Health Insurance Claim Form 1500 Excel - Excel - Excel

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Health Insurance Claim Form 1500 Excel - Excel - Excel Powered By Docstoc
					                                                       EOB Code Crosswalk to HIPAA Standard Codes

           MEDICAID EOB                  HIPAA ADJUSTMENT REASON                      HIPAA REMARK CODE                HIPAA CLAIM STATUS CODE
EOB         DESCRIPTION                        CODE DESCRIPTION                            DESCRIPTION                          DESCRIPTION
1     Fee adjusted to maximum        45 - Charge exceeds fee schedule-            N381 - Consult our contractual      65 - Claim-line has been paid.
      allowable.                     maximum allowable or contracted-             agreement for restrictions-billing- 483 - Maximum coverage amount
                                     legislated fee arrangement. (Use             payment information related to      met or exceeded for benefit period
                                     Group Codes PR or CO depending               these charges.
                                     upon liability).
2     Pre-admission not              197 - Precertification-authorization-        N54 - Claim information is         435 - Notice of Admission
      obtained.                      notification absent.                         inconsistent with pre-certified-
                                                                                  authorized services.


3     Consecutive dates of           125 - Submission-billing error(s).           N63 - Rebill services on separate 187 - Date(s) of service.
      service cannot be billed.                                                   claims.
      List each date separately
      and resubmit.



4     Provider number missing 125 - Submission-billing error(s).                  N77 - Missing-incomplete-invalid   21 - Missing or invalid information.
      or invalid. Enter corrected                                                 designated provider number.
      provider number on the
      claim and submit as a new                                                                                                    132 - Entitys Medicaid
      claim.                                                                                                         provider ID


5     NDC missing, invalid or        125 - Submission-billing error(s).           M119 - Missing-incomplete-         21 - Missing or invalid information.
      not on state file. Correct                                                  invalid-deactivated-withdrawn
      11 digit code required.                                                     National Drug Code (NDC).
      Valid compound NDC -or                                                                                                       218 - NDC number.
      compound indicator and
      all ingredient NDC's
      required, see Pharmacy
      manual.



6     Patient liability-deductible   142 - Monthly Medicaid patient liability     N381 - Consult our contractual      98 - Charges applied to deductible.
      reduced payable amount.        amount.                                      agreement for restrictions-billing-
                                                                                  payment information related to
                                                                                  these charges

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                                                    EOB Code Crosswalk to HIPAA Standard Codes
7    Recipient not eligible for   177 - Patient has not met the required      N30 - Patient ineligible for this    90 - Entity not eligible for medical
     CAP.                         eligibility requirements.                   service.                             benefits for submitted dates of
                                                                                                                   service.
                                                                                                                                                109 -
                                                                                                                   Entity not eligible.
8    Paid per medical             45 - Charge exceeds fee schedule-           N10 - Claim-service adjusted         65 - Claim-line has been paid.
     consultant review.           maximum allowable or contracted-            based on the findings of a review
                                  legislated fee arrangement. (Use            organization-professional consult-
                                  Group Codes PR or CO depending              manual adjudication-medical or
                                  upon liability).                            dental advisor.

9    Service not covered by the 96 - Non-covered charge(s).                   N59 - Alert- Please refer to         21 - Missing or invalid information.
     Medicaid program;                                                        your provider manual for                                     454 -
     Pharmacy, see non-                                                       additional program and               Procedure code for services
     covered items under                                                      provider information                 rendered.
     scope of services in
     manual.
10   Diagnosis or service       125 - Submission-billing error(s).            M76 - Missing-incomplete-invalid 21 - Missing or invalid information.
     invalid for recipient age,                                               diagnosis or condition.                                  475 -
     Verify MID, diagnosis,                                                                                    Procedure code not valid for
     procedure code or                                                                  MA66 - Missing-        patient age.
     procedure code- modifier                                                 incomplete-invalid principal      488 - Diagnosis code(s) for the
     combination for errors.                                                  procedure code.                  services rendered.
     Correct and submit as a
11   new claim.
     Recipient not eligible on  177 - Patient has not met the required        N30 - Patient ineligible for this90 - Entity not eligible for medical
     service date.              eligibility requirements.                     service.                         benefits for submitted dates of
                                                                                                               service.
                                                                                                                                            109 -
                                                                                                               Entity not eligible.
12   Diagnosis or service         125 - Submission-billing error(s).          M76 - Missing-incomplete-invalid 86 - Diagnosis and patient gender
     invalid for recipient sex.                                               diagnosis or condition.          mismatch.

                                                                                                                            474 - Procedure code and
                                                                                                                   patient gender mismatch.


13   Mapped provider ID is not    B7 - This provider was not certified-       No Mapping Required                  91 - Entity not eligible-not
     eligible on service date     eligible to be paid for this procedure-                                          approved for dates of service. 562
                                  service on this date of service.                                                 - Entitys National Provider
                                                                                                                   Identifier (NPI)
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                                                    EOB Code Crosswalk to HIPAA Standard Codes

14   Service denied per         45 - Charge exceeds fee schedule-             N10 - Claim-service adjusted       421 - Medical review attachment-
     medical consultant review. maximum allowable or contracted-              based on the findings of a review information for service(s).
                                legislated fee arrangement. (Use              organization-professional consult-
                                Group Codes PR or CO depending                manual adjudication-medical or
                                upon liability).                              dental advisor.

15   Payment reflected DME         45 - Charge exceeds fee schedule-          N381 - Consult our contractual      107 - Processed according to
     proration.                    maximum allowable or contracted-           agreement for restrictions-billing- contract-plan provisions.
                                   legislated fee arrangement. (Use           payment information related to
                                   Group Codes PR or CO depending             these charges
                                   upon liability).
16   Payment included in           97 - The benefit for this service is       M80 - Not covered when             454 - Procedure code for services
     Health Check fee.             included in the payment-allowance for      performed during the same          rendered.
                                   another service-procedure that has         session-date as a previously
                                   already been adjudicated.                  processed service for the patient.

17   Adjustment request            29 - The time limit for filing has expired. N1 - Alert- You may appeal this 294 - Supporting documentation.
     denied as beyond time                                                     decision in writing within the
     limit.                                                                    required time limits following
                                                                               receipt of this notice by
                                                                               following the instructions
                                                                               included in your contract or
                                                                               plan benefit documents

18   Clam denied, no history to 29 - The time limit for filing has expired.   N1 - Alert- You may appeal this 294 - Supporting documentation.
     justify time limit override,                                             decision in writing within the
     Claims with proper                                                       required time limits following
     documentation should be                                                  receipt of this notice by
     submitted to the EDS                                                     following the instructions
     Provider Service unit.                                                   included in your contract or
                                                                              plan benefit documents

19   Correct date of service to 125 - Submission-billing error(s).            MA67 - Correction to a prior      21 - Missing or invalid information.
     delivery-surgery date only                                               claim.
     and submit as a new claim.
                                                                                                                   187 - Date(s) of service.




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20   Claim being processed      45 - Charge exceeds fee schedule-            MA67 - Correction to a prior       101 - Claim was processed as
     due to incorrect denial formaximum allowable or contracted-             claim.                             adjustment to previous claim.
     eob 525 on previous RA's.  legislated fee arrangement. (Use
                                Group Codes PR or CO depending
                                upon liability).
21   Duplicate of claim-system. 18 - Duplicate claim-service.                M86 - Service denied because      54 - Duplicate of a previously
                                                                             payment already made for same- processed claim-line.
                                                                             similar procedure within set time
                                                                             frame.

