Remittance Advice Codes for Explanation of Payment (EOP) and Explanation of Benefit (EOB) forms Code &C1 &I1 &J1 &L1 &M1 &R1 &S1 &W1 AA1 AC1 ADJ AD1 AE1 AF1 AH1 AN1 AO1 AP1 AR1 AT1 AU1 AWE AZ1 A11 A21 BA1 BB1 BC1 BD1 BE1 BG1 BH1 BI1 BL1 BM1 BM2 BN1 BO1 BP1 BP3 BR1 BU1 Description Denied-Surgery Considered Cosmetic Infertility Services Not Covered Denied By Plan Denied-Lack of Information LOS Not Authorized Service Determined Not Medically Necessary Negotiated Rate for Entire LOS per Authorization Denied-Lack of Sufficient Information Denied-Workers Compensation Allowable Reduced-Assistant Surgeon Paid Under Supplemental Accident Expense Benefit Adjustment to Previously Processed Claim Additional Documentation Required Supp Accident Benefit Max Met for this Accident Repriced According to SDSDBF Contract Accident Letter Sent to Member for Completion Benefit Reduced Due to No Precertification Benefit Reduced-No Second Surgical Opinion Penalty Applied for Non-Precertification Refile with Unified Life Prov: Resubmit with Valid ASA Codes Pending-Please Submit Completed Subrogation Forms Prov: AHP does not Credential Provider Precertification Required Late Notification of Admission Not a Covered Benefit Not a Covered Benefit Precertified Units/Visits Exceeded Unable to Process without Completed Claim Form Service Date Exceeds Authorized Dates Not a Covered Benefit Not a Covered Benefit Procedure Does Not Require Assistant Surgeon Non-Emergency Weekend Admission No Benefits Payable-No Second Opinion was Obtained Benefit Reduced-Multiple Surgical Procedures Benefit Maximum Met-No Further Benefits Available Not a Covered Benefit Submit to Primary Carrier-Resubmit with EOB Not a Covered Benefit Must be Billed with Primary Procedure Claim Repriced for Beech Street Provider Payment for Remaining Charges Pended for Audit
11/3/2006
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Remittance Advice Codes for Explanation of Payment (EOP) and Explanation of Benefit (EOB) forms Code BW1 BX1 BZ1 B10 B12 B13 B15 B18 B20 B30 B40 B50 B51 B61 B71 B80 B81 B90 CA1 CI1 CO1 CR1 C01 C02 C03 C10 C20 C40 C50 C60 C90 DF1 DH1 DN1 DR1 DS1 DU1 DZZ EP1 E01 E02 E03 E04 Description Charges Covered Under Workers Compensation Please Submit Actual Drug Slip from Pharmacist Max Dollar Limit reached for Service Not a Covered Benefit Services Not Documented in Patient Medical Records Previously Paid Claim-Service May Have Been Provided Payment Adjusted Procedure-Service Not Paid Separately Payment Denied Procedure Code/Modifier Invalid for DOS Not a Covered Benefit Service Not Related to Diagnosis Submitted Anesthesia by Operating Surgeon Not Covered Provider Not Covered for Service Rendered Provider Not Covered for Service No Benefits Payable Until the Delivery Not a Covered Benefit Not a Covered Benefit Benefit Period Limit Has Been Exceeded Not a Covered Benefit Contractual Adjustment Due to Third Party Payment CPT Code Inconsistent with Place of Service Refile to Unified Life Claim Rejected: Illegible Submit Legible Claim Not a Covered Benefit Routine Sonograms/Ultrasounds Are Not Covered Charges Included in Allowable Amount Non-Covered Prescription Drug Claims Must be Submitted within Twelve Months Medicare Disallowed the Non Covered Amount Medicaid Disallowed Amount Non-Prescription Medication is Not Covered CASD Repricing for ASBSD Rebill As Rental Item Prov: Resubmit with Valid DRG Submit to Dental Carrier Benefit Reduced-No Predetermination Obtained This Service is Not Covered by Dental Plan Duplicate Procedure Denied DME Rental Has Now Been Purchased Not Covered, Pre-Existing Condition Not a Covered Benefit Not a Covered Benefit Not a Covered Benefit Not a Covered Benefit
11/3/2006
