATE OR INVALID PLACE OF
CHARGES ARE ADJUSTED BASED ON MULTIPLE OR CONCURRENT PROCEDURE RULES. (FOR
M59 EXAMPLE MULTIPLE SURGERY OR DIAGNOSTIC IMAGIN
M6 THE PROCEDURE CODE IS INCONSISTENT WITH THE PATIENT'S AGE.
M6AB THIS SERVICE WAS DISCOUNTED ACCORDING TO DIMENSION AGREEMENT.
SERVICES WERE DISCOUNTED ACCORDING TO THE AMERICAN LIFECARE NETWORK NEGOTIATED
RATE. THE MEMBER IS NOT RESPONSIBLE FOR THE AMOUNT REFLECTED IN THE PROVIDER
M6AC DISCOUNT FIELD.

PAID IN ACCORDANCE TO AMERICAN LIFECARE CONTRACTUAL AGREEMENT. THE INSURED IS NOT
M6AH RESPONSIBLE FOR THE DIFFERENCE BETWEEN THE ALLOWED AMOUNT AND THE DIFFERENCE.
BENEFITS PAYABLE ARE BASED ON COVERED EXPENSES FOR THE LEAST EXPENSIVE SERVICE.
MEMBER RESPONSIBILITY INCLUDES THE DIFFERENCE BETWEEN THE TWO ALLOWED AMOUNTS,
M6AJ REFER TO YOUR BENEFIT PLAN DOCUMENT.
THIS SERVICE WAS DISCOUNTED ACCORDING TO PROVIDER SELECT/ARKANSAS MNGD CARE ORG
M6AK AGREEMENT.
THIS SERVICE WAS DISCOUNTED ACCORDING TO AMERICAN PPO ANCILLARY NETWORK
M6AM AGREEMENT.
M6AP THESE SERVICES WERE DISCOUNTED ACCORDING TO AMERICAN PPO AGREEMENT.
THIS CLAIM HAS BEEN PROCESSED ACCORDING TO THE ARIZONA AMBULANCE SERVICE RATE
SCHEDULE. SERVICES ARE DISCOUNTED ACCORDING TO THE RATE ESTABLISHED BY THE
M6AR ARIZONA DEPARTMENT OF HEALTH SERVICES.
CLAIM REQUIRES REPRICING FROM HEALTHWAYS, PLEASE SUBMIT CLAIMS TO: HEALTHWAYS,
M6AW P.O. BOX 3192, MILWAUKEE, WI 53201-3192
M6AZ PROCESSED ACCORDING TO THE AMERICAN DENTAL PLAN OF WI NEGOTIATED RATE.
THIS PROVIDER IS A MEMBER OF THE AMERICAN LIFECARE NETWORK. SERVICES ARE
M6A0 DISCOUNTED ACCORDING TO THE NEGOTIATED RATE.
THIS PROVIDER IS A MEMBER OF THE AURORA DIRECT NETWORK. SERVICES ARE DISCOUNTED
M6A2 ACCORDING TO THE NEGOTIATED RATE.
THIS CHARGE EXCEEDS THE MAXIMUM ALLOWABLE FEE ALLOWED BY YOUR PLAN. REFER TO
M6BC MEMBER BENEFIT PLAN DOCUMENT.
THIS CHARGE EXCEEDS THE MAXIMUM ALLOWABLE FEE ALLOWED BY YOUR PLAN. REFER TO
M6BH MEMBER BENEFIT PLAN DOCUMENT.
THE ENCLOSED PAYMENT (HUMANA'S RESPONSIBILITY) IS BEING MADE TO YOU BECAUSE
SERVICES WERE PROVIDED BY A NON-PAR PROVIDER. HUMANA WILL MAKE NO PAYMENT TO THE
PROVIDER. YOU ARE RESPONSIBLE FOR ALL PAYMENTS TO THE PROVIDER UP TO THE AMOUNT
OF THE PROVIDER'S BILLED CHARGES. THE AMOUNT REFLECTED UNDER MEMBER
RESPONSIBILITY MAY NOT REFLECT THE TOTAL AMOUNT OF THE NON-PAR PROVIDER'S
M6BM CHARGES.
M6BP TEXAS PROVIDER CONTRACTED CLEAN CLAIM PENALTY APPLIED.
M6B0 CHARGES HAVE BEEN REDUCED. IF BALANCED BILLED, PLEASE CALL 1-866-427-7478.
Humana Remittance Advice Codes

The following codes are updated on a monthly basis. Some codes may have changed since last update.

Last Update: 12/5/07
Code Description
THIS PROVIDER IS A MEMBER OF THE CHOICECARE NETWORK. SERVICES ARE DISCOUNTED
M6CC ACCORDING TO THE CHOICECARE NEGOTIATED RATE.
THESE SERVICES WERE DISCOUNTED ACCORDING TO CONCENTRA AGREEMENT. THE INSURED IS
M6CE NOT RESPONSIBLE FOR THE AMOUNT IN THE NOT COVERED FIELD.
THIS PROVIDER IS A MEMBER OF THE CHOICECARE NETWORK. SERVICES ARE DISCOUNTED
M6CH ACCORDING TO THE CHOICECARE NETWORK.
M6CI CLAIM PAID IN ACCORDANCE WITH THE FIRST STEPS BENEFIT ENHANCEMENT.
THIS PROVIDER IS A MEMBER OF THE CORPHEALTH INC NETWORK. SERVICES ARE DISCOUNTED
M6CM ACCORDING TO THE CORPHEALTH INC NEGOTIATED RATE.
THIS PROVIDER IS NON-PARTICIPATING WITH CORPHEALTH INC. NETWORK. SERVICES PAID PER
THE MAXIMUM ALLOWABLE FEE AND PROVIDER MAY BILL INSURED FOR THIS AMOUNT. PLEASE
M6CN CALL 1-800-760-3263 FOR ANY QUESTIONS.
THE PROVIDER'S PRECERTIFICATION CONTRACTUAL AGREEMENT WAS NOT MET. THE AMOUNT
M6CO IS NOT THE MEMBER'S RESPONSIBILITY/LIABILITY.
THIS SERVICE PAID IN ACCORDANCE TO THE PROVIDER CONTRACTUAL AGREEMENT. INSURED IS
M6CP LIABLE FOR AMOUNT IN INSURED RESPONSIBILITY FIELD.
CLAIM PAID ACCORDING TO CONTRACTED CASE RATE WITH PROVIDER. INSURED NOT LIABLE FOR
M6CR THE DIFFERENCE BETWEEN THE BILLED AND THE ALLOWED AMOUNT.
THIS PROVIDER IS A MEMBER OF THE CHOICECARE NETWORK. SERVICES ARE DISCOUNTED
M6C0 ACCORDING TO THE NEGOTIATED RATE
M6C1 CONTINUITY OF CARE.
THIS PROVIDER IS A MEMBER OF THE COMMUNITY PARTNERS HEALTH PLAN NETWORK.
M6C2 SERVICES ARE DISCOUNTED ACCORDING TO THE NEGOTIATED RATE.
THIS PROVIDER IS A MEMBER OF THE PREFERRED ONE PHYSICIAN NETWORK. SERVICES ARE
M6DC DISCOUNTED ACCORDING TO THE PREFERRED ONE NEGOTIATED RATE.
THIS CHARGE WAS NOT PAYABLE UNDER THE PROVIDER'S CONTRACT. THE INSURED IS NOT
M6DF LIABLE FOR THIS AMOUNT.
THIS PROVIDER IS A MEMBER OF THE PREFERRED ONE HOSPITAL NETWORK. SERVICES ARE
M6DH DISCOUNTED ACCORDING TO THE PREFERRED ONE NEGOTIATED RATE.
THIS CLAIM WAS SUBMITTED WITH INCOMPLETE PRICING INFORMATION. THE PROVIDER OF
SERVICE MUST SUBMIT THIS CLAIM TO PREFERREDONE CLAIMS, P.O. BOX 1527, MINNEAPOLIS, MN
M6DP 55440.
M6DZ PROCESSED ACCORDING TO DIVERSIFIED'S DENTAL SERVICES NEGOTIATED RATE.
THIS PROVIDER IS A MEMBER OF THE PREFERRED ONE NETWORK. SERVICES ARE DISCOUNTED
M6D0 ACCORDING TO THE NEGOTIATED RATE.
THIS PROVIDER IS A MEMBER OF THE DELL NETWORK. SERVICES ARE DISCOUNTED ACCORDING
M6D2 TO NEGOTIATED RATE.
M6EC PAID IN ACCORDANCE TO EMPLOYERS HEALTH CONTRACTUAL AGREEMENT.
M6EH PAID IN ACCORDANCE TO EMPLOYERS HEALTH CONTRACTUAL AGREEMENT.
M6EM THESE SERVICES WERE DISCOUNTED ACCORDING TO EMDX AGREEMENT.
PAYMENT FOR THIS SERVICE HAS BEEN MADE UNDER A PREPAYMENT AGREEMENT BETWEEN
HUMANA AND THE PROVIDER WHO RENDERED THE SERVICE. THE PATIENT IS NOT RESPONSIBLE
M6EN FOR THIS AMOUNT.
M6EP CLAIM PAID ACCORDING TO EXECUTIVE PHYSICAL PROCESSING.

BENEFITS FOR A PRIVATE OR SINGLE-BED ROOM ARE LIMITED TO THE MAXIMUM ALLOWABLE FEE
M6EQ CHARGED FOR A SEMI-PRIVATE ROOM. PLEASE REFER TO YOUR BENEFIT PLAN DOCUMENT.
M6ER THIS SERVICE WAS DISCOUNTED ACCORDING TO ERS AGREEMENT.
Humana Remittance Advice Codes

The following codes are updated on a monthly basis. Some codes may have changed since last update.

Last Update: 12/5/07
Code Description
A CONTRACTED PROVIDER MAY NOT BILL THE DIFFERENCE BETWEEN CONTRACTED AND BILLED
M6EX AMOUNT. INSURED IS NOT LIABLE FOR THIS AMOUNT.
M6E0 PAID IN ACCORDANCE TO EMPLOYERS HEALTH CONTRACTUAL AGREEMENT.

TECHNICAL COMPONENT OF SERVICE REDUCED DUE TO MULTIPLE PROCEDURES BILLED ON THE
M6FC SAME DATE OF SERVICE. WE RELIED ON INTERNAL CRITERIA TO MAKE THIS DETERMINATION.
M6FF THIS SERVICE WAS DISCOUNTED ACCORDING TO PPONEXT/FOCUS-MO AGREEMENT.
THESE SERVICES WERE DISCOUNTED ACCORDING TO FORTIFIED PROVIDER NETWORK
M6FN AGREEMENT.
M6FP TEXAS CLEAN CLAIM PENALTY APPLIED.
A CONTRACTED PROVIDER MAY NOT BILL THE DIFFERENCE BETWEEN CONTRACTED AND BILLED
AMOUNT. THE INSURED IS NOT RESPONSIBLE FOR THE DIFFERENCE BETWEEN THE ALLOWED
M6FS AMOUNT AND THE DIFFERENCE.
THIS PROVIDER IS A MEMBER OF THE FIRST CHOICE NETWORK. SERVICES ARE DISCOUNTED
M6F0 ACCORDING TO THE NEGOTIATED RATE.

M6GA THESE SERVICES WERE DISCOUNTED ACCORDING TO GALAXY HEALTH NETWORK AGREEMENT.
THIS PROVIDER IS A MEMBER OF THE GATEWAY HEALTH ALLIANCE NETWORK. SERVICES ARE
M6G0 DISCOUNTED ACCORDING TO THE NEGOTIATED RATE.
THIS PROVIDER IS A MEMBER OF THE GHI NETWORK ACCESS PROGRAM. SERVICES ARE PAID IN
M6G2 ACCORDANCE WITH THE GHI NETWORK ACCESS PROGRAM.
THIS PROVIDER IS A MEMBER OF THE HUMANA NETWORK. SERVICES ARE DISCOUNTED
M6HC ACCORDING TO THE HUMANA NETWORK NEGOTIATED RATE.
THESE SERVICES WERE DISCOUNTED ACCORDING TO PROVIDER SELECT/HEALTHCARE
M6HD PARTNERS AGREEMENT.
THESE SERVICES WERE DISCOUNTED ACCORDING TO HEALTH COALITION PARTNERS
M6HE AGREEMENT.
M6HF THESE SERVICES WERE DISCOUNTED ACCORDING TO HFNID AGREEMENT.

M6HG THIS SERVICE WAS DISCOUNTED ACCORDING TO COMPREHENSIVE HEALTH GROUP AGREEMENT.
THIS PROVIDER IS A MEMBER OF THE HUMANA NETWORK. SERVICES ARE DISCOUNTED
M6HH ACCORDING TO HUMANA NEGOTIATED RATE.
M6HM THESE SERVICES WERE DISCOUNTED ACCORDING TO HMN/RAN/AMN AGREEMENT.
THESE SERVICES WERE DISCOUNTED ACCORDING TO HEALTH PAYORS ORGANIZATION (HPO)
M6HP AGREEMENT.
THIS SERVICE WAS DISCOUNTED ACCORDING TO PRIMARY HEALTH SERVICES/COMPETITIVE
M6HS HEALTH PLAN AGREEMENT.
M6HZ PROCESSED ACCORDING TO HUMANADENTAL'S NEGOTIATED RATE.
THIS PROVIDER IS A MEMBER OF THE HUMANA NETWORK. SERVICES ARE DISCOUNTED
M6H0 ACCORDING TO THE NEGOTIATED RATE.
THIS PROVIDER IS A MEMBER OF THE CHN SOLUTIONS/NORTHEAST HEALTH DIRECT NETWORK.
SERVICES ARE DISCOUNTED ACCORDING TO THE CHN SOLUTIONS/NORTHEAST HEALTH DIRECT
M6IC NEGOTIATED RATES.
M6IE THIS WAS AN INTEREST PAYMENT. THE INSURED IS NOT RESPONSIBLE FOR THE AMOUNT.
M6IG THESE SERVICES WERE DISCOUNTED ACCORDING TO INTERGROUP AGREEMENT.
THIS PROVIDER IS A MEMBER OF THE CHN SOLUTIONS HOSPITAL NETWORK. SERVICES ARE
M6IH DISCOUNTED ACCORDING TO THE CHN SOLUTIONS NEGOTIATED RATE.

M6IM THIS SERVICE WAS DISCOUNTED ACCORDING TO INDEPENDENT MED SYSTEMS AGREEMENT.
Humana Remittance Advice Codes

The following codes are updated on a monthly basis. Some codes may have changed since last update.

Last Update: 12/5/07
Code Description
THESE SERVICES WERE DISCOUNTED ACCORDING TO INTEGRATED HEALTH PLAN/NHP
M6IN AGREEMENT.