22   Duplicate of claim-system. 18 - Duplicate claim-service.                M86 - Service denied because      54 - Duplicate of a previously
                                                                             payment already made for same- processed claim-line.
                                                                             similar procedure within set time
                                                                             frame.

23   Service requires prior        197 - Precertification-authorization-     N54 - Claim information is         84 - Service not authorized.
     approval.                     notification absent.                      inconsistent with pre-certified-
                                                                             authorized services.
24   Procedure code,              125 - Submission-billing error(s).         No Mapping Required                21 - Missing or invalid information.
     procedure-modifier                                                                                                                 228 - Type
     combination or revenue                                                                                     of bill for UB claim.        453 -
     code is missing , invalid or                                                                               Procedure code modifier(s) for
     invalid for this bill type.                                                                                service(s) rendered.
     Correct and rebill denied
     detail as a new claim.

25   Procedure denied for          6 - The procedure-revenue code is         No Mapping Required                475 - Procedure code not valid for
     patient over 21 years old.    inconsistent with the patients age.                                          patient age.

26   Ventilator care not payable 170 - Payment is denied when               N95 - This provider type -          25 - Entity not approved.
     to this provider type.      performed-billed by this type of provider. provider specialty may not bill
                                                                            this service.
27   Diagnosis code missing or 146 - Diagnosis was invalid for the          M76 - Missing-incomplete-invalid    21 - Missing or invalid information.
     invalid. Verify and enter   date(s) of service reported.               diagnosis or condition.                                     255 -
     the correct diagnosis code                                                                                 Diagnosis code.
     and submit as a new claim.                                                                                 477 - Diagnosis code pointer is
                                                                                                                missing or invalid.



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28   Payment included in           97 - The benefit for this service is      M80 - Not covered when             454 - Procedure code for services
     dialysis charge.              included in the payment-allowance for     performed during the same          rendered.
                                   another service-procedure that has        session-date as a previously
                                   already been adjudicated.                 processed service for the patient.

29   Medicare voucher does         148 - Information from another provider N4 - Missing-incomplete-invalid         285 - Vouchers-explanation of
     not match dates-charges       was not provided or was insufficient-   prior insurance carrier EOB.            benefits (EOB).
     on claim, or voucher not      incomplete.                                                                       492 - Other Procedure Date.
     attached to claim-rebill
     with correct voucher.

30   Medicare Paid in full.        B13 - Previously paid. Payment for this   N381 - Consult our contractual        107 - Processed according to
                                   claim-service may have been provided      agreement for restrictions-billing-   contract-plan provisions.
                                   in a previous payment.                    payment information related to
                                                                             these charges                         591 - Medicare Paid at 100%
31   Partially cutback for other23 - The impact of prior payer(s)            No Mapping Required                   107 - Processed according to
     insurance coverage.        adjudication including payments and-or                                             contract-plan provisions.
                                adjustments.
32   Charge reduced by other    23 - The impact of prior payer(s)       No Mapping Required                        107 - Processed according to
     insurance amount.          adjudication including payments and-or                                             contract-plan provisions.
                                adjustments.
33   CAP service not allowed    96 - Non-covered charge(s).             MA66 - Missing-incomplete-                 454 - Procedure code for services
     on or after January 31,                                            invalid principal procedure code           rendered.
     1992.                                                              or date.
                                                                                      N303 - Missing-
                                                                        incomplete-invalid principal
                                                                        procedure date.
34   Please indicate part B     148 - Information from another provider MA04 - Secondary payment                   85 - Entity not primary.
     Medicare payment in form was not provided or was insufficient-     cannot be considered without the
     locator 54 and resubmit as incomplete.                             identity of or payment information
     a new claim.                                                       from the primary payer. The                               286 - Other
                                                                        information was either not                 payers Explanation of Benefits-
                                                                        reported or was illegible                  payment information.

35   Claim-procedure denied,       115 - Procedure postponed-canceled-       No Mapping Required                   585 - Denied Charge or Non-
     services not rendered.        or delayed.                                                                     covered Charge




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36   UB claim form: Rev code         125 - Submission-billing error(s).        M50 - Missing-incomplete-invalid 228 - Type of bill for UB claim.
     invalid this bill type, other                                             revenue code(s).                 249 - Place of service.
     claims place of service                                                                                        455 - Revenue code for
     missing-invalid for this                                                                                   services rendered.
     procedure. Correct bill                                                           M77 - Missing-
     type or POS and resubmit                                                  incomplete-invalid place of
     as a new claim.                                                           service(s).
37   Detail line not adjusted.       45 - Charge exceeds fee schedule-         No Mapping Required                 247 - Line information.
                                     maximum allowable or contracted-                                                 530 - Claim Adjustment
                                     legislated fee arrangement. (Use                                              Indicator
                                     Group Codes PR or CO depending
                                     upon liability).
38   Noncovered compound             96 - Non-covered charge(s).               M79 - Missing-incomplete-invalid 454 - Procedure code for services
     contains DESI drug or                                                     charge                           rendered.
     DESI equivalent.

39   Medicare denied, no             A1 - Claim-Service denied. At least one   N8 - Crossover claim denied by      107 - Processed according to
     coinsurance or deductible       Remark Code must be provided (may         previous payer and complete         contract-plan provisions.
     or Medicaid payment due.        be comprised of either the Remittance     claim data not forwarded.              585 - Denied Charge or Non-
                                     Advice Remark Code or NCPDP Reject        Resubmit this claim to this payer   covered Charge
                                     Reason Code.) This change to be           to provide adequate data for
                                     effective 7-1-2010- Claim-Service         adjudication
                                     denied. At least one Remark Code
                                     must be provided (may be
                                     comprised of either the NCPDP
                                     Reject Reason Code, or Remittance
                                     Advice Remark Code that is not an
                                     ALERT.)


40   Admission date-date of      125 - Submission-billing error(s).            M52 - Missing-incomplete-invalid 21 - Missing or invalid information.
     service missing or invalid.                                               from date(s) of service.
     Verify and enter correct                                                  N173 - No qualifying hospital     187 - Date(s) of service.
     DOS and submit as a new                                                   stay dates were provided for this                 189 - Facility
     claim.                                                                    episode of care.                  admission date


41   Federal sterilization           16 - Claim-service lacks information      N3 - Missing consent form.          48 - Referral-authorization.
     consent form required           which is needed for adjudication.

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42   Sterilization -abortion        B5 - Coverage-program guidelines             No Mapping Required                21 - Missing or invalid information.
     guidelines not met.            were not met or were exceeded.
43   Acquisition of organs for      109 - Claim not covered by this payer-       No Mapping Required                84 - Service not authorized.
     transplant must be billed      contractor. You must send the claim to
     to the transplant hospital.    the correct payer-contractor.

44   Claim processed for            141 - Claim spans eligible and ineligible No Mapping Required                   20 - Accepted for processing.
     eligible dates only.           periods of coverage.

                                                                                                                                    456 - Covered
45   Procedure included in fee      97 - The benefit for this service is         M80 - Not covered when             453 - Procedure Code Modifier(s)
     for surgery.                   included in the payment-allowance for        performed during the same          for Service(s) Rendered.
                                    another service-procedure that has           session-date as a previously                      454 - Procedure
                                    already been adjudicated.                    processed service for the patient. code for services rendered.