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Remittance Advice Codes for Explanation of Payment (EOP) and Explanation of Benefit (EOB) forms Code E05 E06 E07 E08 E09 FCM FI1 FP1 FR1 GLB FT1 IGI II1 IL1 IMI INC IP1 JN1 KJ1 KN1 KO1 MA1 MD1 MEX MH1 MID MO1 MT1 NB1 NE1 NS1 NV1 OF1 OI1 ON1 PB1 PE1 PF1 PI1 PJ1 PK1 PPR PY1 P01 Description Not a Covered Benefit Not a Covered Benefit Not a Covered Benefit Not a Covered Benefit Not a Covered Benefit First Choice of the Midwest Provider ICU/CCU Has Max Allowable—Allowed may be Reduced Average Semi-Private Rate Allowed Allowed is Usual, Customary & Reasonable for Area Within Global Billing Period Claim Received After Group Termination Date Charges Included in Case Rate Insufficient Information to Determine Medical Necessity Insufficient Provider Information Baby’s Charges Included in Mother’s Per Diem Not Eligible for Separate Reimbursement Charges Included in Allowable Amount Units Designated Incorrectly Undocumented Charges Found in Audit Deductible Adjustment Out of Pocket Adjustment Maximum Allowable Reached Submit to Midlands Choice for Repricing Not Eligible for Separate Reimbursement Submit to Proper Insurance Midlands Choice Provider Modifier Invalid with CPT Medical Documentation Does Not Support Service No Billed Charges Received Not Eligible for Separate Reimbursement Not Billed As Authorized Billed New Patient Code for Established Patient Member Not On File Other Insurance Investigation In Process Out of Network Services Not Covered Provider Billing Service for Self or Family Denied, Possible Pre-Ex, Member/Provider Letter Forthcoming Purchase Price Reached Provider Billed in Error Pre-Existing Investigation In Process Denied, Possible PreExisting Claim Paid to Provider of Services Prov: Resubmit with Provider Name in Box 31 Spec: Pre-X see Service Edits
11/3/2006
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Remittance Advice Codes for Explanation of Payment (EOP) and Explanation of Benefit (EOB) forms Code P31 P41 RD1 RF1 RH1 RM1 ROI RO1 RP1 RQ1 RU1 RX1 RX2 SA1 SB1 SD1 SD2 SS1 S11 TF1 TLC TL1 TP1 ULD UL1 UN1 URN VA1 VIS VS1 WPN WP1 XA1 XB1 XC1 XD1 XE1 XF1 XG1 XH1 XI1 XJ1 XK1 XL1 Description Prov: Resubmit with Supervising Physician Prov: Resubmit with Provider Credentials Listed Prov: Resubmit with Valid CPT Code or Modifier Prov: Refile with Appropriate CPT Code or Modifier Refile with HCPC Level II Code Appropriate Procedure/Modifier Was Not Indicated Submit Other Coverage Information on Dependent Requesting Other Coverage Information from Employee Please Refile to Priority One Medical Records Requested Not Received Unlisted Procedure Code, Submit Medical Records Submit Drug Slips or Drug Log from Pharmacist Please Refile with Pharmacy Payor Exceeds Semi Private Room Rate Private Room Medically Necessary Exceeds Maximum Allowable for ICU/CCU Exceeds Maximum Allowable for ICU/CCU Submit Student Verification from School Registrar State Supplied Vaccine Filing Time Exceeded Claim Repriced for TLC Contract Refile with Unified Life Third Party Liability Unlisted Diagnosis CD Medical Records Requested Claim Has Been Forwarded to Unified Life Submit to URN Transplant Network for Repricing United Resource Network Contracted Rate Refile with Unified Life Visit Not Eligible for Separate Reimbursement Submit Claim to Vision Carrier Claim Repriced for Western Provider Network No Benefits for this Service During Waiting Period Insufficient Information to Pay Claim Submit Admit Type and Date RM & BD Inconsistent with Dates of Service Submit Dates of Service for these Charges Claim Total Does Not Equal Itemization OR Charge with No ICD 9 Surgical Procedure Code Claim has No Patient Status or Type of Bill Units Are Inconsistent with Dates of Service Invalid Date of Service Please Submit Place of Service for this Date Invalid Place of Service Please Submit Daily Itemization