M6IP THESE SERVICES WERE DISCOUNTED ACCORDING TO INTEGRATED HEALTH PLAN AGREEMENT.
M6IT THIS WAS AN INTEREST PAYMENT. THE INSURED IS NOT RESPONSIBLE FOR THE AMOUNT.
M6IW THESE SERVICES WERE DISCOUNTED ACCORDING TO INTERWEST AGREEMENT.
THIS PROVIDER IS A MEMBER OF THE CHN NETWORK. SERVICES ARE DISCOUNTED ACCORDING
M6I0 TO THE NEGOTIATED RATE.
THIS PROVIDER IS A MEMBER OF THE VIRGINIA HEALTH NETWORK (VHN). SERVICES ARE
M6JC DISCOUNTED ACCORDING TO THE VHN NEGOTIATED RATE.
THIS PROVIDER IS A MEMBER OF THE VIRGINIA HEALTH NETWORK (VHN). SERVICES ARE
M6JH DISCOUNTED ACCORDING TO THE VHN NEGOTIATED RATE.
THIS PROVIDER IS A MEMBER OF THE VIRGINIA HEALTH NETWORK (VHN) NETWORK. SERVICES
M6J0 ARE DISCOUNTED ACCORDING TO THE NEGOTIATED RATE.
PAYMENT FOR THIS SERVICE/PROCEDURE HAS BEEN REDUCED BY 50% DUE TO NONPAYMENT OF
M6KA PREMIUM CAUSED BY HURRICANE KATRINA.
THIS PROVIDER IS A MEMBER OF THE KANKAKEE NETWORK. SERVICES ARE DISCOUNTED
M6K0 ACCORDING TO THE NEGOTIATED RATE.

THIS PROVIDER IS A MEMBER OF THE AMERICAN WHOLE HEALTH NETWORK. SERVICES ARE
M6LC PROCESSED ACCORDING TO THE AMERICAN WHOLE HEALTH NETWORK NEGOTIATED RATE.

THIS PROVIDER IS A MEMBER OF THE AMERICAN WHOLE HEALTH NETWORK. SERVICES ARE
M6LH PROCESSED ACCORDING TO THE AMERICAN WHOLE HEALTH NETWORK NEGOTIATED RATE.
M6LR PROCESSED ACCORDING TO THE PHARMACY RECEIPT SUBMITTED.
THIS PROVIDER IS A MEMBER OF THE HEALTHWAYS WHOLE HEALTH. SERVICES ARE
M6L0 DISCOUNTED ACCORDING TO THE NEGOTIATEDNEGOTIATED RATE.
M6L1 CLAIM HAS PAID PER LETTER OF AGREEMENT
PAID ACCORDING TO MEDICAID ALLOWED AMOUNT. THE INSURED IS NOT RESPONSIBLE FOR THE
M6MA DIFFERENCE BETWEEN THE ALLOWED AMOUNT AND CHARGE.
THE ELIGIBLE EXPENSE REFLECTS THE PROVIDER'S CONTRACTED AGREEMENT FOR THE
M6MB MOTHER AND BABY. INSURED NOT RESPONSIBLE FOR THE CHARGE.
THESE SERVICES WERE DISCOUNTED ACCORDING TO MANAGED CARE STRATEGIES NTWK
M6MD AGREEMENT.
M6ME THIS SERVICE WAS DISCOUNTED ACCORDING TO MEDCLAIM SERVICES AGREEMENT.
THESE SERVICES WERE DISCOUNTED ACCORDING TO MEDICAL RESOURCE/GALAXY HEALTH
M6MG NETWORK AGREEMENT.
M6MH PLEASE SUBMIT CLAIMS FOR MENTAL HEALTH AND SUBSTANCE ABUSE TO MAGELLAN.
THIS MEMBER IS CURRENTLY BEING AUDITED. THIS IS NOT AN ADMISSION OF LIABILITY, WE
M6MI RESERVE THE RIGHT TO REQUEST BACK PAYMENT.
M6MK THIS SERVICE WAS DISCOUNTED ACCORDING TO MEDLINK AGREEMENT.
THIS SERVICE WAS DISCOUNTED ACCORDING TO HEALTH PAYORS ORGANIZATION/MIDWEST
M6MM MEDICAL PREFERRED PROVIDERS AGREEMENT.
THESE SERVICES WERE DISCOUNTED ACCORDING TO MEDICAL RESOURCE/NATNL PRVDR NTWK
M6MN AGREEMENT.
M6MP THESE SERVICES WERE DISCOUNTED ACCORDING TO MULTI-PLAN INC. AGREEMENT.

M6MT THESE SERVICES WERE DISCOUNTED ACCORDING TO MEDICAL RESOURCE NTWK AGREEMENT.
Humana Remittance Advice Codes

The following codes are updated on a monthly basis. Some codes may have changed since last update.

Last Update: 12/5/07
Code Description

THIS CHARGE IS NOT COVERED. NO ADDITIONAL PAYMENT CAN BE MADE ONCE DURABLE
M6MX MEDICAL EQUIPMENT HAS BEEN PURCHASED. REFER TO MEMBER BENEFIT PLAN DOCUMENT.
M6MZ PROCESSED ACCORDING TO MASTERCARE DENTAL'S NEGOTIATED RATE.
THIS PROVIDER IS A MEMBER OF THE HMN/RAN NETWORK. SERVICES ARE DISCOUNTED
M6M2 ACCORDING TO THE NEGOTIATED RATE.
THIS PROVIDER IS A MEMBER OF THE FLORIDA MEMORIAL HEALTH NETWORK. SERVICES ARE
M6M3 DISCOUNTED ACCORDING TO THE NEGOTIATED RATE.
THIS PROVIDER IS A MEMBER OF THE MIDLAND CHOICE PPO NETWORK. SERVICES ARE
M6M4 DISCOUNTED ACCORDING TO THE NEGOTIATED RATE.
THE PROVIDER IS A MEMBER OF THE ST VINCENT PPO NETWORK. SERVICES ARE DISCOUNTED
M6M5 ACCORDING TO THE ST VINCENT NEGOTIATED RATE.
THIS PROVIDER IS A MEMBER OF THE ALLIANCE PPO NETWORK. SERVICES ARE DISCOUNTED
M6M6 ACCORDING TO THE ALLIANCE NEGOTIATED RATE.
THIS PROVIDER IS A MEMBER OF THE WAYNE CORP MANAGED CARE NETWORK. SERVICES ARE
M6M7 DISCOUNTED ACCORDING TO THE NEGOTIATED RATE.
THIS PROVIDER IS A MEMBER OF THE MEDICAL COLLEGE OF WISCONSIN NETWORK. SERVICES
M6M8 ARE DISCOUNTED ACCORDING TO THE NEGOTIATED RATE.
THIS SERVICE IS NOT COVERED UNDER INSURED'S PLAN. PLEASE REFER TO LIMITATIONS AND
M6NC EXCLUSIONS PORTION OF INSURED'S BENEFIT PLAN DOCUMENT.
THESE SERVICES WERE DISCOUNTED ACCORDING TO MEDICAL RESOURCE/NATIONAL HOSPITAL
M6NH NETWORK AGREEMENT.
M6NI SERVICE NOT AVAILABLE FROM AN IN-NETWORK PROVIDER.
M6NN THESE SERVICES WERE DISCOUNTED ACCORDING TO NOVANET AGREEMENT.
CHARGE IS OVER THE MAXIMUM ALLOWABLE FEE AND PROVIDER MAY BILL MEMBER FOR THIS
M6NP AMOUNT. REFER TO MEMBER BENEFIT PLAN DOCUMENT.
THIS CLAIM WAS SUBMITTED WITH INCOMPLETE PRICING INFORMATION. THE PROVIDER OF
M6NR SERVICE MUST SUBMIT THIS CLAIM TO PPOM, PO BOX 2720, FAMINGTON HILLS, MI 48333.
M6NS PAID IN ACCORDANCE WITH PRIME HEALTH SERVICES.

M6NX THESE SERVICES WERE DISCOUNTED ACCORDING TO PPONEXT/PHN/HEALTHSTAR AGREEMENT.
M6NZ PROCESSED ACCORDING TO THE MAXIMUM FEE ALLOWED BY YOUR PLAN.
THIS PROVIDER IS A MEMBER OF THE NETWORK HEALTH PLAN. SERVICES ARE DISCOUNTED
M6N0 ACCORDING TO THE NEGOTIATED RATE.
THIS SERVICE PAID IN ACCORDANCE TO THE PROVIDER CONTRACTUAL AGREEMENT. INSURED IS
M6OC LIABLE FOR AMOUNT IN INSURED RESPONSIBILITY FIELD.
THIS SERVICE PAID IN ACCORDANCE TO THE PROVIDER CONTRACTUAL AGREEMENT. INSURED IS
M6OH LIABLE FOR AMOUNT IN INSURED RESPONSIBILITY FIELD.
THIS PROVIDER IS A MEMBER OF THE MHNET NETWORK. SERVICES ARE DISCOUNTED
M6O1 ACCORDING TO THE NEGOTIATED RATE.
THIS PROVIDER IS A MEMBER OF THE CORPHEALTH NETWORK. SERVICES ARE DISCOUNTED
M6O2 ACCORDING TO THE NEGOTIATED RATE
THIS PROVIDER IS A MEMBER OF THE ORTHONET NETWORK. SERVICES ARE DISCOUNTED
M6O3 ACCORDING TO THE NEGOTIATED RATE.
M6PA CLAIM ADJUSTED AND REPROCESSED AT IN NETWORK LEVEL OF BENEFITS.
A CONTRACTED PROVIDER MAY NOT BILL THE DIFFERENCE BETWEEN CONTRACTED AND BILLED
AMOUNT. THE INSURED IS NOT RESPONSIBLE FOR THE DIFFERENCE BETWEEN THE ALLOWED
M6PC AMOUNT AND THE DIFFERENCE.
Humana Remittance Advice Codes

The following codes are updated on a monthly basis. Some codes may have changed since last update.

Last Update: 12/5/07
Code Description
THIS SERVICE PAID IN ACCORDANCE TO THE PROVIDER CONTRACTUAL AGREEMENT. INSURED IS
M6PD LIABLE FOR AMOUNT IN INSURED RESPONSIBILITY FIELD.
M6PE THESE SERVICES WERE DISCOUNTED ACCORDING TO PREFERRED CARE AGREEMENT.
THESE SERVICES WERE DISCOUNTED ACCORDING TO PROVIDER SELECT/CONSUMER HEALTH
M6PF NETWORK AGREEMENT.

M6PG THESE SERVICES WERE DISCOUNTED ACCORDING TO PROVIDER SELECT NTWK AGREEMENT.
THESE SERVICES WERE DISCOUNTED ACCORDING TO PHS/HEALTH PAYORS ORGANIZATION; LTD.
M6PH AGREEMENT.
THESE SERVICES WERE DISCOUNTED ACCORDING TO PRIMARY HEALTH SERVICE (PHS)
M6PI AGREEMENT.
THESE CHARGES ARE INCLUDED IN THE CASE RATE DEAL. THEREFORE, THE INSURED IS NOT
M6PL RESPONSIBLE.
THESE SERVICES WERE DISCOUNTED ACCORDING TO PROVIDER SELECT/MANAGED HEALTH
M6PM NETWORK AGREEMENT.
THIS SERVICE WAS DISCOUNTED ACCORDING TO HEALTH PAYORS ORGANIZATION/INTEGRATED
M6PN HEALTH PLAN/FPN AGREEMENT.
THIS AMOUNT REFLECTS A CONTRACTED AGREEMENT WITH THE PROVIDER. INSURED NOT
M6PO RESPONSIBLE FOR THIS AMOUNT.
THIS SERVICE IS INCLUDED IN THE NEGOTIATED RATE WITH THE PROVIDER. INSURED NOT
M6PP RESPONSIBLE FOR THIS CHARGE.
THESE SERVICES WERE DISCOUNTED ACCORDING TO PROVIDER SELECT/FLORA HEALTH
M6PS NETWORK AGREEMENT.
THIS PROVIDER OF SERVICE IS NOT A QUALIFIED PRACTITIONER AND IS NOT COVERED UNDER
M6PT INSURED'S PLAN.
THESE SERVICES WERE DISCOUNTED ACCORDING TO PROVIDER SELECT/UNIVERSAL HEALTH
M6PU NETWORK AGREEMENT.
THIS AMOUNT REFLECTS A CONTRACTED AGREEMENT WITH THE PROVIDER. YOU ARE NOT
M6P0 RESPONSIBLE FOR THIS AMOUNT.
THIS SERVICE WAS DISCOUNTED ACCORDING TO HEALTH PAYORS ORGANIZATION/COMPETITIVE
M6P1 HEALTH PLAN AGREEMENT.
THIS SERVICE WAS DISCOUNTED ACCORDING TO PHS/HPO/INTEGRATED HEALTH PLAN
M6P2 AGREEMENT.
M6P3 THIS SERVICE WAS DISCOUNTED ACCORDING TO IG/HPO/INTER HLTH PLAN AGREEMENT.
M6P4 THIS SERVICE WAS DISCOUNTED ACCORDING TO INTERPLAN AGREEMENT.
THIS SERVICE WAS DISCOUNTED ACCORDING TO PRIME HEALTH SERVICES/PPONEXT
M6P5 AGREEMENT.
M6QM THIS SERVICE WAS DISCOUNTED ACCORDING TO QMEDWORX AGREEMENT.
THIS PROVIDER IS A MEMBER OF THE PHN NETWORK. SERVICES ARE DISCOUNTED ACCORDING
M6Q0 TO THE NEGOTIATED RATE.
THIS PROVIDER IS A MEMBER OF THE QUALCARE PPO. SERVICES ARE TO BE PAID IN
M6Q2 ACCORDANCE WITH QUALCARE PPO CONTRA
TO PROCESS THIS CLAIM THE PROVIDER OF SERVICE MUST SUBMIT IT TO THE NETWORK FOR
M6RE REPRICING. SUBMIT THIS CLAIM TO HEALTHEOS PLUS PO BOX 6090 DEPERE, WI 54115.
THIS IS A REIMBURSEMENT FOR EXCESS DEDUCTIBLE TAKEN THROUGH YOUR INTEGRATED
M6RX HEALTH PLAN.
THIS PROVIDER IS A MEMBER OF THE SAGAMORE PLUS PHYSICIAN NETWORK. SERVICES ARE
M6SC DISCOUNTED ACCORDING TO THE SAGAMORE PLUS NEGOTIATED RATE.
Humana Remittance Advice Codes

The following codes are updated on a monthly basis. Some codes may have changed since last update.