46   Patient liability-deductible   142 - Monthly Medicaid patient liability     N58 - Missing-incomplete-invalid   483 - Maximum coverage amount
     exceeds allowed amount.        amount.                                      patient liability amount.          met or exceeded for benefit period.

47   Rebill single procedure        125 - Submission-billing error(s).           M15 - Separately billed services- 258 - Days-units for procedure-
     code combining service                                                      tests have been bundled as they revenue code.
     and- or multiple units and                                                  are considered components of
     file as a new claim.                                                        the same procedure. Separate                           476 - Missing or
                                                                                 payment is not allowed.           invalid units of service.


48   Panel partially paid on        B15 - This service-procedure requires        N20 - Service not payable with     107 - Processed according to
     previous claim or detail.      that a qualifying service-procedure be       other service rendered on the      contract-plan provisions.
                                    received and covered. The qualifying         same date.                            101 - Claim was processed as
                                    other service-procedure has not been                                            adjustment to previous claim.
                                    received-adjudicated.

49   Medical necessity is not       50 - These are non-covered services          N180 - This item or service does   411 - Medical necessity for non-
     apparent.                      because this is not deemed a medical         not meet the criteria for the      routine service(s).
                                    necessity by the payer.                      category under which it was
                                                                                 billed.




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51   Claim split to facilitate      125 - Submission-billing error(s).        MA15 - Alert- Your claim has      72 - Claim contains split payment.
     processing.                                                              been separated to expedite
                                                                              handling. You will receive a
                                                                              separate notice for the other
                                                                              services reported


52   Office and-clinic visit        97 - The benefit for this service is      M80 - Not covered when             454 - Procedure code for services
     includes payment for           included in the payment-allowance for     performed during the same          rendered.
     service.                       another service-procedure that has        session-date as a previously
                                    already been adjudicated.                 processed service for the patient.

53   Payment included in daily      97 - The benefit for this service is      M80 - Not covered when             454 - Procedure code for services
     care.                          included in the payment-allowance for     performed during the same          rendered.
                                    another service-procedure that has        session-date as a previously
                                    already been adjudicated.                 processed service for the patient.

54   Radiation management           119 - Benefit maximum for this time    M86 - Service denied because      259 - Frequency of service.
     allowed once per day.          period or occurrence has been reached. payment already made for same-
                                                                           similar procedure within set time                        612 - Per
                                                                           frame.                            Day Limit Amount

55   Service is included in the     97 - The benefit for this service is      M80 - Not covered when             454 - Procedure code for services
     fee for visual aid.            included in the payment-allowance for     performed during the same          rendered.
                                    another service-procedure that has        session-date as a previously
                                    already been adjudicated.                 processed service for the patient.

56   Office visit included in fee   97 - The benefit for this service is      M80 - Not covered when             454 - Procedure code for services
     for service.                   included in the payment-allowance for     performed during the same          rendered.
                                    another service-procedure that has        session-date as a previously
                                    already been adjudicated.                 processed service for the patient.

57   DME and orthotic or            108 - Rent-purchase guidelines were       M86 - Service denied because      259 - Frequency of service.
     prosthetic equipment           not met.                                  payment already made for same-
     allowed once in 2 yrs for                                                similar procedure within set time
     ages 00-20.                                                              frame.




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58   Service dates prior to      125 - Submission-billing error(s).           MA31 - Missing-incomplete-        187 - Date(s) of service.
     admission date. Verify                                                   invalid beginning and ending              189 - Facility admission
     admit date and DOS.                                                      dates of the period billed.       date
     Correct and rebill as a new
     claim.

59   Adjustments equal to or      45 - Charge exceeds fee schedule-           MA22 - Payment of less than       104 - Processed according to plan
     less than one dollar         maximum allowable or contracted-            $1.00 suppressed.                 provisions.
     denied.                      legislated fee arrangement. (Use
                                  Group Codes PR or CO depending
                                  upon liability).
60   Not in accordance with       B5 - Coverage-program guidelines            No Mapping Required               21 - Missing or invalid information.
     Medical Policy guidelines.   were not met or were exceeded.

61   Full recoupment, bill        109 - Claim not covered by this payer-      MA04 - Secondary payment           585 - Denied Charge or Non-
     Medicare.                    contractor. You must send the claim to      cannot be considered without the covered Charge
                                  the correct payer-contractor.               identity of or payment information
                                                                              from the primary payer. The
                                                                              information was either not
                                                                              reported or was illegible.

62   Durable Medical              108 - Rent-purchase guidelines were         No Mapping Required               21 - Missing or invalid information.
     Equipment guidelines not not met.
     met.
63   Correct assistant            125 - Submission-billing error(s).          MA130 - Your claim contains       276 - UB04-HCFA-1450-1500
     surgeons claim using TOS                                                 incomplete and-or invalid         claim form.
     08 in field 24C of the HCFA-                                             information, and no appeal rights                      481 - Claim
     1500 claim form and                                                      are afforded because the claim is submission format is invalid.
     resubmit as a new claim.                                                 unprocessable. Please submit a
                                                                              new claim with the complete-
                                                                              correct information.

64   Service included in total    97 - The benefit for this service is        M80 - Not covered when             454 - Procedure code for services
     Maternity Flat fee.          included in the payment-allowance for       performed during the same          rendered.
                                  another service-procedure that has          session-date as a previously
                                  already been adjudicated.                   processed service for the patient.

65   Only provider of service     B20 - Procedure-service was partially       N32 - Claim must be submitted    84 - Service not authorized.
     may bill.                    or fully furnished by another provider.     by the provider who rendered the
                                                                              service.
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66   Duplicate payment to          18 - Duplicate claim-service.            M86 - Service denied because      54 - Duplicate of a previously
     other provider.                                                        payment already made for same- processed claim-line.
                                                                            similar procedure within set time
                                                                            frame.

67   Claim payment recouped.       129 - Prior processing information       N36 - Claim must meet primary   116 - Claim submitted to incorrect
     File with Medicare carrier    appears incorrect.                       payer’s processing requirements payer.
     using HIC # indicated on                                               before we can consider payment.
     list mailed to your office.
     Be sure to use the
     appropriate claim form to
     bill Medicare.

68   Bill Medicare Part B carrier. 22 - This care may be covered by         MA04 - Secondary payment           116 - Claim submitted to incorrect
                                   another payer per coordination of        cannot be considered without the payer.
                                   benefits.                                identity of or payment information
                                                                            from the primary payer. The
                                                                            information was either not
                                                                            reported or was illegible.

69   Bill Medicare Part A carrier. 22 - This care may be covered by         MA04 - Secondary payment           116 - Claim submitted to incorrect
                                   another payer per coordination of        cannot be considered without the payer.
                                   benefits.                                identity of or payment information
                                                                            from the primary payer. The
                                                                            information was either not
                                                                            reported or was illegible.

70   CAP dollar limitation has     45 - Charge exceeds fee schedule-        N381 - Consult our contractual      483 - Maximum coverage amount
     been met.                     maximum allowable or contracted-         agreement for restrictions-billing- met or exceeded for benefit period.
                                   legislated fee arrangement. (Use         payment information related to
                                   Group Codes PR or CO depending           these charges
                                   upon liability).
71   Only two radiation            119 - Benefit maximum for this time      No Mapping Required                259 - Frequency of service.
     treatments allowed in a 7     period or occurrence has been reached.
     day period.