11/3/2006
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Remittance Advice Codes for Explanation of Payment (EOP) and Explanation of Benefit (EOB) forms Code XU1 XX1 YA1 YB1 YC1 YD1 YE1 YF1 YG1 YH1 YI1 YJ1 YK1 YM1 YN1 YO1 Z10 Z20 Z30 0F1 001 002 003 007 009 014 015 017 018 028 029 034 035 038 053 057 058 078 099 10 102 109 11 119 Description Please Submit Itemization on a Standard UB-82 Form Diagnosis Meets Pre-Ex Condition Please Submit a Copy of the Operative Report Please Submit a Copy of the Pathology Report X-Rays for the Service Are Requested Please Submit a Copy of the Emergency Room Report Medical Records Have Been Requested from Physician Medical Records Have Been Requested from Hospital Add. Information Has Been Requested from the Employee Pending Receipt of Subrogation Form From Employee Prov: Resubmit with Valid Diagnosis Code Pending Receipt of Surgeon’s Bill Please Submit Date, Place & Details of Injury Submit No Fault Explanation of Benefits Prov: Resubmit with Valid CPT, DX Code or Modifier Please Submit Current ADA Codes Payment % Reduced-Claim Recd 46-90 Days After Service Payment % Reduced-Claim Recd 91-120 Days After Service Claim Denied-Not Filed within 120 Days of Service Patient Not on File Reasonable and Customary Fee Allowed Please Send Letter of Medical Necessity Services Prior to Effective Date or After Term Date Service Submitted Invalid for Member Age Service Submitted Invalid for Member Sex Deductible Reached Maximum Coverage Amount Reached Sex Invalid for Coverage Dependent Eligibility Investigation in Progress Maximum Benefit Limit Reached for Service Out of Pocket Maximum Reached Diagnosis Submitted Invalid for Member Age Diagnosis Submitted Invalid for Member Sex Benefit Rider Not Selected as an Option Member Not Eligible for Benefit Reimbursement for Excess Provider Payment Reimbursement from COB Credit Banking Medicare is the Primary Payor Duplicate Charge Previously Processed Diagnosis Inconsistent with Patient Gender Major Medical Adjustment Send Claim to Correct Payor Diagnosis Inconsistent with Procedure Benefit Maximum for Time Period Reached
11/3/2006
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Remittance Advice Codes for Explanation of Payment (EOP) and Explanation of Benefit (EOB) forms Code 12 125 128 133 146 149 16 17 18 19 22 26 27 31 4 5 51 53 54 6 62 7 8 9 96 97 Description Diagnosis Inconsistent with Provider Type Adjusted Due to Submission/Billing Error Newborn Service Covered in Mothers Allowance Disposition of Claim/Service Pending Review Payment Denied Diagnosis Invalid for DOS Lifetime Max Reached for Service/Benefit Lacks Info Needed for Adjudication Requested Information Not Provided/Insufficient Duplicate Claim/Service Denied as Work Related Injury/Illness Payment Adjust May Be Covered by Other Payor/COB Expenses Incurred Prior to Coverage Expenses Incurred After Coverage Terminated Denied Patient Cannot Be Identified As Our Insured Procedure Code Inconsistent with Modifier Used/Missing Procedure Code/Bill Type Inconsistent with POS NonCovered Services This is Pre-Existing Condition Service by Immediate Relative or Household Member Multiple Physicians/Assistants Are Not Covered In This Case Procedure Code/Revenue Code Inconsistent with Patient Age Payment Denied/Reduced for Absence Exceeded Auth Procedure/Rev Code Inconsistent with Patient Sex Procedure Code Inconsistent with Provider Type/Specialty Diagnosis Inconsistent with Patient Age NonCovered Charges Included in Allowance for Other Service/Procedure
11/3/2006
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