Last Update: 12/5/07
Code Description
THIS PROVIDER IS A MEMEBER OF THE SAGAMORE PLUS HOSPITAL NETWORK. SERVICES ARE
M6SH DISCOUNTED ACCORDING TO THE SAGAMORE PLUS NEGOTIATED RATE.
THE CONTRACTED RATE FOR THIS SERVICE HAS BEEN MET. THE INSURED IS NOT LIABLE FOR THE
M6SL CHARGE.
THESE SERVICES WERE DISCOUNTED ACCORDING TO PROVIDER SELECT/PREFERRED CARE
M6SP AGREEMENT.
THIS PROVIDER IS A MEMBER OF THE SEGAMORE PLUS NETWORK. SERVICES ARE DISCOUNTED
M6S0 ACCORDING TO THE NEGOTIATED RATE.
WE HAVE COMPLETED OUR AUDIT OF YOUR CLAIM AND PROCESSED THE REMAINING BALANCE
M6TA ACCORDING TO YOUR PLAN.
THIS PROVIDER IS A MEMBER OF THE HEALTHEOS PLUS PHYSICIAN NETWORK. SERVICES ARE
M6TC DISCOUNTED ACCORDING TO THE NEGOTIATED RATE.
THIS PROVIDER IS A MEMBER OF THE HEALTHEOS PLUS PHYSICIAN NETWORK. SERVICES ARE
M6TH DISCOUNTED ACCORDING TO THE NEGOTIATED RATE.
M6TM CLAIM PAID ACCORDING TO TEAMSTERS EXECUTIVE REIMBURSEMENT PLAN PROCESSING.
THIS SERVICE WAS DISCOUNTED ACCORDING TO CAI/INTERWEST TRADITIONAL NETWORK
M6TN AGREEMENT.
THESE SERVICES WERE DISCOUNTED ACCORDING TO THREE RIVERS PROVIDER NETWORK
M6TR (TRPN) AGREEMENT.
M6TU THIS CLAIM NEEDS TO BE SUBMITTED TO URN FOR REPRICING.
THIS PROVIDER IS A MEMBER OF THE HEALTHEOS PLUS NETWORK. SERVICES ARE DISCOUNTED
M6T0 ACCORDING TO THE NEGOTIATED RATE.
M6T1 TRANSITION OF CARE.
THIS PROVIDER IS A MEMBER OF THE MEDCOST PHYSICIAN NETWORK. SERVICES ARE
M6UC DISCOUNTED ACCORDING TO THE MEDCOST NEGOTIATED RATE.
THIS PROVIDER IS A MEMBER OF THE MEDCOST HOSPITAL NETWORK. SERVICES ARE
M6UH DISCOUNTED ACCORDING TO THE MEDCOST NEGOTIATED RATE.
THIS PROVIDER IS A MEMBER OF THE MEDCOST NETWORK. SERVICES ARE DISCOUNTED
M6U0 ACCORDING TO THE NEGOTIATED RATE.
A CONTRACTED PROVIDER MAY NOT BILL THE DIFFERENCE BETWEEN CONTRACTED AND BILLED
M6VA AMOUNT. INSURED IS NOT LIABLE FOR AMOUNT IN INSURED RESPONSIBILITY FIELD.
THIS PROVIDER IS A MEMBER OF THE PREFERRED COMMUNITY CHOICE PHYSICIAN NETWORK.
SERVICES ARE DISCOUNTED ACCORDING TO THE PREFERRED COMMUNITY CHOICE NEGOTIATED
M6VC RATE.
THIS PROVIDER IS A MEMBER OF THE PREFERRED COMMUNITY CHOICE HOSPITAL NETWORK.
SERVICES ARE DISCOUNTED ACCORDING TO THE PREFERRED COMMUNITY CHOICE NEGOTIATED
M6VH RATE.
THIS CLAIM HAS BEEN FORWARDED TO HORIZON BEHAVIORAL SERVICES, OUR DESIGNATED
CARRIER. TO EXPEDITE FUTURE CLAIM CONSIDERATIONS PLEASE SEND DIRECTLY TO: HORIZON
M6VV BEHAVIORAL SERVICES, PO BOX 953309, LAKE MARY, FL 32795-3309.
THIS PROVIDER IS A MEMBER OF THE PREFERRED COMMUNITY PREFERRED NETWORK.
M6V0 SERVICES ARE DISCOUNTED ACCORDING TO THE NEGOTIATED RATE.
THE COVERED PERSON'S BENEFIT RESERVE WAS USED TO REIMBURSE THE PREVIOUSLY UNPAID
M6WA EXPENSES FOR PRESCRIPTION DRUGS.
REIMBURSEMENT IS NOT AVAILABLE FOR THIS CLAIM AS THE COORDINATION OF BENEFITS
M6WD RESERVE ACCOUNT IS CURRENTLY EMPTY.
CLAIM PROCESSED PER PROSPECTIVE PAYMENT SYSTEM AS DIRECTED IN LETTER OF
M6WL AGREEMENT.
Humana Remittance Advice Codes

The following codes are updated on a monthly basis. Some codes may have changed since last update.

Last Update: 12/5/07
Code Description
THIS PROVIDER IS A MEMBER OF THE WASHOE PREFERRED NETWORK. SERVICES ARE
M6W0 DISCOUNTED ACCORDING TO THE NEGOTIATED RATE.
THIS PROVIDER IS A MEMBER OF THE COFINITY (FORMERLY KNOWN AS PPOM) PHYSICIAN
M6XC NETWORK. SERVICES ARE DISCOUNTEDACCORDING TO THE COFINITY NEGOTIATED RATE.
THIS PROVIDER IS A MEMBER OF THE COFINITY (FORMERLY KNOWN AS PPOM) HOSPITAL
M6XH NETWORK. SERVICES ARE DISCOUNTED ACCORDING TO THE COFINITY NEGOTIATED RATE.
PAYMENT MADE IS AN EXCEPTION TO NORMAL PLAN BENEFITS. FUTURE CLAIMS WILL BE
SUBJECT TO AND PROCESSED BASED ON NORMAL PLAN BENEFITS. THIS IS NOT A CHANGE IN
M6XP PLAN BENEFITS.
M6XZ PROCESSED ACCORDING TO DENTEMAX NEGOTIATED RATE.
THIS PROVIDER IS A MEMBER OF THE PPOM NETWORK. SERVICES ARE DISCOUNTED ACCORDING
M6X0 TO THE NEGOTIATED RATE.
THIS PROVIDER IS A MEMBER OF THE FABOH PHYSICIAN NETWORK. SERVICES ARE DISCOUNTED
M6YC ACCORDING TO THE FABOH NEGOTIATED RATE.
THIS PROVIDER IS A MEMBER OF THE FABOH HOSPITAL NETWORK. SERVICES ARE DISCOUNTED
M6YH ACCORDING TO THE FABOH NEGOTIATED RATE.
THIS PROVIDER IS A MEMBER OF THE FABOH NETWORK. SERVICES ARE DISCOUNTED
M6Y0 ACCORDING TO THE NEGOTIATED RATE.
M6ZC PAID IN ACCORDANCE TO PROVIDER CONTRACTUAL AGREEMENT.
M6ZH PAID IN ACCORDANCE TO PROVIDER CONTRACTUAL AGREEMENT.
CHARGES FOR OUTPATIENT SERVICES WITH THIS PROXIMITY TO IMPATIENT SERVICES ARE NOT
M60 COVERED.
THIS PROVIDER IS A MEMBER OF THE KMEGH NETWORK. SERVICES ARE DISCOUNTED
M600 ACCORDING TO THE NEGOTIATED RATE.
M61 CHARGES ADJUSTED AS PENALTY FOR FAILURE TO OBTAIN SECOND SURGICAL OPINION.
THIS PROVIDER IS A MEMBER OF THE COMMUNITY ALLIANCE HEALTH NETWORK. SERVICES ARE
M610 DISCOUNTED ACCORDING TO THE NEGOTIATED RATE.
PAYMENT DENIED/REDUCED FOR ABSENCE OF, OR EXCEEDED, PRE-
M62 CERTIFICATION/AUTHORIZATION.
THIS SERVICE PAID IN ACCORDANCE TO THE PROVIDER CONTRACTUAL AGREEMENT. SERVICES
M62C ARE DISCOUNTED ACCORDING TO THE NEGOTIATED RATE.

M62D TOTAL CHARGES FOR THESE SERVICES EXCEED THE MAXIMUM FEES ALLOWED BY THE PLAN.
THIS SERVICE PAID IN ACCORDANCE TO THE PROVIDER CONTRACTUAL AGREEMENT. SERVICES
M62H ARE DISCOUNTED ACCORDING TO THE NEGOTIATED RATE.
M62M THESE SERVICES WERE DISCOUNTED ACCORDING TO MULTI-PLAN INC. AGREEMENT.
CLAIM DENIED AS INFORMATION THAT WAS PREVIOUSLY REQUESTED FROM CORPHEALTH HAS
M62X NOT BEEN RECEIVED. PLEASE CALL 1-800-760-3263 FOR ANY QUESTIONS.
THIS SERVICE IS PAID IN ACCORDANCE TO PROVIDER CONTRACTUAL AGREEMENT. SERVICES
M620 ARE DISCOUNTED ACCORDING TO THENEGOTIATED RATE.
THESE SERVICES WERE DISCOUNTED ACCORDING TO TRPN/THREE RIVERS PROVIDER NETWORK
M63A AGREEMENT
M63B THESE SERVICES WERE DISCOUNTED ACCORDING TO TRPN/BUCKEYE AGREEMENT
THESE SERVICES WERE DISCOUNTED ACCORDING TO TRPN/MCS-MANAGED CARE STRATEGIES
M63C AGREEMENT
THESE SERVICES WERE DISCOUNTED ACCORDING TO IHP/INTEGRATED HEALTH PLAN
M63D AGREEMENT
M63E THESE SERVICES WERE DISCOUNTED ACCORDING TO PPO NEXT AGREEMENT
Humana Remittance Advice Codes

The following codes are updated on a monthly basis. Some codes may have changed since last update.

Last Update: 12/5/07
Code Description

M63F THESE SERVICES WERE DISCOUNTED ACCORDING TO BEECH STREET AP NETWORK AGREEMENT
M63G THESE SERVICES WERE DISCOUNTED ACCORDING TO AMN/HMN/RAN AGREEMENT.
M63H THESE SERVICES WERE DISCOUNTED ACCORDING TO DEVON AGREEMENT.
THESE SERVICES WERE DISCOUNTED ACCORDING TO FORTIFIED PROVIDER NETWORKS
M63I AGREEMENT.
M63J THESE SERVICES WERE DISCOUNTED ACCORDING TO MEDICAL RESOURCE AGREEMENT.
THESE SERVICES WERE DISCOUNTED ACCORDING TO NATIONAL PROVIDER NETWORK
M63K AGREEMENT.
THESE SERVICES WERE DISCOUNTED ACCORDING TO AMERICAN HEALTH RESOURCE NETWORK
M63L AGREEMENT.
THIS PROVIDER IS A MEMBER OF THE HEALTHNET NETWORK. SERVICES ARE DISCOUNTED
M630 ACCORDING TO THE NEGOTIATED RATE.
M64A THESE SERVICES WERE DISCOUNTED ACCORDING TO NPPN AGREEMENT.

M64B THESE SERVICES WERE DISCOUNTED ACCORDING TO NPPN/ABPA/PROHEALTH AGREEMENT.
M64C THESE SERVICES WERE DISCOUNTED ACCORDING TO NPPN/AMERICAS PPO AGREEMENT.
THESE SERVICES WERE DISCOUNTED ACCORDING TO NPPN/ASSOCIATION OF PRIMARY CARE
M64D PHYS AGREEMENT.
THESE SERVICES WERE DISCOUNTED ACCORDING TO NPPN/BAPTIST HEALTH SERVICES GROUP
M64E AGREEMENT.
THESE SERVICES WERE DISCOUNTED ACCORDING TO NPPN/CARRINGTON INTERNATIONAL
M64F GROUP AGREEMENT.
THESE SERVICES WERE DISCOUNTED ACCORDING TO NPNN/CONSUMER HEALTH NETWORK
M64G AGREEMENT.
THESE SERVICES WERE DISCOUNTED ACCORDING TO NPPN/CONSUMER HEALTH NETWORK - NJ
M64H AGREEMENT.
THESE SERVICES WERE DISCOUNTED ACCORDING TO NPPN/COLUMBIA HCA NORTH TEXAS
M64I DIVISION AGREEMENT.
THESE SERVICES WERE DISCOUNTED ACCORDING TO NPPN/COMMUNITY HEALTH PARTNERS
M64J AGREEMENT.
THESE SERVICES WERE DISCOUNTED ACCORDING TO NPPN/DAHLBERG MIRACLE EAR
M64K AGREEMENT.
M64L THESE SERVICES WERE DISCOUNTED ACCORDING TO NPPN/DIMENSION AGREEMENT.
THESE SERVICES WERE DISCOUNTED ACCORDING TO NPPN/FAMILY HEALTH AMERICA
M64M AGREEMENT.
M64N THESE SERVICES WERE DISCOUNTED ACCORDING TO NPPN/FCM AGREEMENT.
THESE SERVICES WERE DISCOUNTED ACCORDING TO NPPN/HEALTH POINT PHYSICIANS
M64O HOSPITALS ORG. AGREEMENT.

M64P THESE SERVICES WERE DISCOUNTED ACCORDING TO NPPN/HEALTHCARE DIRECT AGREEMENT.
M64Q THESE SERVICES WERE DISCOUNTED ACCORDING TO NPPN/HNA AGREEMENT.
M64R THESE SERVICES WERE DISCOUNTED ACCORDING TO NPPN/HEALTHSPAN AGREEMENT.
M64S THESE SERVICES WERE DISCOUNTED ACCORDING TO NPPN/HEARTLAND AGREEMENT.
THESE SERVICES WERE DISCOUNTED ACCORDING TO NPPN/HENRY FORD HEALTH SYSTEM
M64T AGREEMENT.
M64U THESE SERVICES WERE DISCOUNTED ACCORDING TO NPPN/MAYAN PPO AGREEMENT.
THESE SERVICES WERE DISCOUNTED ACCORDING TO NPPN/MENTAL HEALTH NETWORK
M64V AGREEMENT.
Humana Remittance Advice Codes

The following codes are updated on a monthly basis. Some codes may have changed since last update.

Last Update: 12/5/07
Code Description
M64W THESE SERVICES WERE DISCOUNTED ACCORDING TO NPPN/ZENEKS AGREEMENT.
M64X THESE SERVICES WERE DISCOUNTED ACCORDING TO NPPN/TRPN - CFMC AGREEMENT.
M64Y THESE SERVICES WERE DISCOUNTED ACCORDING TO NPPN/TRPN-PHS-FCHP AGREEMENT.
M64Z THESE SERVICES WERE DISCOUNTED ACCORDING TO NPPN/TRPN-PHS-TRAC AGREEMENT.
THIS PROVIDER IS A MEMBER OF THE PHYSICANS CARE NETWORK. SERVICES ARE DISCOUNTED
M640 ACCORDING TO THE NEGOTIATED RATE.
M65A THESE SERVICES WERE DISCOUNTED ACCORDING TO NPPN/TRPN-PHS-WORX AGREEMENT.
M65B THESE SERVICES WERE DISCOUNTED ACCORDING TO NPPN/TRPN-PHS-WKPT AGREEMENT.
M65C THESE SERVICES WERE DISCOUNTED ACCORDING TO NPPN/TRPN-PHS-MTST AGREEMENT.
M65D THESE SERVICES WERE DISCOUNTED ACCORDING TO NPPN/TRPN-PHS AGREEMENT.
M65E THESE SERVICES WERE DISCOUNTED ACCORDING TO NPPN/TRPN-PHS-PLUS AGREEMENT.
M65F THESE SERVICES WERE DISCOUNTED ACCORDING TO NPPN/TRPN-PHS-RSLT AGREEMENT.
M65G THESE SERVICES WERE DISCOUNTED ACCORDING TO NPPN/TRPN-PHS-LOGI AGREEMENT.
THESE SERVICES WERE DISCOUNTED ACCORDING TO NPPN/TRPN-QHP / TRPN-PHS-QHP
M65H AGREEMENT.
M65I THESE SERVICES WERE DISCOUNTED ACCORDING TO NPPN/TRPN - ASPA AGREEMENT.
THESE SERVICES WERE DISCOUNTED ACCORDING TO NPPN/TRPN - PREMIUM HEALTH
M65J AGREEMENT.
M65K THESE SERVICES WERE DISCOUNTED ACCORDING TO NPPN/OPN AGREEMENT.
THESE SERVICES WERE DISCOUNTED ACCORDING TO NPPN/PHYSICIANS CARE NETWORK
M65L AGREEMENT.