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72   Similar item previously      B15 - This service-procedure requires    N20 - Service not payable with     107 - Processed according to
     rented or purchased.         that a qualifying service-procedure be   other service rendered on the      contract-plan provisions.
                                  received and covered. The qualifying     same date.                                101 - Claim was processed
                                  other service-procedure has not been                                        as adjustment to previous claim.
                                  received-adjudicated.

73   Claim paid copayment         3 - Co-payment Amount.                   No Mapping Required                65 - Claim-line has been paid.
     deducted.
74   Rebill for services on a     125 - Submission-billing error(s).       N34 - Incorrect claim form-format 59 - Non-electronic request for
     paper claim.                                                          for this service.                 information.

                                                                                                                          277 - Paper claim.



75   Resubmit as an             16 - Claim-service lacks information       M29 - Missing operative note-      294 - Supporting documentation.
     adjustment and attach      which is needed for adjudication.          report.
     medical records, operative                                            N163 - Medical Record does not
     notes, federal statements                                             support code billed per the code                 317- Patients
     or other pertinent                                                    definition.                        medical records.    421 - Medical
     information                                                                                              review attachment-information for
                                                                                                              service(s)

76   Services not payable in   110 - Billing date predates service date.   N301 - Missing-incomplete-            510 - Future date
     advance.                                                              invalid procedure date(s).
77   Rebill newborn care on a  125 - Submission-billing error(s).          N56 - Procedure code billed is        454 - Procedure code for services
     separate claim and submit                                             not correct-valid for the service     rendered.
     as a new claim.                                                       billed or the date of service billed.




78   Rebill as a new claim        125 - Submission-billing error(s).       N56 - Procedure code billed is        454 - Procedure code for services
     using the procedure code                                              not correct-valid for the service     rendered.
     for subsequent care.                                                  billed or the date of service billed.




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79   This service is not payable 170 - Payment is denied when               N95 - This provider type -          25 - Entity not approved.
     to your provider type or    performed-billed by this type of provider. provider specialty may not bill
     specialty in accordance                                                this service.
     with Medicaid guidelines.


80   Units of service are not    125 - Submission-billing error(s).          M53 - Missing-incomplete-invalid 258 - Days-units for procedure-
     consistent with dates of                                                days or units of service.         revenue code.
     service physician claims:                                                N345 - Date range not valid with
     If dates are not                                                        units submitted.
     consecutive list each date
     of service on a separate
     line. Correct and resubmit.
81   Procedure allowed once in 149 - Lifetime benefit maximum has            N117 - This service is paid only   259 - Frequency of service.
     a lifetime.               been reached for this service-benefit         once in a patients lifetime.
                               category.
82   Service is not consistent 125 - Submission-billing error(s).            M76 - Missing-incomplete-invalid 488 - Diagnosis code(s) for the
     with-or not covered for                                                 diagnosis or condition.          services rendered.
     this diagnosis-or
     description does not
     match diagnosis.


83   Exceeds legislative limits.   119 - Benefit maximum for this time       N130 - Alert- Consult plan         259 - Frequency of service.
                                   period or occurrence has been reached. benefit documents for
                                                                             information about restrictions
                                                                             for this service
84   Recipient is partially        141 - Claim spans eligible and ineligible No Mapping Required                187 - Date(s) of service.
     ineligible for service        periods of coverage.
     dates. Resubmit a new
     claim billing only eligible                                                                                         456 - Covered Day(s).
     dates of service.




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85   Attending provider ID is     A1 - Claim-Service denied. At least         N253 - Missing-incomplete-         21 - Missing or invalid information.
     missing, invalid, or         one Remark Code must be provided            invalid attending provider primary
     unresolved. Verify           (may be comprised of either the             identifier.
     attending provider ID and    Remittance Advice Remark Code or                                                            562 - Entitys National
     resubmit as a new claim or   NCPDP Reject Reason Code.) This                                                Provider Identifier (NPI)
     contact EDS Provider         change to be effective 7-1-2010-
     Services if ID is correct    Claim-Service denied. At least one
86   Adjustment of claim          Remark Code must be provided
                                  45 - Charge exceeds fee schedule-           No Mapping Required                101 - Claim was processed as
     system.                      maximum allowable or contracted-                                               adjustment to previous claim.
                                  legislated fee arrangement. (Use
                                  Group Codes PR or CO depending
                                  upon liability).
87   Only 22 radiation            119 - Benefit maximum for this time         M86 - Service denied because      259 - Frequency of service.
     treatments allowed in 4      period or occurrence has been reached.      payment already made for same-
     wks.                                                                     similar procedure within set time
                                                                              frame.                       N357
                                                                              - Time frame requirements
                                                                              between this service-procedure-
                                                                              supply and a related service-
                                                                              procedure-supply have not been
                                                                              met

88   Included in fee for          97 - The benefit for this service is        M80 - Not covered when             454 - Procedure code for services
     services.                    included in the payment-allowance for       performed during the same          rendered.
                                  another service-procedure that has          session-date as a previously
                                  already been adjudicated.                   processed service for the patient.

89   Prior approval number        15 - Payment adjusted because the           N54 - Claim information is         21 - Missing or invalid information.
     missing or invalid. Verify   submitted authorization number is           inconsistent with pre-certified-
     and- or add PA number        missing, invalid, or does not apply to      authorized services.
     and submit as a new claim.   the billed services or provider.                                                      84 - Service not authorized.

90   Duplicate charge denied.     18 - Duplicate claim-service.               M86 - Service denied because      54 - Duplicate of a previously
                                                                              payment already made for same- processed claim-line.
                                                                              similar procedure within set time
                                                                              frame.




                                                                           Page 13
                                                     EOB Code Crosswalk to HIPAA Standard Codes



91   Patient liab-deduct equal     142 - Monthly Medicaid patient liability   N381 - Consult our contractual      98 - Charges applied to deductible.
     Medicare-Medicaid             amount.                                    agreement for restrictions-billing-
     allowable.                                                               payment information related to
                                                                              these charges
92   Medicare suspect-paid         23 - The impact of prior payer(s)          No Mapping Required                 65 - Claim-line has been paid.
     Medicaid only.                adjudication including payments and-or
                                   adjustments.
93   Patient deceased per state 13 - The date of death precedes the       N1 - Alert- You may appeal this 88 - Entity not eligible for benefits
     eligibility file. If date of  date of service.                       decision in writing within the  for submitted dates of service.
     service and recipient MID                                            required time limits following
     are correct, submit claim                                            receipt of this notice by
     to DMA, Claims Analysis                                              following the instructions
     Unit, see billing guidelines.                                        included in your contract or
                                                                          plan benefit documents

94   Resubmit claim indicating 22 - This care may be covered by               MA04 - Secondary payment             171 - Other insurance coverage
     private insurance payment another payer per coordination of              cannot be considered without the     information (health, liability, auto,
     or applicable occurrence  benefits.                                      identity of or payment information   etc.).                           285 -
     code. If documented                                                      from the primary payer. The          Vouchers-explanation of benefits
     insurance denial required                                                information was either not           (EOB).                 286 - Other
     submit with claim on                                                     reported or was illegible.           payers Explanation of Benefits-
     provider inquiry form.                                                                        N479 -          payment information.
                                                                              Missing Explanation of Benefits
                                                                              (Coordination of Benefits or
                                                                              Medicare Secondary Payer).

95   Medicare denied.            148 - Information from another provider      N82 - Provider must accept           132 - Entitys Medicaid provider id.
     Resubmit corrected claim    was not provided or was insufficient-        insurance payment as payment
     or if medicare override     incomplete. At least one Remark Code         in full when a third party payer
     required, submit as         must be provided (may be comprised           contract specifies full
     inquiry with claim and      of either the Remittance Advice              reimbursement.
     medicare EOMB attached.     Remark Code or NCPDP Reject
                                 Reason Code.)
96   Patient liab-deduct applied 142 - Monthly Medicaid patient liability     No Mapping Required                  98 - Charges applied to deductible.
     to Medicare-Medicaid        amount.
     allowable.



                                                                          Page 14
                                                   EOB Code Crosswalk to HIPAA Standard Codes



97    Paid in part-full by         23 - The impact of prior payer(s)      N360 - Alert- Coordination of       107 - Processed according to
      Medicare.                    adjudication including payments and-or benefits has not been               contract-plan provisions.
                                   adjustments.                           calculated when estimating           286 - Other payers Explanation
                                                                          benefits for this pre-              of Benefits-payment information.
                                                                          determination. Submit
                                                                          payment information from the
                                                                          primary payer with the
                                                                          secondary claim.          N381 -
                                                                          Consult our contractual
                                                                          agreement for restrictions-billing-
                                                                          payment information related to
                                                                          these charges

98    Fee adjusted to maximum      45 - Charge exceeds fee schedule-        N381 - Consult our contractual      65 - Claim-line has been paid.
      payable.                     maximum allowable or contracted-         agreement for restrictions-billing- 483 - Maximum coverage amount
                                   legislated fee arrangement. (Use         payment information related to      met or exceeded for benefit period
                                   Group Codes PR or CO depending           these charges
                                   upon liability).
99    Paid as billed.              Should not be cross walked for an 835    Should not be cross walked for        65 - Claim-line has been paid.
                                   since there will not be a CAS segment.   an 835 since there will not be a
                                                                            CAS segment.
100   Payment will appear as       101 - Predetermination: anticipated      N381 - Consult our contractual        3 - Claim has been adjudicated
      financial transaction in the payment upon completion of services      agreement for restrictions-billing-   and is awaiting payment cycle.
      future.                      or claim adjudication.                   payment information related to
                                                                            these charges
101   Pending normal in-house     133 - The disposition of this claim-      No Mapping Required                   3 - Claim has been adjudicated
      processing.                 service is pending further review.                                              and is awaiting payment cycle.
102   Pending in-house review.    133 - The disposition of this claim-      No Mapping Required                   3 - Claim has been adjudicated
                                  service is pending further review.                                              and is awaiting payment cycle.
103   Recipient MID ineligible on 31 - Claim denied as patient cannot be    No Mapping Required                   88 - Entity not eligible for benefits
      service date-under review. identified as our insured.                                                       for submitted dates of service.

104   Recipient number not on      31 - Claim denied as patient cannot be   MA27 - Missing-incomplete-            32 - Subscriber and policy number-
      state file-under review.     identified as our insured.               invalid entitlement number or         contract number not found.
                                                                            name shown on the claim.




                                                                         Page 15
                                                      EOB Code Crosswalk to HIPAA Standard Codes

105   Date of service is prior to 14 - The date of birth follows the date      No Mapping Required                 158 - Entitys date of birth.
      date of birth. If date of     of service.                                                                                 88 - Entity not eligible
      service and recipient MID                                                                                    for benefits for submitted dates of
      are correct, submit claim                                                                                    service.
      to DMA Claims Analysis
      Unit, see billing guidelines.


106   Recipient file problem         31 - Claim denied as patient cannot be    N30 - Patient ineligible for this   56 - Awaiting eligibility
      under state review.            identified as our insured.                service.                            determination.
107   Charges for Sterilization      96 - Non-covered charge(s).               M79 - Missing-incomplete-invalid    454 - Procedure code for services
      deleted.                                                                 charge                              rendered.
108   Charges deleted for            141 - Claim spans eligible and ineligible No Mapping Required                 88 - Entity not eligible for benefits
      ineligible dates of service.   periods of coverage.                                                          for submitted dates of service.

                                                                                                                                    187 - Date(s) of
                                                                                                                   service.
109   Accommodation-                 45 - Charge exceeds fee schedule-         N153 - Missing-incomplete-          65 - Claim-line has been paid.
      reimbursement rate             maximum allowable or contracted-          invalid room and board rate.        631 - Reimbursement Rate
      adjusted to rate on file.      legislated fee arrangement. (Use          N381 - Consult our contractual
                                     Group Codes PR or CO depending            agreement for restrictions-billing-
                                     upon liability).                          payment information related to
                                                                               these charges
110   EDS changed claim due to 125 - Submission-billing error(s).              MA27 - Missing-incomplete-          30 - Subscriber and subscriber id
      recipient name-number                                                    invalid entitlement number or       mismatched.
      mismatch.                                                                name shown on the claim.




111   Settlement amount added 45 - Charge exceeds fee schedule-                No Mapping Required                 104 - Processed according to plan
      to claims payment due tomaximum allowable or contracted-                                                     provisions.
      state authorized payout.legislated fee arrangement. (Use
                              Group Codes PR or CO depending
                              upon liability).
112   Check amount reduced by 45 - Charge exceeds fee schedule-                MA67 - Correction to a prior        101 - Claim was processed as
      recoupment amount.      maximum allowable or contracted-                 claim.                              adjustment to previous claim.
                              legislated fee arrangement. (Use
                              Group Codes PR or CO depending
                              upon liability).

                                                                            Page 16
                                                    EOB Code Crosswalk to HIPAA Standard Codes

113   Refund amount applied &      45 - Charge exceeds fee schedule-         No Mapping Required                104 - Processed according to plan
      1099 credited for returned   maximum allowable or contracted-                                             provisions.
      Medicaid payments.           legislated fee arrangement. (Use
                                   Group Codes PR or CO depending
                                   upon liability).
114   Voided amount applied to     45 - Charge exceeds fee schedule-         No Mapping Required                104 - Processed according to plan
      1099 liability.              maximum allowable or contracted-                                             provisions.
                                   legislated fee arrangement. (Use
                                   Group Codes PR or CO depending
                                   upon liability).
115   Adj of claim pending in      133 - The disposition of this claim-      No Mapping Required                3 - Claim has been adjudicated
      process-system.              service is pending further review.                                           and is awaiting payment cycle.
116   Reduced for deductible.      1 - Deductible Amount.                    N381 - Consult our contractual     98 - Charges applied to deductible.
                                                                             agreement for restrictions-billing-
                                                                             payment information related to
                                                                             these charges
117   Denied for deductible.       A1 - Claim-Service denied. At least       N381 - Consult our contractual      98 - Charges applied to deductible.
                                   one Remark Code must be provided          agreement for restrictions-billing-
                                   (may be comprised of either the           payment information related to
                                   Remittance Advice Remark Code or          these charges
                                   NCPDP Reject Reason Code.) This
                                   change to be effective 7-1-2010-
                                   Claim-Service denied. At least one
                                   Remark Code must be provided
                                   (may be comprised of either the
                                   NCPDP Reject Reason Code, or
                                   Remittance Advice Remark Code
                                   that is not an ALERT.)



118   Claim awaiting eligibility   31 - Claim denied as patient cannot be    N142 The original claim was        56 - Awaiting eligibility
      file update. Claim will be   identified as our insured.                denied. Resubmit a new claim,      determination.
      resubmitted for you.                                                   not a replacement claim.