M65M THESE SERVICES WERE DISCOUNTED ACCORDING TO NPPN/PHYSICIANS NETWORK AGREEMENT.
M65N THESE SERVICES WERE DISCOUNTED ACCORDING TO NPPN/PPO OF INDIANA AGREEMENT.

M65O THESE SERVICES WERE DISCOUNTED ACCORDING TO NPPN/PPOIN/PROHEALTH AGREEMENT.

M65P THESE SERVICES WERE DISCOUNTED ACCORDING TO NPPN/PPO OF KENTUCKY AGREEMENT.
THESE SERVICES WERE DISCOUNTED ACCORDING TO NPPN/QUALCHOICE OF ARKANSAS
M65Q AGREEMENT.
M65R THESE SERVICES WERE DISCOUNTED ACCORDING TO NPPN/SELECT PPO AGREEMENT.
THESE SERVICES WERE DISCOUNTED ACCORDING TO NPPN/SIGNATURE (NASHVILLE)
M65S AGREEMENT.
THESE SERVICES WERE DISCOUNTED ACCORDING TO NPPN/SUSQUEHANNA HEALTH CARE
M65T AGREEMENT.

M65U THESE SERVICES WERE DISCOUNTED ACCORDING TO NPPN/THE INITIAL GROUP AGREEMENT.
M65V THESE SERVICES WERE DISCOUNTED ACCORDING TO NPPN/TRPN AGREEMENT.
M65W THESE SERVICES WERE DISCOUNTED ACCORDING TO NPPN/TRPN-BUCKEYE AGREEMENT.
THESE SERVICES WERE DISCOUNTED ACCORDING TO NPPN/TRPN-PREFERRED MENTAL HEALTH
M65X MANAGEMENT AGREEMENT.
M65Y THESE SERVICES WERE DISCOUNTED ACCORDING TO NPPN/PIPA AGREEMENT.
M65Z THESE SERVICES WERE DISCOUNTED ACCORDING TO NPPN/UNICARE AGREEMENT.
THIS PROVIDER IS A MEMBER OF THE PREVEA NETWORK. SERVICES ARE DISCOUNTED
M650 ACCORDING TO THE NEGOTIATED RATE.
M66 BLOOD DEDUCTIBLE.

M66A THESE SERVICES WERE DISCOUNTED ACCORDING TO UP&UP/AHP CONTRACTUAL AGREEMENT
Humana Remittance Advice Codes

The following codes are updated on a monthly basis. Some codes may have changed since last update.

Last Update: 12/5/07
Code Description

M66B THESE SERVICES WERE DISCOUNTED ACCORDING TO NPPN/UNIVERSAL - NEVADA AGREEMENT.
M66C THESE SERVICES WERE DISCOUNTED ACCORDING TO NPPN/GHN AGREEMENT.
M66D THESE SERVICES WERE DISCOUNTED ACCORDING TO NPPN/HFN AGREEMENT.
M66E THESE SERVICES WERE DISCOUNTED ACCORDING TO NPPN/INTERPLAN AGREEMENT.
THESE SERVICES WERE DISCOUNTED ACCORDING TO HPO AFFILIATED NETWORKS DISCOUNT
M66F RATE AGREEMENT.

M66G THESE SERVICES WERE DISCOUNTED ACCORDING TO NPPN/HEALTH CHOICE OF MS AGREEMENT.
THESE SERVICES WERE DISCOUNTED ACCORDING TO NPPN/MRI/PROVIDER STRATEGIES
M66H AGREEMENT.
THESE SERVICES WERE DISCOUNTED ACCORDING TO NPPN/INTERWEST TRADITIONAL
M66I AGREEMENT.
M66J THESE SERVICES WERE DISCOUNTED ACCORDING TO NPPN/MRI/GHN AGREEMENT.
THESE SERVICES WERE DISCOUNTED ACCORDING TO NPPN/INTERPLAN/NORTHWEST ONE
M66K AGREEMENT.
THESE SERVICES WERE DISCOUNTED ACCORDING TO NPPN/INTERPLAN HEALTH GROUP
M66L AGREEMENT.
M66M THESE SERVICES WERE DISCOUNTED ACCORDING TO NPPN/HPO/MMPP AGREEMENT.
THESE SERVICES WERE DISCOUNTED ACCORDING TO NPPN/ARIZONA MEDICAL NETWORK
M66N AGREEMENT.
M66O THESE SERVICES WERE DISCOUNTED ACCORDING TO NPPN/BAYCARE AGREEMENT.
M66P THESE SERVICES WERE DISCOUNTED ACCORDING TO NPPN/BELTONE AGREEMENT.

M66Q THESE SERVICES WERE DISCOUNTED ACCORDING TO NPPN/AMERICAN PPO INC. AGREEMENT.

M66R THESE SERVICES WERE DISCOUNTED ACCORDING TO NPPN/HEALTH MANAGEMENT AGREEMENT.
THESE SERVICES WERE DISCOUNTED ACCORDING TO NPPN/INDEPENDENT MEDICAL SYSTEMS
M66S AGREEMENT.
M66T THESE SERVICES WERE DISCOUNTED ACCORDING TO NPPN/INTERGROUP AGREEMENT.

M66U THESE SERVICES WERE DISCOUNTED ACCORDING TO NPPN/INTERWEST HEALTH AGREEMENT.

M66V THESE SERVICES WERE DISCOUNTED ACCORDING TO NPPN/MEDICAL RESOURCES AGREEMENT.
M66W THESE SERVICES WERE DISCOUNTED ACCORDING TO NPPN/NOVANET AGREEMENT.
M66X THESE SERVICES WERE DISCOUNTED ACCORDING TO NPPN/HPO AGREEMENT.
THESE SERVICES WERE DISCOUNTED ACCORDING TO NPPN/HPO-CHP/PACIFIC HLTH ALLIANCE
M66Y AGREEMENT.
M66Z THESE SERVICES WERE DISCOUNTED ACCORDING TO NPPN/HPO/CHP AGREEMENT.
THIS PROVIDER IS A MEMBER OF THE SIMPLICITY NETWORK. SERVICES ARE DISCOUNTED
M660 ACCORDING TO THE NEGOTIATED RATE
M67A THESE SERVICES WERE DISCOUNTED ACCORDING TO NPPN/HPO/HCP AGREEMENT.
M67B THESE SERVICES WERE DISCOUNTED ACCORDING TO NPPN/HPO/MHN AGREEMENT.
M67C THESE SERVICES WERE DISCOUNTED ACCORDING TO NPPN/HPO/PHS AGREEMENT.
M67D THESE SERVICES WERE DISCOUNTED ACCORDING TO NPPN/MRI/NHN AGREEMENT.
M67E THESE SERVICES WERE DISCOUNTED ACCORDING TO NPPN/MRI/NPN AGREEMENT.
M67F THESE SERVICES WERE DISCOUNTED ACCORDING TO NPPN/TRPN/FPN AGREEMENT.
M67G THESE SERVICES WERE DISCOUNTED ACCORDING TO NPPN/TRPN/MCS PPO AGREEMENT.
M67H THESE SERVICES WERE DISCOUNTED ACCORDING TO NPPN/PPO NEXT AGREEMENT.
Humana Remittance Advice Codes

The following codes are updated on a monthly basis. Some codes may have changed since last update.

Last Update: 12/5/07
Code Description
M67I THESE SERVICES WERE DISCOUNTED ACCORDING TO NPPN/RURAL ARIZONA AGREEMENT.
THESE SERVICES WERE DISCOUNTED ACCORDING TO NPPN/UNIVERSAL - LOUISIANA
M67J AGREEMENT.

M67K THESE SERVICES WERE DISCOUNTED ACCORDING TO PLANCARE AMERICA/PCA AGREEMENT.
THESE SERVICES WERE DISCOUNTED ACCORDING TO PRIME HEALTH SERVICES/INTEGRATED
M67L HEALTH GROUP AGREEMENT.
M67M THESE SERVICES WERE DISCOUNTED ACCORDING TO NPPN/PREF MET HLT AGREEMENT.
M67N THESE SERVICES WERE DISCOUNTED ACCORDING TO NPPN/LEE PHO AGREEMENT.

M67O THESE SERVICES WERE DISCOUNTED ACCORDING TO NPPN/NPN/MED. NET. CO AGREEMENT.

M67P THESE SERVICES WERE DISCOUNTED ACCORDING TO NPPN/NPN/IN. PROHLTNT AGREEMENT.

M67Q THESE SERVICES WERE DISCOUNTED ACCORDING TO NPPN/NPN/PREMIERCARE AGREEMENT.
M67R THESE SERVICES WERE DISCOUNTED ACCORDING TO MCRG AGREEMENT.
M67S THESE SERVICES WERE DISCOUNTED ACCORDING TO IPS/HTPN AGREEMENT.
M67T THESE SERVICES WERE DISCOUNTED ACCORDING TO THE INITIAL GROUP AGREEMENT.
M67U THESE SERVICES WERE DISCOUNTED ACCORDING TO USA MCO AGREEMENT.
THESE SERVICES WERE DISCOUNTED ACCORDING TO PRIME HEALTH/PROVIDER NET
M67V AGREEMENT.
THIS PROVIDER IS A MEMBER OF THE CHOICECARE NETWORK. SERVICES ARE DISCOUNTED
M67X ACCORDING TO THE CHOICECARE NEGOTIATED RATE.
THESE SERVICES WERE DISCOUNTED ACCORDING TO COALITION AMERICA INC. (CAI)
M67Y CONTRACTED RATE AGREEMENT.
THIS PROVIDER IS A MEMBER OF THE CAREPLUS/ALL SAINTS NETWORK. SERVICES ARE
M676 DISCOUNTED ACCORDING TO THE NEGOTIATED RATE.
M68 DRG WEIGHT.
THIS PROVIDER IS A MEMBER OF HUMANA NETWORK. SERVICES ARE DISCOUNTED ACCORDING
M68I TO THE HUMANA NETWORK NEGOTIATED RATE.
THIS PROVIDER IS A MEMBER OF THE ENCORE NETWORK. SERVICES ARE DISCOUNTED
M680 ACCORDING TO THE NEGOTIATED RATE.
M689 PROVIDER MUST RESUBMIT CLAIM TO CORRECT PAYOR.
M69 DAY OUTLIER AMOUNT.
M7 THE PROCEDURE CODE IS INCONSISTENT WITH THE PATIENT'S GENDER.
CHARGES FOR ALTERNATIVE MEDICINE ARE NOT A COVERED EXPENSE. REFER TO YOUR
M7AL BENEFIT PLAN DOCUMENT FOR MORE INFORMATION.

M7AM THESE EXPENSES HAVE BEEN PAID BY MEDICARE AND ARE NOT ELIGIBLE FOR ADDITIONAL REIM
BIRTH CONTROL DEVICES AND ALL RELATED SERVICES ARE NOT A COVERED EXPENSE. REFER
M7BC TO YOUR BENEFIT PLAN DOCUMENT FOR MORE INFORMATION.
CHARGES EXCEED DAILY ALLOWANCE FOR CHIROPRACTIC SERVICES. PLEASE REFER TO THE
M7CM BENEFIT PLAN DOCUMENT.
ONLY SERVICES RELATED TO A COMPLICATION OF PREGNANCY ARE COVERED BY YOUR PLAN.
THEREFORE THIS IS NOT A COVERED EXPENSE. REFER TO YOUR BENEFIT PLAN DOCUMENT FOR
M7CP MORE INFORMATION.
M7CR CRNA REDUCTION APPLIED. THE PATIENT IS NOT RESPONSIBLE FOR THIS AMOUNT.
Humana Remittance Advice Codes

The following codes are updated on a monthly basis. Some codes may have changed since last update.

Last Update: 12/5/07
Code Description
THE MAXIMUM YEARLY COGNITIVE THERAPY BENEFIT HAS BEEN MET. THEREFORE THESE
SERVICES ARE NOT COVERED. REFER TO YOUR BENEFIT PLAN DOCUMENT FOR MORE
M7CT INFORMATION.
SERVICES THAT CAN BE CATEGORIZED AS CUSTODIAL CARE ARE NOT A COVERED EXPENSE.
M7CU REFER TO YOUR BENEFIT PLAN DOCUMENT FOR MORE INFORMATION.
M7C0 YOUR COINSURANCE MAXIMUM LIMIT HAS BEEN MET. SERVICES ARE PAYABLE AT 100%
M7DA THE DENTAL MAXIMUM BENEFIT HAS BEEN MET.
SERVICES PERFORMED BY A HYGIENIST OR DENTURIST ARE NOT COVERED. PLEASE REFER TO
M7DB YOUR BENEFIT PLAN DOCUMENT.

M7DF THE ORTHODONTIC LIFETIME MAXIMUM HAS BEEN MET. NO FURTHER BENEFITS ARE AVAILABLE.
M7DG THIS SERVICE IS NOT A COVERED BENEFIT UNDER YOUR DENTAL PLAN.
M7DH THIS IMPLANT SERVICE IS NOT A COVERED BENEFIT UNDER YOUR DENTAL PLAN.

M7DJ SERVICE NOT COVERED. MEMBER RECEIVES DISCOUNT BY VISITING PARTICIPATING PROVIDER.

M7DK THE DENTAL PATIENT EXCEEDS THE AGE REQUIREMENTS FOR THIS SERVICE TO BE COVERED.
REPAIRS, REPLACEMENTS, OR DME EQUIPMENT THAT IS FOR CONVENIENCE AND NOT BEING
USED PRIMARILY TO TREAT A BODILY INJURY OR SICKNESS ARE NOT COVERED. REFER TO YOUR
M7DM BENEFIT PLAN DOCUMENT FOR MORE INFORMATION.
DENTAL RELATED SERVICES THAT ARE NOT TREATING A DENTAL INJURY ARE NOT A COVERED
M7DN EXPENSE. REFER TO YOUR BENEFITPLAN DOCUMENT FOR MORE INFORMATION.
SERVICES RENDERED BY A DENTIST THAT IS NOT YOUR PRIMARY CARE DENTIST ARE NOT
M7DQ COVERED.
THE DENTAL IMPLANT MAXIMUM HAS BEEN MET. PLEASE REFER TO THE IMPLANT RIDER SECTION
M7DV OF YOUR BENEFIT PLAN DOCUMENT.
VISION CLAIMS ARE PROCESSED BY EYEMED. PLEASE ASK YOUR VISION PROVIDER TO FORWARD
M7DW THIS CLAIM TO EYEMED.
DENTAL SERVICES ARE NOT COVERED UNDER MEDICAL PLAN UNLESS IT IS A RESULT OF AN
INJURY OR TRAUMA. IF THE SERVICE MEETS THESE CRITERIA, CONTACT HUMANA AT THE
M7D2 NUMBER ON THE BACK OF YOUR CARD.
EDUCATIONAL OR VOCATIONAL THERAPY, MATERIALS, TESTING OR TRAINING IS NOT COVERED.
M7ED REFER TO YOUR BENEFIT PLAN DOCUMENT FOR MORE INFORMATION.
NO BENEFITS ARE AVAILABLE FOR THIS CONDITION DUE TO THE EXCLUSION RIDER ON THE
M7EH POLICY.
M7EP THE EXECUTIVE PHYSICAL BENEFIT LIMIT HAS BEEN MET. SERVICES ARE DENIED.

M7FC SERVICES DENIED, THE CALENDAR YEAR MAXIMUM HAS BEEN MET FOR FIRST STEPS BENEFIT.
CHARGES FOR ROUTINE FOOT SERVICES ARE NOT COVERED BY YOUR POLICY. REFER TO YOUR
M7FT BENEFIT PLAN DOCUMENT FOR MORE INFORMATION.
M7FY SERVICES DENIED, THE LIFETIME MAXIMUM HAS BEEN MET FOR FIRST STEPS BENEFIT.
MEDICATIONS OR HORMONES TO STIMULATE GROWTH, WITHOUT A LABORATORY-CONFIRMED
DIAGNOSIS OF GROWTH HORMONE DEFICIENCY ARE NOT A COVERED EXPENSE. REFER TO
M7GH YOUR BENEFIT PLAN DOCUMENT FOR MORE INFORMATION.
GENETIC TESTING IS NOT A COVERED BENEFIT UNDER YOUR PLAN. PLEASE REVIEW THE
M7GT LIMITATIONS AND EXCLUSIONS SECTION OF THE BENEFIT PLAN DOCUMENT.
SERVICES PROVIDED BY A HOME HEALTH AIDE ARE NOT A COVERED EXPENSE. REFER TO YOUR
M7HA BENEFIT PLAN DOCUMENT FOR MORE INFORMATION.
Humana Remittance Advice Codes

The following codes are updated on a monthly basis. Some codes may have changed since last update.

Last Update: 12/5/07
Code Description
HEARING AIDES, EXAMS AND DEVICES ARE NOT A COVERED EXPENSE. REFER TO YOUR BENEFIT
M7HE PLAN DOCUMENT FOR MORE INFORMATION.
HAIR PROSTHESIS, HAIR TRANSPLANTS OR IMPLANTS, AND WIGS ARE NOT A COVERED EXPENSE.
M7HR REFER TO YOUR BENEFIT PLAN DOCUMENT FOR MORE INFORMATION.
SERVICES HAVE EXCEEDED THE $600 MAXIMUM COVERAGE FOR INITIAL DIAGNOSIS. PLEASE
M7H1 REFER TO THE MEMBER'S BENEFIT PLAN DOCUMENT.
SERVICES HAVE EXCEEDED THE $50 MAXIMUM COVERAGE FOR OUTPATIENT SERVICES PER VISIT.
M7H2 PLEASE REFER TO THE MEMBER'S BENEFIT PLAN DOCUMENT.
SERVICES HAVE EXCEEDED THE $2500 ANNUAL BENEFIT. PLEASE REFER THE MEMBER'S BENEFIT
M7H3 PLAN DOCUMENT.
SERVICES HAVE EXCEEDED THE $10,000 LIFETIME BENEFIT. PLEASE REFER TO THE MEMBER'S
M7H4 BENEFIT PLAN DOCUMENT.
THE HOSPICE MAXIMUM PAYABLE BENEFIT HAS BEEN MET FOR THE YEAR, THEREFORE, THIS
M7H6 SERVICE IS NOT COVERED. REFER TO THE BENEFIT PLAN DOCUMENT.
THE MAXIMUM YEARLY HOME HEALTH CARE BENEFIT HAS BEEN MET. THEREFORE, THESE
SERVICES ARE NOT COVERED. REFER TO YOUR BENEFIT PLAN DOCUMENT FOR MORE
M7H7 INFORMATION.
CHARGE EXCEEDS THE PROVIDERS CONTRACTED FEE ARRANGEMENT. THE MAXIMUM
M7H8 BENEFIT/FREQUENCY LIMIT HAS BEEN MET FOR THIS CHIROPRACTIC SERVICE.
SERVICES RELATED TO THE TREATMENT OF INFERTILITY ARE NOT A COVERED EXPENSE. REFER
M7IF TO YOUR BENEFIT PLAN DOCUMENT FOR MORE INFORMATION.
THE MAXIMUM YEARLY BENEFIT FOR THE TREATMENT OF INFERTILITY HAS BEEN MET
THEREFORE; THESE SERVICES ARE NOT COVERED. REFER TO YOUR BENEFIT PLAN DOCUMENT
M7IM FOR MORE INFORMATION.
M7I9 THE MAXIMUM INPATIENT/PARTIAL HOSPITAL THERAPY BENEFIT HAS BEEN MET.
M7J7 YOUR MAXIMUM BENEFIT PAYABLE FOR TMJ HAS BEEN MET.
THE FAMILY LIFETIME SUBSTANCE ABUSE MAXIMUM HAS BEEN MET. NO FURTHER BENEFITS ARE
M7LF AVAILABLE.
THE INDIVIDUAL LIFETIME SUBSTANCE ABUSE MAXIMUM HAS BEEN MET. NO FURTHER BENEFITS
M7LI ARE AVAILABLE.
M7L1 YOUR LIFETIME MAXIMUM HAS BEEN MET. NO FURTHER BENEFITS ARE AVAILABLE.
THE MEDICAID AGENCY HAS ALREADY BILLED HUMANA AND A BENEFIT DETERMINATION FOR THIS
SERVICE HAS BEEN COMMUNICATED. THE SERVICING PROVIDER WILL NEED TO CONTACT THE
M7MS MEDICAID AGENCY FOR REIMBURSEMENT CONSIDERATION.

M7M1 CHARGES EXCEED DAILY ALLOWANCE FOR INPATIENT STAY. NO FURTHER BENEFITS AVAILABLE.
A NON-LICENSED PROVIDRER/FACILITY/PHARMACY IS NOT COVERED UNDER YOUR PLAN. REFER
M7NL TO YOUR BENEFIT PLAN DOCUMENT.
SERVICES PROVIDED AT A NON-QUALIFIED TREATMENT FACILITY ARE NOT A COVERED EXPENSE.
M7NQ REFER TO YOUR BENEFIT PLAN DOCUMENT FOR MORE INFORMATION.
M7NY NEW YORK STATE SURCHARGE POOL ELECTION.
THIS SERVICE IS NOT DOCUMENTED IN THE RECORDS SUBMITTED FOR REVIEW. REVIEW HAS
M7N1 BEEN COMPLETED BY ORTHONET, LLMEMBER IS NOT RESPONSIBLE FOR CHARGES.

THIS SERVICE WAS DENIED AS IT IS NOT DOCUMENTED IN THE RECORDS SUBMITTED. REVIEW
M7N2 HAS BEEN COMPLETED BY ORTHONET, LLC. MEMBER IS NOT RESPONSIBLE FOR CHARGES.
CHARGES FOR THIS SERVICE ARE CONSIDERED TO BE PART OF ANOTHER SERVICE PROVIDED AT
M7N4 THE SAME TIME. SERVICES HAVE BEEN REVIEWED BY ORTHONET, LLC.
Humana Remittance Advice Codes

The following codes are updated on a monthly basis. Some codes may have changed since last update.

Last Update: 12/5/07
Code Description
THIS AMOUNT IS NOT SEPARATELY PAYABLE. SERVICES HAVE BEEN REVIEWED BY ORTHONET,
M7N6 LLC.
ASSISTANT SURGEON/SURGICAL ASSISTANT SERVICES NOT WARRANTED FOR THIS PROCEDURE.
M7N8 REVIEW HAS BEEN COMPLETED BY ORTHONET, LLC.
TEAM SURGERY SERVICES NOT WARRANTED FOR THIS PROCEDURE. REVIEW HAS BEEN
M7N9 COMPLETED BY ORTHONET, LLC.
LIFETIME MAXIMUM MORBID OBESITY BENEFIT HAS BEEN MET. NO FURTHER BENEFITS ARE
M7OB AVAILABLE.
YOUR MEDICAL PLAN WILL ONLY COVER THE RENTAL OF OXYGEN EQUIPMENT, THEREFORE THIS
PURCHASE IS NOT A COVERED EXPENSE. REFER TO YOUR BENEFIT PLAN DOCUMENT FOR MORE
M7OR INFORMATION.
M7O0 YOUR MAXIMUM OUTPATIENT THERAPY BENEFIT HAS BEEN MET.

CHARGES FOR THIS SERVICE ARE NOT COVERED. WEIGHT CONTROL OR OBESITY TREATMENT
M7O1 METHODS ARE EXCLUDED. REFER TO YOUR BENEFIT PLAN DOCUMENT FOR MORE INFORMATION.
THIS IS NOT A COVERED EXPENSE UNDER THE PREVENTATIVE PLAN. THE CLAIM HAS BEEN
M7PR FORWARDED TO YOUR PRIMARY HUMANAPOLICY.

BENEFITS FOR A PRIVATE OR SINGLE-BED ROOM ARE LIMITED TO THE MAXIMUM ALLOWABLE FEE
M7PX CHARGED FOR A SEMI-PRIVATE ROOM. PLEASE REFER TO YOUR BENEFIT PLAN DOCUMENT.
DENTAL PROSTHETICS ARE NOT COVERED UNLESS IT IS A RESULT OF AN INJURY, TRAUMA OR
CONGENITAL DEFECT. IF THE SERVICE MEETS THESE CRITERIA, CONTACT HUMANA AT THE
M7P2 NUMBER ON THE BACK OF YOUR CARD.
THE MAXIMUM YEARLY PHYSICAL/ OCCUPATIONAL THERAPY BENEFIT HAS BEEN MET.
THEREFORE THESE SERVICES ARE NOT COVERED. REFER TO YOUR BENEFIT PLAN DOCUMENT
M7P8 FOR MORE INFORMATION.
YOUR PLAN ONLY COVERS INPATIENT FACILITY CHARGES. PLEASE REFER TO YOU BENEFIT PLAN
M7RB DOCUMENT .

THE AGE LIMIT FOR ROUTINE IMMUNIZATIONS HAS BEEN REACHED. THEREFORE, THIS SERVICE IS
M7RI NOT COVERED. REFER TO YOUR BENEFIT PLAN DOCUMENT FOR MORE INFORMATION.
PAYMENT ADJUSTED AS HUMANA'S POLICY FOR DURABLE MEDICAL EQUIPMENT IS TO PAY
M7RP RENTAL PRICE UP TO PURCHASE PRICE.PLEASE SUBMIT FUTURE CLAIMS AS RENTALS.
CLAIM HAS BEEN DENIED. MEDICAL SERVICES ARE NOT COVERED UNDER THE MEMBER'S
PHARMACY PLAN. PLEASE SUBMIT THE CLAIM TO THE MEDICAL INSURANCE CARRIER FOR
M7RX CONSIDERATION.
CHARGES DENIED BY CONTRACTUAL ARRANGEMENT FOR RADIOLOGY SERVICES. MEMBER NOT
M7R1 RESPONSIBLE.
CHARGES DENIED BY CONTRACTUAL ARRANGEMENT FOR RADIOLOGY SERVICES. MEMBER NOT
M7R2 RESPONSIBLE.
TREATMENT OF A NICOTINE HABIT OR ADDICTION INCLUDING BUT NOT LIMITED TO PATCHES,
HYPNOSIS, SMOKING CESSATION CLASSES OR TAPES IS NOT A COVERED EXPENSE. PLEASE
M7SM REFER TO YOUR BENEFIT PLAN DOCUMENT.

SERVICES RENDERED BY A STANDBY PHYSICIAN, UNLESS MEDICALLY NECESSARY ARE NOT A
M7SS COVERED EXPENSE. REFER TO YOUR BENEFIT PLAN DOCUMENT FOR MORE INFORMATION.
VITAMINS, DIETARIES, AND ANY OTHER NON-PRESCRIPTION SUPPLEMENTS ARE NOT A COVERED
M7SV EXPENSE. REFER TO YOUR BENEFIT PLAN DOCUMENT FOR MORE INFORMATION.
Humana Remittance Advice Codes

The following codes are updated on a monthly basis. Some codes may have changed since last update.

Last Update: 12/5/07
Code Description
THE MAXIMUM YEARLY SKILLED NURSING FACILITY BENEFIT HAS BEEN MET. THEREFORE THESE
SERVICES ARE NOT COVERED. REFER TO YOUR BENEFIT PLAN DOCUMENT FOR MORE
M7S8 INFORMATION.
THE MAXIMUM YEARLY SPEECH/COGNITIVE THERAPY BENEFIT HAS BEEN MET. THEREFORE
THESE SERVICES ARE NOT COVERED. REFER TO YOUR BENEFIT PLAN DOCUMENT FOR MORE
M7S9 INFORMATION.
TRAVEL CHARGES, WHICH ARE NOT MEDICALLY NECESSARY, ARE NOT COVERED UNLESS
RELATED TO A TRANSPLANT. REFER TO YOUR BENEFIT PLAN DOCUMENT FOR MORE
M7TC INFORMATION.
CHARGES FOR TELEPHONE CONSULTATIONS/ TELEMEDICINE ARE NOT COVERED. REFER TO
M7TM YOUR BENEFIT PLAN DOCUMENT FOR MORE INFORMATION.
MEDICAL TESTIMONY IS NOT A COVERED EXPENSE. REFER TO YOUR BENEFIT PLAN DOCUMENT
M7TS FOR MORE INFORMATION.
M7T1 THE MAXIMUM NON-MEDICAL TRANSPLANT BENEFIT HAS BEEN MET.
CHARGES RELATED TO TEMPORARY LODGING, FOR A TRANSPLANT, IS COVERED UP TO A
SPECIFIED DOLLAR AMOUNT. THESE CHARGES EXCEED THIS AMOUNT AND ARE NOT COVERED.
M7T2 REFER TO YOUR BENEFIT PLAN DOCUMENT FOR MORE INFORMATION.
M7UK HUMANA'S RESPONSIBILITY TO REIMBURSE U.S. BANK.
SERVICES RELATED TO THE PRESCRIBED TREATMENT FOR THE CORRECTION OF EYE
REFRACTIVE DISORDERS ARE NOT A COVERED EXPENSE. REFER TO YOUR BENEFIT PLAN
M7VI DOCUMENT FOR MORE INFORMATION.
M70 COST OUTLIER AMOUNT.
THE LIFETIME MAXIMUM HAS BEEN MET. NO FURTHER BENEFITS ARE AVAILABLE. REFER TO THE
M701 MEMBER'S BENEFIT PLAN DOCUMENT.
M702 YOUR MAXIMUM PREVENTATIVE BENEFIT HAS BEEN MET.