119   Adjustment paid correctly    B13 - Previously paid. Payment for this   N381 - Consult our contractual      107 - Processed according to
      per Medicaid guidelines.     claim-service may have been provided      agreement for restrictions-billing- contract-plan provisions.
                                   in a previous payment.                    payment information related to               101 - Claim was
                                                                             these charges                       processed as adjustment to
                                                                                                                 previous claim.

                                                                          Page 17
                                                      EOB Code Crosswalk to HIPAA Standard Codes
120   Recipient MID number          125 - Submission-billing error(s).         MA61 - Missing-incomplete-          21 - Missing or invalid information.
      missing. Enter MID and                                                   invalid social security number or
      submit as a new claim.                                                   health insurance claim number.
                                                                                                                                478 - Claim
                                                                                                                   submitters identifier (patient
                                                                                                                   account number) is missing.
121   Refile this claim & EOB -     A1 - Claim-Service denied. At least        MA130 - Your claim contains       481 - Claim-submission format is
      system.                       one Remark Code must be provided           incomplete and-or invalid         invalid.
                                    (may be comprised of either the            information, and no appeal rights
                                    Remittance Advice Remark Code or           are afforded because the claim is
                                    NCPDP Reject Reason Code.) This            unprocessable. Please submit a
                                    change to be effective 7-1-2010-           new claim with the complete-
                                    Claim-Service denied. At least one         correct information.
                                    Remark Code must be provided
                                    (may be comprised of either the
                                    NCPDP Reject Reason Code, or
                                    Remittance Advice Remark Code
                                    that is not an ALERT.)



122   Dates of service before       197 - Precertification-authorization-      N54 - Claim information is          84 - Service not authorized.
      prior approval date. Verify   notification absent.                       inconsistent with pre-certified-
      DOS and PA number;                                                       authorized services.
      correct and submit as a                                                                                             187 - Date(s) of service.
      new claim.

123   Dates of service after prior 197 - Precertification-authorization-       N54 - Claim information is          84 - Service not authorized.
      approval date, Verify DOS notification absent.                           inconsistent with pre-certified-
      and PA number; correct                                                   authorized services.
      and submit as a new claim.                                                                                          187 - Date(s) of service.

124   Exceeds state dental          119 - Benefit maximum for this time    N362 - The number of Days or      259 - Frequency of service.
      limitation.                   period or occurrence has been reached. Units of Service exceeds our
                                                                           acceptable maximum
125   Previously paid on claim-     18 - Duplicate claim-service.          M86 - Service denied because      259 - Frequency of service.
      system.                                                              payment already made for same-
                                                                           similar procedure within set time
                                                                           frame.

                                                                            Page 18
                                                        EOB Code Crosswalk to HIPAA Standard Codes

126   Rebill service using            125 - Submission-billing error(s).         N56 - Procedure code billed is        454 - Procedure code for services
      appropriate habilitation                                                   not correct-valid for the service     rendered.
      code.                                                                      billed or the date of service billed.




127   Not in accordance with          B5 - Coverage-program guidelines           No Mapping Required                    21 - Missing or invalid information.
      Dental Policy guidelines.       were not met or were exceeded.

128   Services not approved by        45 - Charge exceeds fee schedule-          N10 - Claim-service adjusted       89 - Entity not eligible for dental
      dental consultant.              maximum allowable or contracted-           based on the findings of a review benefits for submitted dates of
                                      legislated fee arrangement. (Use           organization-professional consult- service.
                                      Group Codes PR or CO depending             manual adjudication-medical or
                                      upon liability).                           dental advisor.

129   No patient liability on         142 - Monthly Medicaid patient liability   N58 - Missing-incomplete-invalid       21 - Missing or invalid information.
      claim for partial month         amount.                                    patient liability amount.
      billing.
130   Paid per dental consultant      45 - Charge exceeds fee schedule-          N10 - Claim-service adjusted       65 - Claim-line has been paid.
      review.                         maximum allowable or contracted-           based on the findings of a review
                                      legislated fee arrangement. (Use           organization-professional consult-
                                      Group Codes PR or CO depending             manual adjudication-medical or
                                      upon liability).                           dental advisor.

131   Resubmit as a new claim         16 - Claim-service lacks information       N29 - Missing documentation-           294 - Supporting documentation.
      with operative record           which is needed for adjudication.          orders-notes-summary-report-           317 - Patients medical records.
      and/or Labor & Delivery                                                    chart.                                 421 - Medical review attachment-
      reocrd, history physical,                                                        N163 - Medical record does       information for service(s)
      discharge summary,                                                         not support code billed per the
      pathology report and                                                       code definition.
      ultrasound report.

132   Rebill with patient liability   125 - Submission-billing error(s).         MA31 - Missing-incomplete-             189 - Facility admission date
      amount and-or correct                                                      invalid beginning and ending
      admission date.                                                            dates of the period billed.

                                                                                             N58 - Missing-
                                                                                 incomplete-invalid patient liability
                                                                                 amount.

                                                                             Page 19
                                                    EOB Code Crosswalk to HIPAA Standard Codes


133   Enter correct bill type in   125 - Submission-billing error(s).       MA30 - Missing-incomplete-          21 - Missing or invalid information.
      form locator 4 and submit                                             invalid type of bill.
      as a new claim.




134   Units-days and -or rate are 125 - Submission-billing error(s).        M53 - Missing-incomplete-invalid 258 - Days-units for procedure-
      not consistent with                                                   days or units of service.        revenue code.
      charges.
                                                                                  M54 - Missing-incomplete-
                                                                            invalid total charges.


135   Patient status missing/not   125 - Submission-billing error(s).       MA43 - Missing-incomplete-          21 - Missing or invalid information.
      in accordance with                                                    invalid patient status.
      medicaid
      policy/inconsistent with                                                                                               431 - Provide
      days/dates billed.                                                                                       condition-functional status at time
                                                                                                               of service.              90 - Entity
                                                                                                               not eligible for medical benefits for
136   Charge reduced per         45 - Charge exceeds fee schedule-          N10 - Claim-service adjusted       421 - Medical review attachment-
      medical consultant review. maximum allowable or contracted-           based on the findings of a review information for service(s)
                                 legislated fee arrangement. (Use           organization-professional consult-
                                 Group Codes PR or CO depending             manual adjudication-medical or
                                 upon liability).                           dental advisor.

137   Days reduced per Medical     45 - Charge exceeds fee schedule-        N10 - Claim-service adjusted       421 - Medical review attachment-
      Policy review.               maximum allowable or contracted-         based on the findings of a review information for service(s)
                                   legislated fee arrangement. (Use         organization-professional consult-
                                   Group Codes PR or CO depending           manual adjudication-medical or
                                   upon liability).                         dental advisor.

138   Non allowable charges        96 - Non-covered charge(s).              M54 - Missing-incomplete-invalid 21 - Missing or invalid information.
      deleted.                                                              total charges.                                           454 -
                                                                                                  M79 -       Procedure code for services
                                                                            Missing-incomplete-invalid charge rendered.

139   Services limited             177 - Patient has not met the required   N30 - Patient ineligible for this   56 - Awaiting eligibility
      presumptive eligibility.     eligibility requirements.                service.                            determination.