M703 PREVENTATIVE SERVICES RENDERED BY A NON-PARTICIPATING PROVIDER ARE NOT COVERED.
WE DETECTED A CODING ERROR. THE DIAGNOSIS IS NOT COMPATIBLE WITH THE PROCEDURE
M706 BILLED. WE RELIED ON INTERNAL CRITERIA TO MAKE THIS DETERMINATION.
M71 PRIMARY PAYER AMOUNT.
M71A ORTHONET DENIED AUTHORIZATION FOR THIS SERVICE.
M71B ORTHONET DENIED AUTHORIZATION FOR THIS SERVICE.
DOCUMENTATION IS REQUIRED TO CONSIDER PAYMENT FOR UNLISTED SERVICE. WE RELIED ON
M711 INTERNAL CRITERIA TO MAKE THIS DETERMINATION.
PATIENT DOES NOT MEET STATE RECOMMENDED REQUIREMENTS FOR PREVENTATIVE CARE AS
M712 DEFINED BY YOUR BENEFIT PLAN DOCUMENT.
M713 ADMINISTRATIVE CHARGE IS DENIED DUE TO NO CORRESPONDING VACCINATION CHARGE.
SERVICES HAVE BEEN DENIED, THE PATIENT DOES NOT MEET THE AGE REQUIREMENTS FOR THIS
M72A PREVENTATIVE SERVICE TO BE COVERED.
THIS CLAIM HAS BEEN DENIED AS ADDITIONAL INFORMATION REQUESTED FROM BOTH THE
MEMBER AND PROVIDER HAVE NOT BEENRECEIVED. THIS CLAIM WILL BE RECONSIDERED UPON
M72B RECEIPT OF THE REQUESTED INFORMATION.
PROCEDURE CODE SUBMITTED INDICATES SERVICE IS FOR DOCUMENTATION PURPOSES ONLY.
M72C DOCUMENTATION IS NOT REIMBURSESEPARATELY.
CLAIM HAS BEEN DENIED AS THE REQUESTED INFORMATION FOR PRIOR DATES OF SERVICE WAS
NOT RECEIVED FROM THE PROVIDER. THIS CLAIM WILL BE RECONSIDERED UPON RECEIPT OF
M72D THE REQUESTED INFORMATION.
Humana Remittance Advice Codes

The following codes are updated on a monthly basis. Some codes may have changed since last update.

Last Update: 12/5/07
Code Description
THIS CLAIM HAS BEEN DENIED AS THE PRIMARY CARRIER PAYMENT INFORMATION REQUESTED
FROM THE PROVIDER HAS NOT BEEN RECEIVED. THIS CLAIM WILL BE RECONSIDERED UPON
M72E RECEIPT OF THE REQUESTED INFORMATION.
M72J MEDICAL RECORDS HAVE NOT BEEN RECEIVED FROM THE PROVIDER.
THIS CLAIM HAS BEEN DENIED AS ADDITIONAL INFORMATION REQUESTED FROM THE MEMBER
HAS NOT BEEN RECEIVED. THIS CLAIM WILL BE RECONSIDERED UPON RECEIPT OF THE
M72M REQUESTED INFORMATION.
THIS CLAIM HAS BEEN DENIED FOR MEDICAL RECORDS THAT WERE PREVIOUSLY REQUESTED
FROM ANOTHER PROVIDER WHICH HAVE NOT BEEN RECEIVED. THIS CLAIM WILL BE CONSIDERED
M72N UPON RECEIPT OF THE REQUESTED INFORMATION.
THIS CLAIM HAS BEEN DENIED AS PRIOR CARRIER INFORMATION REQUESTED FROM THE MEMBER
HAS NOT BEEN RECEIVED. THE CLAIM WILL BE RECONSIDERED UPON RECEIPT OF THE
M72P REQUESTED INFORMATION.
THIS TREATMENT IS NOT MEDICALLY NECESSARY AS DEFINED BY YOUR PLAN AND IS NOT
M721 ELIGIBLE FOR COVERAGE. PLEASE REFER TO LETTER UNDER SEPARATE COVER.

M722 THIS CHARGE IS DENIED BECAUSE COSMETIC SURGERIES AS PLAN DEFINED ARE NOT COVERED.
SERVICES THAT ARE EXPERIMENTAL, INVESTIGATIONAL, OR FOR RESEARCH PURPOSES ARE NOT
M724 A COVERED BENEFIT. REFER TO YOUR BENEFIT PLAN DOCUMENT.

WE DETECTED A CODING ERROR. THE PROCEDURE BILLED IS NOT COMPATIBLE WITH THE
M725 GENDER OF THE PATIENT. WE RELIED ON INTERNAL CRITERIA TO MAKE THIS DETERMINATION
SERVICES THAT ARE NOT AUTHORIZED, PRESCRIBED OR PERFORMED BY A QUALIFIED
PRACTITIONER ARE NOT COVERED. REFER TO YOUR BENEFIT PLAN DOCUMENT FOR MORE
M726 INFORMATION.
TAKE HOME DRUGS DISPENSED AT A PHYSICIAN'S OFFICE OR MEDICAL FACILITY ARE NOT
M728 COVERED. REFER TO YOUR BENEFIT PLAN DOCUMENT.
M735 THIS TRANSPLANT SERVICE IS NOT A COVERED EXPENSE.
M736 THESE SERVICES ARE NOT COVERED DUE TO NON-APPROVAL OF AUTHORIZATION.
TREATMENT FOR SERIOUS MENTAL ILLNESS IS NOT COVERED UNDER THIS POLICY, PLEASE
M738 REFER TO YOUR BENEFIT PLAN DOCUMENT.

M739 THE ALLOWED AMOUNT FOR THIS SERVICE HAS BEEN APPLIED TO THE BENEFIT ALLOWANCE.
M74 INDIRECT MEDICAL EDUCATION ADJUSTMENT.
WE DETECTED A CODING ERROR. THE PROVIDER MUST SUBMIT CORRECTED INFORMATION OR A
CORRECTED BILLING FOR RECONSIDERATION. WE RELIED ON INTERNAL CRITERIA TO MAKE THIS
DETERMINATION. THIS INFORMATION WILL BE SUPPLIED TO YOU UPON REQUEST, FREE OF
M741 CHARGE.
THE ALLOWED AMOUNT FOR THIS SERVICE HAS BEEN APPLIED TO THE PREVENTATIVE CARE
M743 MAXIMUM ALLOWANCE.
BEHAVIOR HEALTH SERVICES FOR THIS PLAN ARE ADMINISTERED BY OASIS. PLEASE RESUBMIT
TO OASIS AT THE ADDRESS LISTED ON THE MEMBER'S INSURANCE CARD: OASIS 30
M748 MONTGOMERY STREET, SUITE 604 JERSEY CITY, NJ 07302
PLEASE SUBMIT TO VALUE OPTIONS. BEHAVIORAL HEALTH SERVICES ARE NOT ADMINISTERED BY
M749 HUMANA.
M75 DIRECT MEDICAL EDUCATION ADJUSTMENT.
YOUR MAXIMUM PREVENTIVE BENEFIT (MAMMOGRAM) HAS BEEN MET. PLEASE REFER TO YOUR
M751 BENEFIT PLAN DOCUMENT FOR FURTHER INFORMATION.
M752 YOUR MAXIMUM PREVENTIVE BENEFIT (VISION EXAM) HAS BEEN MET.
Humana Remittance Advice Codes

The following codes are updated on a monthly basis. Some codes may have changed since last update.

Last Update: 12/5/07
Code Description
YOUR MAXIMUM PREVENTIVE BENEFIT (VISION EXAM) HAS BEEN MET. PLEASE REFER TO YOUR
M753 BENEFIT PLAN DOCUMENT FOR FURTHER INFORMATION.
THE PATIENT EXCEEDS THE AGE REQUIREMENTS FOR THIS SERVICE TO BE COVERED. PLEASE
M754 REFER TO YOUR BENEFIT PLAN DOCUMENT FOR FURTHER INFORMATION.
THIS SERVICE IS NOT COVERED UNDER YOUR NON-NETWORK BENEFIT. PLEASE REFER TO THE
M755 LIMITATIONS AND EXCLUSIONS PORTION OF YOUR BENEFIT PLAN DOCUMENT.
YOUR MAXIMUM PHYSICAL/OCCUPATIONAL/SPEECH THERAPY BENEFIT HAS BEEN MET. PLEASE
M758 REFER TO YOUR BENEFIT PLAN DOCUMENT FOR FURTHER INFORMATION.
M76 DISPROPORTIONATE SHARE ADJUSTMENT.
THE MAXIMUM BENEFIT FOR THIS CHIROPRACTIC SERVICE HAS BEEN MET. NO FURTHER
BENEFITS ARE AVAILABLE. PLEASE REFER TO YOUR BENEFIT PLAN DOCUMENT FOR FURTHER
M761 INFORMATION.
THESE SERVICES ARE NOT ADMINISTERED BY HUMANA. PLEASE RESUBMIT TO THE MEMBER'S
M762 BEHAVIORAL HEALTH VENDOR.
THE PROCEDURE CODE IS INCONSISTENT WITH THE PROVIDER TYPE/SPECIALTY. WE RELIED ON
INTERNAL CRITERIA TO MAKE THIS DECISION. THIS INFORMATION WILL BE SUPPLIED TO YOU
M763 UPON REQUEST, FREE OF CHARGE.
THE PROCEDURE CODE IS INCONSISTENT WITH THE PROVIDER TYPE/SPECIALTY. WE RELIED ON
INTERNAL CRITERIA TO MAKE THIS DECISION. THIS INFORMATION WILL BE SUPPLIED TO YOU
M764 UPON REQUEST, FREE OF CHARGE.
THE SETTING IS NOT APPROPRIATE FOR THE REQUIRED TREATMENT. WE RELIED ON INTERNAL
CRITERIA TO MAKE THIS DECISION. THIS INFORMATION WILL BE SUPPLIED TO YOU UPON
M765 REQUEST, FREE OF CHARGE.
THE DIAGNOSIS IS NOT COMPATIBLE WITH THE PROCEDURE BILLED AND/OR RECORDS
M766 SUBMITTED DO NOT SUPPORT SERVICES RENDERED.
THE MAXIMUM BENEFIT FOR THIS PHYSICAL THERAPY SERVICE HAS BEEN MET. NO FURTHER
BENEFITS ARE AVAILABLE. PLEASE REFER TO YOUR BENEFIT PLAN DOCUMENT FOR FURTHER
M769 INFORMATION.
THE MAXIMUM BENEFIT FOR THIS OCCUPATIONAL THERAPY SERVICE HAS BEEN MET. NO
FURTHER BENEFITS ARE AVAILABLE. PLEASE REFER TO YOUR BENEFIT PLAN DOCUMENT FOR
M770 FURTHER INFORMATION.
THE MAXIMUM BENEFIT FOR THIS SPEECH THERAPY SERVICE HAS BEEN MET. NO FURTHER
BENEFITS ARE AVAILABLE. PLEASE REFER TO YOUR BENEFIT PLAN DOCUMENT FOR FURTHER
M771 INFORMATION.
SERVICES DENIED. MEMBER DID NOT RESPOND TO UTILIZATION MANAGEMENT ADMINISTRATOR.
BENEFITS WILL BE AVAILABLE ONCE A $1000 PENALTY IS REACHED OR UTILIZATION MANAGEMENT
M774 ADMINISTRATOR IS CONTACTED.
THE ALLOWED AMOUNT FOR THIS SERVICE HAS BEEN APPLIED TO THE AMBULANCE BENEFIT
M775 ALLOWANCE.
M78 NON-COVERED DAYS/ROOM CHARGES ADJUSTMENT.
CLAIM DENIED. RECORDS PREVIOUSLY REQUESTED TO DETERMINE APPROPRIATENESS OF
M783 SETTING WERE NOT RECEIVED. SUBMIT RECORDS FOR CLAIMS RECONSIDERATION.
BASED ON PRESENTING SYMPTOMS, THE EMERGENCY ROOM WAS AN INAPPROPRIATE SETTING
M784 FOR CARE ACCORDING TO PLAN DOCUMENTS.
BENEFITS ARE PAYABLE FOR MEDICAL SCREENING EXAM TO EVALUATE NECESSITY OF
M785 EMERGENCY TREATMENT.
PROLOTHERAPY IS NOT COVERED UNDER THE PLAN. PLEASE REFER TO THE LIMITATIONS AND
M790 EXCLUSIONS PORTION OF THE MEMBER'S BENEFIT PLAN DOCUMENT.
Humana Remittance Advice Codes

The following codes are updated on a monthly basis. Some codes may have changed since last update.

Last Update: 12/5/07
Code Description
EXPENSES FOR PERSONAL HYGIENE EQUIPMENT ARE NOT COVERED UNDER THE PLAN. PLEASE
REFER TO THE LIMITATIONS AND EXCLUSIONS PORTION OF THE MEMBERS BENEFIT PLAN
M791 DOCUMENT.
ORTHOTICS THAT ARE NOT CUSTOM-MADE OR CUSTOM-FITTED ARE NOT COVERED UNDER THE
PLAN. PLEASE REFER TO THE LIMITATIONS AND EXCLUSIONS PORTION OF THE MEMBER'S
M792 BENEFIT PLAN DOCUMENT.
FABRIC SUPPORTS ARE NOT COVERED UNDER THE PLAN. PLEASE REFER TO THE LIMITATIONS
M793 AND EXCLUSIONS PORTION OF THE MEMBER'S BENEFIT PLAN DOCUMENT.
SERVICES CONSIDERED AN INTEGRAL PART OF ANOTHER SERVICE ARE NOT COVERED UNDER
THE PLAN. PLEASE REFER TO THE LILIMITATIONS AND EXCLUSIONS PORTION OF THE MEMBER'S
M794 BENEFIT PLAN DOCUMENT.
EYEGLASSES OR CONTACT LENSES ARE NOT COVERED EXCEPT AS THE RESULT OF AN ACCIDENT
OR FOLLOWING CATARACT SURGERY. PLEASE REFER TO THE LIMITATIONS AND EXCLUSIONS
M795 PORTION OF THE BENEFIT PLAN DOCUMENT.
PRESCRIPTION DRUGS ARE NOT COVERED UNLESS ADMINISTERED WHILE INPATIENT, DURING AN
OFFICE VISIT, OR BY A HOME HEALTH CARE AGENCY. PLEASE REFER TO THE MEMBER'S BENEFIT
M796 PLAN DOCUMENT.