                                                                        Page 20
                                                     EOB Code Crosswalk to HIPAA Standard Codes



140   Room charges reduced to       45 - Charge exceeds fee schedule-         N153 - Missing-incomplete-          65 - Claim-line has been paid.
      semi-private or ward rate.    maximum allowable or contracted-          invalid room and board rate.        181 - Hospitals room rate.
                                    legislated fee arrangement. (Use          N381 - Consult our contractual
                                    Group Codes PR or CO depending            agreement for restrictions-billing-
                                    upon liability).                          payment information related to
                                                                              these charges
141   Bill only one months          125 - Submission-billing error(s).        N61 - Rebill services on separate 21 - Missing or invalid information.
      services per claim form .                                               claims.




142   Denied item must be           184 - The prescribing-ordering provider   N95 - This provider type -         91 - Entity not eligible-not
      obtained from state optical   is not eligible to prescribe-order the    provider specialty may not bill    approved for dates of service.
      contractor.                   service billed.                           this service.
143   Medicaid ID number not        31 - Claim denied as patient cannot be    No Mapping Required                33 - Subscriber and subscriber id
      on state eligibility file.    identified as our insured.                                                   not found.

                                                                                                                       97 - Patient eligibility not
                                                                                                                 found with entity.
144   Level of care not approved 185 - The rendering provider is not          N95 - This provider type -         91 - Entity not eligible-not
      for this provider number.  eligible to perform the service billed.      provider specialty may not bill    approved for dates of service.
                                                                              this service.
145   No Hysterectomy               16 - Claim-service lacks information      M127 - Missing patient medical     21 - Missing or invalid information.
      statement on file.            which is needed for adjudication.         record for this service.                                       294 -
                                                                              N3 - Missing consent form.         Supporting documentation.
                                                                                                                               421 - Medical review
                                                                                                                 attachment-information for
                                                                                                                 service(s).

146   Covered days paid at          45 - Charge exceeds fee schedule-         N153 - Missing-incomplete-          65 - Claim-line has been paid.
      intermediate care rate.       maximum allowable or contracted-          invalid room and board rate.
                                    legislated fee arrangement. (Use          N381 - Consult our contractual
                                    Group Codes PR or CO depending            agreement for restrictions-billing-                   456 - Covered
                                    upon liability).                          payment information related to      Day(s)
                                                                              these charges



                                                                           Page 21
                                                   EOB Code Crosswalk to HIPAA Standard Codes


147   Claim cutback per hospital 119 - Benefit maximum for this time    N362 - The number of Days or        227 - Hospital information
      days certification.        period or occurrence has been reached. Units of Service exceeds our
                                                                        acceptable maximum.
                                                                        N381 - Consult our contractual
                                                                        agreement for restrictions-billing-
                                                                        payment information related to
                                                                        these charges.
148   Utilization length of stay B5 - Coverage-program guidelines       MA32 - Missing-incomplete-          259 - Frequency of service.
      cut off exceeded.          were not met or were exceeded.         invalid number of covered days
                                                                        during the billing period.                456 - Covered Day(s)
                                                                         N362 - The number of Days or
                                                                        Units of Service exceeds our
                                                                        acceptable maximum.
                                                                        N381 - Consult our contractual
                                                                        agreement for restrictions-billing-
                                                                        payment information related to
                                                                        these charges

149   Leave of absence charges     78 - Non-Covered days-Room charge       M79 - Missing-incomplete-invalid 258 - Days-units for procedure-
      not covered.                 adjustment.                             charge                           revenue code.

150   Day of discharge not         78 - Non-Covered days-Room charge       No Mapping Required               258 - Days-units for procedure-
      covered.                     adjustment.                                                               revenue code.

151   Pending recoupment of      133 - The disposition of this claim-      No Mapping Required                 3 - Claim has been adjudicated
      claim - system.            service is pending further review.                                            and is awaiting payment cycle.
152   Paid as billed per         45 - Charge exceeds fee schedule-         N381 - Consult our contractual      65 - Claim-line has been paid.
      Department of Health       maximum allowable or contracted-          agreement for restrictions-billing- 107 - Processed according to
      Services review.           legislated fee arrangement. (Use          payment information related to      contract-plan provisions.
                                 Group Codes PR or CO depending            these charges
                                 upon liability).
153   Ancillary charges included 125 - Submission-billing error(s).        M2 - Not paid separately when     21 - Missing or invalid information.
      in per diem rate.                                                    the patient is an inpatient.




                                                                        Page 22
                                                   EOB Code Crosswalk to HIPAA Standard Codes
154   Procedure code does not 125 - Submission-billing error(s).          M53 - Missing-incomplete-invalid 251 - Total anesthesia minutes.
      allow multiple units or                                             days or units of service.
      billings. Anesthesia
      providers; one unit equals                                                                                523 - Anesthesia Unit Count
      1 minute for general
      anesthesia TOS 07. Rebill
      corrected claim.
155   Medicare denied             96 - Non-covered charge(s).             N381 - Consult our contractual        454 - Procedure code for services
      ambulance service. Not                                              agreement for restrictions-billing-   rendered.
      covered by Medicaid.                                                payment information related to
                                                                          these charges
156   Laboratory revenue code     125 - Submission-billing error(s).      M51 -Missing-incomplete-invalid       454 - Procedure code for services
      requires corresponding                                              procedure code(s).                    rendered.
      lab CPT code. Enter CPT
      code and resubmit as a                                                                                               455 - Revenue code for
      new claim.                                                                                                services rendered.


157   Late discharge non          96 - Non-covered charge(s).             N50 - Missing-incomplete-invalid      457 - Non-Covered Day(s)
      covered by Medicaid.                                                discharge information.
158   This revenue code           125 - Submission-billing error(s).      M51 -Missing-incomplete-invalid       454 - Procedure code for services
      requires a CPT laboratory                                           procedure code(s).                    rendered.
      procedure code.
                                                                                                                           455 - Revenue code for
                                                                                                                services rendered.


159   Rebill for non-waiver       125 - Submission-billing error(s).      N34 - Incorrect claim form-format 228 - Type of bill for UB claim
      services on an approved                                             for this service.
      UB claim form




160   File with Medicare.         22 - This care may be covered by        MA04 - Secondary payment           116 - Claim submitted to incorrect
                                  another payer per coordination of       cannot be considered without the payer.
                                  benefits.                               identity of or payment information
                                                                          from the primary payer. The
                                                                          information was either not
                                                                          reported or was illegible.


                                                                       Page 23
                                                     EOB Code Crosswalk to HIPAA Standard Codes
161   Report does not justify      150 - Payment adjusted because the      No Mapping Required                 304 - Reports for service.
      higher fee.                  payer deems the information submitted
                                   does not support this level of service.

162   Indicate date of delivery, 125 - Submission-billing error(s).          MA31 - Missing-incomplete-        21 - Missing or invalid information.
      name of delivering                                                     invalid beginning and ending
      physician and date patient                                             dates of the period billed.
      was first seen for                                                                                         192 - Date of first service for
      condition.                                                                                               current series-symptom-illness.


164   Procedure code is not        125 - Submission-billing error(s).        M51 - Missing-incomplete-invalid 21 - Missing or invalid information.
      consistent with HCPC                                                   procedure code(s).
      description and-or billed
      amount. Refile corrected                                                                                   454 - Procedure code for
      claim or attach                                                                                          services rendered.
      explanation.
165   Breakdown charges using      125 - Submission-billing error(s).        N63 - Rebill services on separate 454 - Procedure code for services
      individual procedure                                                   claim lines.                      rendered.
      codes.