EXPENSES FOR EXERCISE EQUIPMENT ARE NOT COVERED UNDER THE PLAN. PLEASE REFER TO
M797 THE LIMITATIONS AND EXCLUSIONSPORTION OF THE MEMBER'S BENEFIT PLAN DOCUMENT.
HYPERHIDROSIS SURGERY IS NOT COVERED UNDER YOUR PLAN. PLEASE REFER TO THE
M798 LIMITATIONS AND EXCLUSIONS PORTION OF THE MEMBER'S BENEFIT PLAN DOCUMENT.
THESE SERVICES ARE NOT ADMINISTERED BY HUMANA. PLEASE SUBMIT TO THE MEMBER'S
M799 ROUTINE VISION VENDOR.
M8 THE PROCEDURE CODE IS INCONSISTENT WITH THE PROVIDER TYPE.
M8DO THIS CHARGE WAS COORDINATED WITH THE OTHER DENTAL CARRIER.
THE PROVIDER ACCEPTED ASSIGNMENT WITH MEDICARE. AS A RESULT, BENEFITS MAY BE
M8MA REDUCED.
BASED ON MEDICARE ELIGIBILITY, BENEFITS WERE ESTIMATED AS IF THEY WERE PAID BY
M8ME MEDICARE.

M8MO PROVIDER DID NOT ACCEPT MEDICARE ASSIGNMENT. DISCOUNT, IF APPLICABLE, IS DUE TO DEAL.
M80 OUTLIER DAYS.
SERVICES PROVIDED FOR WORK-RELATED INJURIES ARE NOT COVERED. CHARGES SHOULD BE
SUBMITTED TO THE WORKMAN'S COMPENSATION CARRIER FOR CONSIDERATION. REFER TO THE
M800 BENEFIT PLAN DOCUMENT FOR MORE INFORMATION.
CLAIM DENIED UNTIL INFORMATION THAT WAS PREVIOUSLY REQUESTED IS RECEIVED
M804 CONCERNING ACCIDENT/INJURY.
AT YOUR REQUEST WE WILL NOT CONSIDER THESE EXPENSES UNDER YOUR PLAN. FOR FUTURE
M806 CONSIDERATION, SUBMIT A WRITTEN REQUEST.
SERVICES PROVIDED FOR WORK-RELATED INJURIES ARE NOT COVERED. THE CHARGES SHOULD
BE SUBMITTED TO YOUR WORKMAN'S COMPENSATION CARRIER FOR CONSIDERATION. REFER TO
M809 YOUR BENEFIT PLAN DOCUMENT FOR MORE INFORMATION.
AUTOMOBILE, HOME AND PREMISE INSURANCE IS PRIMARY OVER THE GROUP HEALTH POLICY.
M810 RELATED INJURY CHARGES WILL BE DENIED.
PLEASE FORWARD A COPY OF THE OTHER INSURANCE CARRIER'S PAYMENT. WE NEED THIS
M811 INFORMATION TO PROCESS THE CHARGE(S).
PLEASE FORWARD A COPY OF MEDICARE' S PAYMENT. WE NEED THIS INFORMATION TO PROCESS
M813 THE CHARGE(S).
Humana Remittance Advice Codes

The following codes are updated on a monthly basis. Some codes may have changed since last update.

Last Update: 12/5/07
Code Description
M815 THE CHARGES WERE COORDINATED WITH THE OTHER INSURANCE CARRIER.
THE PROVIDER ACCEPTED ASSIGNMENT WITH MEDICARE. AS A RESULT, BENEFITS MAY BE
M816 REDUCED.
M817 BENEFITS WERE COORDINATED WITH MEDICARE INSURANCE.
M819 THE CHARGES WERE COORDINATED WITH THE OTHER INSURANCE CARRIER.
THE PROVIDER ACCEPTED ASSIGNMENT WITH MEDICARE. AS A RESULT, BENEFITS MAY BE
M820 REDUCED.
M823 THE CHARGES WERE COORDINATED WITH THE OTHER INSURANCE CARRIER.
M824 BENEFITS WERE COORDINATED WITH MEDICARE INSURANCE.
ADDITIONAL BENEFITS WERE PAID DUE TO COORDINATION WITH THE OTHER INSURANCE
M831 CARRIER.
M833 THIS CHARGE WAS COORDINATED WITH YOUR MEDICAL PLAN.
CLAIM DENIED AS SERVICES/PROCEDURES NOT APPROVED BY MEDICARE ARE NOT COVERED
M834 UNDER THE PLAN.
THIS CLAIM HAS BEEN DENIED BECAUSE DIVORCE DECREE INFORMATION REGARDING THE
MEMBERS FINANCIAL RESPONSIBILITY IS NEEDED IN ORDER TO PROCESS THE APPROPRIATE
M836 PAYMENT.

THIS PLAN IS THE SECONDARY PLAN. THE SUM OF THE BENEFIT PAYABLE BY THIS PLAN WHEN
M838 ADDED TO THE PRIMARY PLAN'S BENEFIT WILL NOT EXCEED THIS PLAN'S NORMAL LIABILITY.
PLEASE FORWARD A COPY OF THE OTHER INSURANCE CARRIER'S PAYMENT. WE NEED THIS
M839 INFORMATION TO PROCESS THE CHARGE(S).

M841 AUTOMOBILE, HOME AND PREMISE INSURANCE IS PRIMARY OVER THE GROUP HEALTH POLICY
M842 WORKERS COMPENSATION INSURANCE IS PRIMARY OVER THE GROUP HEALTH POLICY
THE ALLOWABLE AMOUNT FOR THIS CLAIM HAS BEEN REDUCED BASED UPON THE IMPACT OF
M843 THE PRIMARY PLAN'S ADJUDICATION INCLUDING PAYMENTS AND/OR ADJUSTMENTS.
FOR THIS CLAIM TO BE CONSIDERED FOR PAYMENT, THE MEMBER MUST BE ENROLLED IN
M849 MEDICARE PART B.
M85 INTEREST AMOUNT.
M87 TRANSFER AMOUNT.
ADJUSTMENT AMOUNT REPRESENTS COLLECTION AGAINST RECEIVABLE CREATED IN PRIOR
M88 OVERPAYMENT.
M89 PROFESSIONAL FEES REMOVED FROM CHARGES.
M891 CHARGES YOU ARE NOT FINANCIALLY RESPONSIBLE FOR ARE NOT COVERED.
M9 THE DIAGNOSIS IS INCONSISTENT WITH THE PATIENT'S AGE.

PAYMENT HAS BEEN ADJUSTED BECAUSE AN INCORRECT CHARGE AMOUNT WAS PROCESSED ON
M9CA THE ORIGINAL CLAIM. PAYMENT HASBEEN REDUCED BY THE AMOUNT OF THE OVERPAYMENT.

PAYMENT HAS BEEN ADJUSTED BECAUSE AN INCORRECT CHARGE AMOUNT WAS PROCESSED ON
M9CB THE ORIGINAL CLAIM. PAYMENT HASBEEN INCREASED BY THE AMOUNT OF THE UNDERPAYMENT.
PAYMENT HAS BEEN ADJUSTED BECAUSE AN INCORRECT CHARGE AMOUNT WAS PROCESSED ON
M9CC THE ORIGINAL CLAIM.

M9DB THE TOTAL FEE CHARGED FOR THIS ORTHODONTIC TREATMENT PHASE HAS BEEN PROCESSED
M9DF THIS CHARGE WAS DISTRIBUTED WITH THE COVERED SERVICES.
M9DG THIS CHARGE WAS DISTRIBUTED WITH THE COVERED SERVICES.
Humana Remittance Advice Codes

The following codes are updated on a monthly basis. Some codes may have changed since last update.

Last Update: 12/5/07
Code Description
BENEFITS ARE BASED ON THE ALTERNATE PROVISION OF THE PLAN. ALTERNATE PROVISION
M9DM APPLIES ONLY TO THE PROSTHESIS OVER THE IMPLANT.
M9DP THE ORTHODONTIC FEE HAS BEEN PRO-RATED.
THIS CLAIM HAS BEEN DENIED FOR REQUIRED RECORDS, X-RAY AND/OR PERIODONTAL
M9D1 CHARTING THAT WERE PREVIOUSLY REQUESTED AND HAVE NOT BEEN RECEIVED

M9D4 THE TOTAL FEE CHARGED FOR THIS ORTHODONTIC TREATMENT PHASE HAS BEEN PROCESSED.
THIS PLAN PROVIDES BENEFITS FOR CROWNS ONLY ON TEETH THAT ARE EXTENSIVELY DECAYED
M9D5 AND/OR ACCIDENTALLY BROKEN.
THIS PLAN PROVIDES BENEFITS FOR CROWNS ONLY ON TEETH THAT ARE EXTENSIVELY DECAYED
M9D6 AND/OR ACCIDENTALLY BROKEN.
GENERAL ANESTHESIA PERFORMED FOR INSURED MANAGEMENT OR APPREHENSION IS NOT
M9D7 COVERED.
THIS TOOTH WAS MISSING PRIOR TO YOUR EFFECTIVE DATE. THEREFORE, THE INITIAL
M9D8 PLACEMENT OF THIS PROSTHESIS IS NOT COVERED UNDER YOUR DENTAL PLAN.
APPROVAL PENDING COMPLETION OF ROOT CANAL THERAPY. FOR RECONSIDERATION,
M9D9 RESUBMIT THIS ESTIMATE WITH A RADIOGRAPH OF THE COMPLETED ROOT CANAL.
THIS IS CONSIDERED A TMJ RELATED EXPENSE, AND THEREFORE IS NOT A COVERED BENEFIT
M9EO UNDER YOUR DENTAL PLAN.
PAYMENT ADJUSTED AS CHARGES HAVE ALREADY BEEN PAID UNDER THE BASIC PLAN. PAYMENT
M9EP REFLECTS ADDITIONAL BENEFITSPAID UNDER THE EXECUTIVE PLAN.
OTHER INSURANCE IS PRIMARY. FOR FASTER PAYMENT PLEASE INCLUDE A COPY OF THEIR EOB
M9E1 FOR THESE CHARGES ALONG WITH THIS COMPLETED STATEMENT.
M9E2 THIS PLAN DOES NOT PROVIDE BENEFITS FOR COSMETIC DENTISTRY
ACTIVE PERIODONTAL DISEASE IS NOT EVIDENT, OPTIONAL TREATMENT BENEFITS HAVE BEEN
M9E3 APPLIED.
WE HAVE RECONSIDERED YOUR CLAIM/PRE-ESTIMATE DUE TO REQUEST FOR ADDITIONAL
M9E4 REVIEW. A LETTER WILL BE FORTHCOMING.
THIS EXPLANATION CODE IS USED TO DENY ANY OCCLUSAL GUARD IF THE POLICY DOES NOT
M9E5 ALLOW COVERAGE.
M9E6 BENEFITS ARE BASED ON LIMITED AREAS REQUIRING TREATMENT.
BENEFITS ARE BASED ON THE ALTERNATE TREATMENT PROVISION OF THE PLAN. BENEFITS MAY
M9E7 BE APPLIED TO THE TREATMENT PLAN CHOSEN BY THE PATIENT AND/OR PROVIDER.
M9E8 THIS SERVICE CAN ONLY BE CONSIDERED IF ACTIVE PERIODONTAL DISEASE EXISTS.
BENEFITS ARE BASED ON THE OPTIONAL TREATMENT PROVISION OF THE PLAN. BENEFITS MAY
M9E9 BE APPLIED TO THE TREATMENT PLAN CHOSEN BY THE PATIENT/PROVIDER.
BENEFITS ARE BASED ON THE ALTERNATE SERVICE PROVISION OF THE PLAN. BENEFITS MAY BE
M9F1 APPLIED TO THE TREATMENT PLAN CHOSEN BY THE PATIENT/PROVIDER.
BENEFITS ARE BASED ON THE OPTIONAL TREATMENT PROVISION OF THE PLAN. BENEFITS MAY
M9F2 BE APPLIED TO THE TREATMENT PLAN CHOSEN BY THE PATIENT/PROVIDER.
PAYMENT FOR PRE-ORTHODONTIC WORK IS INCLUDED IN THE ALLOWANCE FOR ORTHODONTIC
M9F3 SERVICE AND/OR TREATMENT PLAN.

M9F4 THIS SERVICE CAN ONLY BE CONSIDERED WITH ADEQUATE DOCUMENTATION OF NECESSITY.
THERE ARE NO BENEFITS AVAILABLE FOR THE INITIAL REPLACEMENT OF ROOT TIPS AS ROOT
M9F5 TIPS ARE CONSIDERED TO BE NON-FUNCTIONING.
M9F6 ADJUSTMENT REFLECTS CHARGES IN EXCESS OF USUAL AND CUSTOMARY.
M9F9 ALL OR PART OF THE BENEFIT IS BEING USED TOWARD A PRIOR OVERPAYMENT.
M9G1 SERVICES INCLUDE ALL ADJUSTMENTS AND RELINES ACCORDING TO THE PLAN.
Humana Remittance Advice Codes

The following codes are updated on a monthly basis. Some codes may have changed since last update.

Last Update: 12/5/07
Code Description
M9G2 THIS IS AN ADJUSTMENT OF A PREVIOUSLY PROCESSED CLAIM
BENEFITS ARE BASED ON THE ALTERNATE SERVICE PROVISION OF THE PLAN. PLEASE REFER TO
THE SCHEDULE OF BENEFITS, ALTERNATE SERVICES SECTION OF YOUR BENEFIT PLAN
M9G3 DOCUMENT.
THIS PROCEDURE WILL BE REVIEWED ONCE THE ROOT PLANING AND SCALING IS COMPLETED
M9G4 AND UPDATED POST HEALING PERIODONTAL CHARTING IS SUBMITTED.
M9G5 THIS SERVICE WILL BE RECONSIDERED ONCE THE ROOT CANAL IS RETREATED.
THE SCHEDULED AMOUNT FOR THIS SERVICE HAS BEEN INCREASED TO REFLECT THE
M9H9 COMPLEXITIES OF THE PROCEDURE PERFORMED.
M9I1 PENDING THE SUCCESS OF THE PERIODONTAL POCKET ELIMINATION.
OTHER INSURANCE IS PRIMARY. FOR FASTER PAYMENT PLEASE INCLUDE A COPY OF THEIR EOB
M9I2 FOR THESE CHARGES ALONG WITH THIS COMPLETED STATEMENT

M9I3 MAJOR AND PROSTHODONTIC SERVICES ARE PROCESSED (PAID) ON THE PREPARATION DATE
M9J2 THERE IS NO COVERAGE FOR SERVICES NOT RENDERED.
TOOTH IS PERIODONTALLY COMPROMISED, BENEFITS WILL BE CONSIDERED IF FURTHER
M9J3 INFORMATION IS RECEIVED.
BASED ON THE INFORMATION PROVIDED. THE MEDICAL NECESSITY IS NOT EVIDENT. PATIENT
M9J4 MANAGEMENT DOES NOT CONSTITUTE MEDICAL NECESSITY.
REMOVAL OF ASYMPTOMATIC WISDOM TEETH ARE NOT A COVERED BENEFIT. PLEASE REFER TO
M9J5 THE EXCLUSION IN YOUR CERTIFICATE OF BENEFITS.
M9J6 MAJOR AND PROSTHODONTIC SERVICES ARE PROCESSED ON THE PREPARATION DATE.
SUBMITTED DOCUMENTATION DOES NOT ESTABLISH THAT THIS PROCEDURE IS REQUIRED FOR
M9J7 NORMAL HEALING.
THIS PROCEDURE WILL BE REVIEWED ONCE THE ROOT PLANING AND SCALING IS COMPLETED
M9J8 AND UPDATED POST HEALING PERIODONTAL CHARTING IS SUBMITTED.
M9J9 THIS SERVICE WILL BE RECONSIDERED ONCE THE ROOT CANAL IS RETREATED.
M9L0 THIS SERVICE DOES NOT SATISFY THE CRITERIA FOR ALLOWABLE BENEFITS.
A CROWN BUILDUP IS A BENEFIT ONLY WHEN LOSS OF TOOTH STRUCTURE NECESSITATES IT TO
M9L7 PROVIDE RETENTION.
SPACE MAINTAINERS ARE ONLY COVERED IN ORDER TO RETAIN SPACE FOR THE PREMATURE
M9L8 LOSS OF PRIMARY TEETH.
M9L9 PRIOR CARRIER COVERED FULL ORTHODONTIC CASE FEE.
THE CLAIM HAS BEEN DENIED AS INJURY INFORMATION WAS REQUESTED FROM THE MEMBER
AND HAS NOT BEEN RECEIVED. NO FURTHER ACTION WILL BE TAKEN UNTIL THE INJURY
M9M1 INFORMATION IS RECEIVED.
M9M2 ADJUSTMENT MADE DUE TO EXCESS FAMILY DEDUCTIBLE TAKEN.
THIS SERVICE IS NOT COVERED UNDER YOUR PLAN UNLESS PERFORMED BY A LICENSED
M9M3 DENTIST.

M9M4 THIS POLICY DOES NOT PROVIDE BENEFITS FOR SERVICES PROVIDED BY A FAMILY MEMBER.
CLAIM DENIED AS ADDITIONAL ACCIDENT/INJURY INFORMATION NEEDED TO PROCESS. TO HAVE
M9M5 YOUR CLAIM RECONSIDERED, PLEASE CONTACT US.
IF MORE THAN ONE SURGICAL SERVICE IS PERFORMED ON THE SAME DAY, ONLY THE MOST
M9M6 INCLUSIVE SURGICAL SERVICE WILL BE CONSIDERED A COVERED SERVICE.
INITIAL REPLACEMENT OF TEETH FOLLOWING EXTRACTIONS MUST OCCUR WITHIN 12 MONTHS.
M9M7 PLEASE REFER TO YOUR DENTAL PLAN FOR SPECIFICS.
APPROVAL PENDING EXTRACTION OF TOOTH/TEETH. PLEASE RESUBMIT FOR REVIEW UPON
M9M8 COMPLETION OF THE EXTRACTION.
Humana Remittance Advice Codes

The following codes are updated on a monthly basis. Some codes may have changed since last update.

Last Update: 12/5/07
Code Description
APPROVAL PENDING EXTRACTION OF TOOTH/TEETH. PLEASE RESUBMIT FOR REVIEW UPON
M9M9 COMPLETION OF THE EXTRACTIONS.
M9N1 THIS PROCEDURE IS NOT COVERED BECAUSE THE PRIMARY PROCEDURE IS NOT COVERED.
FULL MOUTH RESTORATION ARE NOT COVERED. FULL MOUTH RESTORATION CONSISTS OF 5 OR
M9N2 MORE UNITS OF FIXED OR REMOVABLE PROSTHETICS.
M9P5 THIS ESTIMATE IS VALID FOR A LIMITED TIME. REFER TO YOUR DENTAL PLAN.
THIS PLAN DOES NOT PROVIDE BENEFITS FOR SERVICES NECESSITATED BY ATTRITION OR
M9R1 ABRASION.
THIS PLAN DOES NOT PROVIDE BENEFITS FOR SERVICES TO RESTORE OCCLUSION OR ALTER
M9R2 VERTICAL DIMENSION.
M9R3 PLAN EXCLUDES TREATMENT OF CONGENITAL/DEVELOPMENTAL MALFORMATIONS.
PERIO MAINTENANCE INCLUDES AN EXAMINATION, CHARTING, SCALING & ROOT PLANING, AND
M9R4 POLISHING.
A COPY OF THE MEDICAL CARRIER'S EXPLANATION OF BENEFITS IS NECESSARY TO PROCESS
M9R5 THE CHARGE.
ALLOWANCE WAS BASED ON THE NUMBER OF PONTICS NECESSARY, NOT TO EXCEED THE
M9R6 NORMAL COMPLIMENT OF TEETH.
ABUTMENT CROWNS OF NON-COVERED BRIDGE ELIGIBLE ONLY IF TEETH ARE EXTENSIVELY
M9R7 DECAYED OR ACCIDENTALLY BROKEN.
NO BENEFITS AVAILABLE FOR THE REPLACEMENT OF THIS TOOTH, AS IT IS CONSIDERED TO BE
M9R8 NON-FUNCTIONING TOOTH.
M9R9 ALLOWABLE BENEFITS WERE COMBINED WITH THE RELATED SERVICES.
BENEFITS FOR SERVICES COVERED UNDER YOUR MEDICAL PLAN ARE NOT AVAILABLE UNDER
M9S6 YOUR DENTAL PLAN.
M9S7 PAYMENT REFLECTS TAX.
M9S8 PAYMENT REFLECTS INTEREST.
M9TI TO PROCESS CLAIMS WE NEED AN ITEMIZED BILL WITH A DIAGNOSIS.
ITEMIZATION IS NEEDED TO DETERMINE THE CORRECT PAYMENT OF THIS CLAIM. CLAIM WILL BE
M9T1 RECONSIDERED WHEN THE ITEMIZATION IS RECEIVED.
THIS SERVICE/PROCEDURE IS NOT ALLOWED AS IT WAS SUBMITTED WITHOUT THE NECESSARY
COST TO PROVIDER, SUPPLIER, OR PRACTITIONER INFORMATION NEEDED TO SUPPORT
M9X2 MODIFIER FB. WE RELIED ON INTERNAL CRITERIA TO MAKE THIS DETERMINATION.
THIS SERVICE/PROCEDURE IS NOT ALLOWED AS IT WAS SUBMITTED WITHOUT CORRESPONDING
REVENUE AND/OR CPT CODES NEEDED TO SUPPORT THE BILLED HCPCS CODE. WE RELIED ON
M9Y2 INTERNAL CRITERIA TO MAKE THIS DETERMINATION.
M90 INGREDIENT COST ADJUSTMENT.
M90C CASH RECEIPT - FULL CREDIT FROM THIRD PARTY.
M900 THIS CHECK WILL REPLACE THE ORIGINAL PAYMENT.
PREVIOUSLY PAID. PAYMENT FOR THIS CLAIM/SERVICE MAY HAVE BEEN PROVIDED IN A
M901 PREVIOUS PAYMENT.
M91 DISPENSING FEE ADJUSTMENT.
M91V CHECK VOID ADDR WRONG NOT REISSUED
THE DIAGNOSIS CODE PROVIDED IS CONSIDERED INVALID. THIS MEANS IT MAY BE TERMED,
INVALID OR REQUIRE A 4TH OR 5TH DIGIT. WE RELIED ON INTERNAL CRITERIA TO MAKE THIS
M92A DETERMINATION.
THE DIAGNOSIS CODE BILLED IS NOT COMPATIBLE WITH THE AGE OF THE PATIENT. WE RELIED
M92B ON INTERNAL CRITERIA TO MAKE THIS DETERMINATION.
THE DIAGNOSIS CODE BILLED IS NOT COMPATIBLE WITH THE SEX OF THE PATIENT. WE RELIED
M92C ON INTERNAL CRITERIA TO MAKE THIS DETERMINATION.
Humana Remittance Advice Codes

The following codes are updated on a monthly basis. Some codes may have changed since last update.

Last Update: 12/5/07
Code Description
DENTAL SERVICES ARE NOT COVERED UNDER MEDICAL PLAN UNLESS IT IS A RESULT OF AN
INJURY OR TRAUMA. IF THE SERVICE IS A RESULT OF AN INJURY OR TRAUMA, CONTACT HUMANA
M92D AT THE NUMBER ON THE BACK OF YOUR CARD.
THIS HCPCS CODE NOT CONSIDERED TO BE A VALID CODE. WE RELIED ON INTERNAL CRITERIA
M92E TO MAKE THIS DETERMINATION.
THE PROCEDURE CODE BILLED IS NOT COMPATIBLE WITH THE AGE OF THE PATIENT. WE RELIED
M92F ON INTERNAL CRITERIA TO MAKE THIS DETERMINATION.
THE PROCEDURE CODE BILLED IS NOT COMPATIBLE WITH THE SEX OF THE PATIENT. WE RELIED
M92G ON INTERNAL CRITERIA TO MAKE THIS DETERMINATION.
THIS PROVIDER HAS REQUESTED THIS DENIAL OF COVERAGE NOTICE AS THE CLAIM CONTAINS
M92H ALL NON-COVERED SERVICES.

THIS CLAIM CONTAINS DUPLICATE CHARGE(S) OR AN INAPPROPRIATE NUMBER OF UNITS FOR
M92I THE BILLED PROCEDURE. WE RELIED ON INTERNAL CRITERIA TO MAKE THIS DETERMINATION.
A BILATERAL PROCEDURE WAS REPORTED WITHOUT THE APPROPRIATE MODIFIER(S). WE
M92J RELIED ON INTERNAL CRITERIA TO MAKE THIS DETERMINATION.
THIS CLAIM CONTAINS AN INAPPROPRIATE SPECIFICATION OF A BILATERAL PROCEDURE. WE
M92K RELIED ON INTERNAL CRITERIA TO MAKE THIS DETERMINATION.
THIS SERVICE/PROCEDURE IS CONSIDERED TO BE MUTUALLY EXCLUSIVE TO THE PRIMARY
PROCEDURE AND SHOULD NOT HAVE BEEN BILLED SEPARATELY. WE RELIED ON INTERNAL
M92L CRITERIA TO MAKE THIS DETERMINATION.
THIS PROCEDURE IS CONSIDERED TO BE AN INTEGRAL PART OF THE PRIMARY PROCEDURE AND
SHOULD NOT BE BILLED SEPARATELY. WE RELIED ON INTERNAL CRITERIA TO MAKE THIS
M92M DETERMINATION.
THIS SERVICE/PROCEDURE IS INCIDENTAL, AND THEREFORE NOT REIMBURSED SEPARATELY. WE
M92N RELIED ON INTERNAL CRITERIA TO MAKE THIS DETERMINATION.

TERMINATED PROCEDURES ARE NOT ALLOWED WHEN BILLED AS A BILATERAL PROCEDURE OR
M92P WITH MULTIPLE UNITS. WE RELIED ON INTERNAL CRITERIA TO MAKE THIS DETERMINATION.
THIS SERVICE/PROCEDURE IS CONSIDERED TO BE MUTUALLY EXCLUSIVE TO THE PRIMARY
PROCEDURE AND SHOULD NOT HAVE BEEN BILLED SEPARATELY. WE RELIED ON INTERNAL
M92Q CRITERIA TO MAKE THIS DETERMINATION.
THIS PROCEDURE IS CONSIDERED TO BE AN INTEGRAL PART OF THE PRIMARY PROCEDURE AND
SHOULD NOT BE BILLED SEPARATELY. WE RELIED ON INTERNAL CRITERIA TO MAKE THIS
M92R DETERMINATION.
ROOM CHARGE IS NOT COVERED SEPARATELY AS THE CLAIM DOES NOT CONTAIN A VALID
PROCEDURE REQUIRING OBSERVATION. WE RELIED ON INTERNAL CRITERIA TO MAKE THIS
M92S DETERMINATION.
SERVICES AND/OR SUPPLIES BILLED SEPARATELY FOR NOT COVERED SERVICES/PROCEDURES
ARE NOT REIMBURSABLE BY THE PLAN. WE RELIED ON INTERNAL CRITERIA TO MAKE THIS
M92T DETERMINATION.
SERVICE/PROCEDURE IS MISSING THE REQUIRED CORRESPONDING HCPCS CODE. WE RELIED
M92U ON INTERNAL CRITERIA TO MAKE THIS DETERMINATION.
M92V CHECK DEFACED
MULTIPLE CODES DESCRIBING SIMILAR SERVICES ARE NOT TO BE BILLED TOGETHER. WE RELIED
M92W ON INTERNAL CRITERIA TO MAKE THIS DETERMINATION.
THIS SERVICE/PROCEDURE IS NOT ALLOWED AS IT WAS SUBMITTED WITHOUT THE NECESSARY
COST TO PROVIDER, SUPPLIER, ORPRACTITIONER INFORMATION NEEDED TO SUPPORT MODIFIER
M92X FB. WE RELIED ON INTERNAL CRITERIA TO MAKE THIS DETERMINATION.
Humana Remittance Advice Codes

The following codes are updated on a monthly basis. Some codes may have changed since last update.

Last Update: 12/5/07
Code Description
THIS SERVICE/PROCEDURE IS NOT ALLOWED AS IT WAS SUBMITTED WITHOUT CORRESPONDING
REVENUE AND/OR CPT CODES NEEDED TO SUPPORT THE BILLED HCPCS CODE. WE RELIED ON
M92Y INTERNAL CRITERIA TO MAKE THIS DETERMINATION.
THE REVENUE CODE REPORTED WAS NOT VALID FOR THE DATES OF SERVICE OR THE CLAIM LINE
M92Z WAS SUBMITTED WITHOUT A REVENUE CODE.
M93V CHECK VOID AFTER 90 DAYS
M94 PROCESSED IN EXCESS OF CHARGES.
M94V VOIDED DUE TO CONSOLIDATION
M95 BENEFITS ADJUSTED. PLAN PROCEDURES NOT FOLLOWED.
M95V STOP PAYMENT - REISSUED
M96 NON-COVERED CHARGE(S).
M96C CASH RECEIPT - FULL REFUND FROM MEMBER
PAYMENT ADJUSTED BECAUSE THE BENEFIT FOR THIS SERVICE IS INCLUDED IN THE
M97 PAYMENT/ALLOWANCE FOR ANOTHER SERVICE/PROCEDURE
M97C CASH RECEIPT - PARTIAL REFUND FROM MEMBER
M98C CASH RECEIPT - FULL REFUND FROM PROVIDER
M99 MEDICARE SECONDARY PAYER ADJUSTMENT AMOUNT.
M99C CASH RECEIPT - PARTIAL REFUND FROM PROVIDER