166   Pending Buy-In               133 - The disposition of this claim-      No Mapping Required              3 - Claim has been adjudicated
      investigation.               service is pending further review.                                         and is awaiting payment cycle.
167   No charge billed. Enter      125 - Submission-billing error(s).        M54 - Missing-incomplete-invalid 178 - Submitted charges.
      billed amount and submit                                               total charges.
      detail as a new claim.




168   Billed amount reduced by     96 - Non-covered charge(s).               M79 - Missing-incomplete-invalid 454 - Procedure code for services
      non-covered charge.                                                    charge                           rendered.

169   Billed amount equal to       96 - Non-covered charge(s).               M79 - Missing-incomplete-invalid 178 - Submitted charges.
      non-covered charge.                                                    charge                             454 - Procedure code for
                                                                                                              services rendered.
                                                                                                                    596 - Non-covered Charge
                                                                                                              Amount
                                                                          Page 24
                                                      EOB Code Crosswalk to HIPAA Standard Codes




170   Refile on EPSDT claim          A1 - Claim-Service denied. At least one N34 - Incorrect claim form-format 276 - UB04-HCFA-1450-1500
      form.                          Remark Code must be provided (may       for this service.                 claim form.
                                     be comprised of either the Remittance                                                               481 -
                                     Advice Remark Code or NCPDP Reject                                        Claim submission format is invalid.
                                     Reason Code.) This change to be
                                     effective 7-1-2010- Claim-Service
                                     denied. At least one Remark Code
                                     must be provided (may be comprised
                                     of either the NCPDP Reject Reason
                                     Code, or Remittance Advice Remark
                                     Code that is not an ALERT.)


172   Less than 3 months pre-        125 - Submission-billing error(s).         N188 - The approved level of       345 - Treatment plan for service-
      natal care apparently                                                     care does not match the            diagnosis
      given: Bill appropriate                                                   procedure code submitted.
      antepartum or E&M code                                                                                                             306 -
      depending on number of                                                                                       Detailed description of service.
      visits.
173   Transportation not to the      117 - Payment adjusted because             N157 - Transportation to-from      101 - Claim was processed as
      nearest appropriate            transportation is only covered to the      this destination is not covered.   adjustment to previous claim.
      facility. Please resubmit an   closest facility that can provide the                                                     429 - Loaded miles
      adjustment with                necessary care.                                                               and charges for transport to
      documentation to justify                                                                                     nearest facility with appropriate
      transport to this facility.                                                                                  services.                       430 -
                                                                                                                    Nearest appropriate facility.

174   Service date must be           125 - Submission-billing error(s).         M53 - Missing-incomplete-invalid 187 - Date(s) of service.
      same as birthdate with                                                    days or units of service.
      unit of 1.                                                                                     MA31 -
                                                                                Missing-incomplete-invalid
                                                                                beginning and ending dates of
                                                                                the period billed.




                                                                             Page 25
                                                    EOB Code Crosswalk to HIPAA Standard Codes




175   Admit hour required on       125 - Submission-billing error(s).       N46 - Missing-incomplete-invalid   21 - Missing or invalid information.
      outpatient claim format.                                              admission hour.




176   Refile on the approved UB 125 - Submission-billing error(s).          MA30 - Missing-incomplete-         228 - Type of bill for UB claim.
      claim format using the                                                invalid type of bill.                                       276 - UB04-
      correct bill type.                                                                                       HCFA-1450-1500 claim form




177   Multiple providers may not 125 - Submission-billing error(s).         N61 - Rebill services on separate 21 - Missing or invalid information.
      bill on same claim form:                                              claims.
      resubmit with one
      provider per claim form.



178   Purchase of vaccine not   23 - The impact of prior payer(s)      No Mapping Required                     21 - Missing or invalid information.
      indicated on EPSDT claim. adjudication including payments and-or                                                                 107 -
      Immunization paid to DHS. adjustments.                                                                   Processed according to contract-
                                                                                                               plan provisions.

179   Service covered by HMO.      24 - Payment for charges adjusted.     No Mapping Required                  96 - No agreement with entity.
                                   Charges are covered under a capitation                                       585 - Denied Charge or Non-
                                   agreement-managed care plan.                                                covered Charge

180   Monitor equipment not        B15 - This service-procedure requires    N20 - Service not payable with     258 - Days-units for procedure-
      payable when patient in      that a qualifying service-procedure be   other service rendered on the      revenue code.
      ICU-CCU.                     received and covered. The qualifying     same date.
                                   other service-procedure has not been
                                   received-adjudicated.




                                                                        Page 26
                                                     EOB Code Crosswalk to HIPAA Standard Codes



181   Refile on optical claim       125 - Submission-billing error(s).      N34 - Incorrect claim form-format 481 - Claim-submission format is
      form.                                                                 for this service.                 invalid.




182   All claims suspended      133 - The disposition of this claim-        N187 - Alert- You may request      46 - Internal review-audit.
      pending financial review. service is pending further review.          a review in writing within the
      Contact EDS PROVIDER                                                  required time limits following
      SERVICES 1-800-688-6696.                                              receipt of this notice by
                                                                            following the instructions
                                                                            included in your contract or
                                                                            plan benefit documents

183   Refile on Home Health         125 - Submission-billing error(s).      N34 - Incorrect claim form-format 481 - Claim-submission format is
      claim format.                                                         for this service.                 invalid.




184   Only one visit allowed per    119 - Benefit maximum for this time    M86 - Service denied because      259 - Frequency of service.
      day.                          period or occurrence has been reached. payment already made for same-
                                                                           similar procedure within set time                         612 - Per
                                                                           frame.                            Day Limit Amount

185   Rebill service using          153 - Payment adjusted because the    M123 - Missing-incomplete-        21 - Missing or invalid information.
      appropriate code for          payer deems the information submitted invalid name, strength, or dosage
      dosage.                       does not support this dosage.         of the drug furnished.

186   Tooth surface missing or      125 - Submission-billing error(s).      N75 - Missing-incomplete-invalid   21 - Missing or invalid information.
      invalid. Correct detail and                                           tooth surface information.
      resubmit claim.




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                                                    EOB Code Crosswalk to HIPAA Standard Codes




187   Quadrant or arch indicator 125 - Submission-billing error(s).        N37 - Missing-incomplete-invalid   21 - Missing or invalid information.
      missing or invalid.                                                  tooth number-letter.                                       245 - Dental
                                                                                                              quadrant-arch




188   Refile on inpatient claim    125 - Submission-billing error(s).      N34 - Incorrect claim form-format 481 - Claim-submission format is
      format.                                                              for this service.                 invalid.




189   Refile on the approved       125 - Submission-billing error(s).      N34 - Incorrect claim form-format 481 - Claim-submission format is
      ADA dental claim form                                                for this service.                 invalid.




190   Dates of service changed   45 - Charge exceeds fee schedule-         No Mapping Required                187 - Date(s) of service.
      for fiscal year end.       maximum allowable or contracted-
                                 legislated fee arrangement. (Use
                                 Group Codes PR or CO depending
                                 upon liability).
191   Medicaid ID number does 140 - Patient-Insured health                 No Mapping Required                30 - Subscriber and subscriber id
      not match patient name.    identification number and name do not                                        mismatched.
                                 match.
192   Allow once-year under age 119 - Benefit maximum for this time        M90 - Not covered more than        259 - Frequency of service.
      25 without prior approval. period or occurrence has been reached.    once in a 12 month period.




                                                                        Page 28
                                                    EOB Code Crosswalk to HIPAA Standard Codes




193   Allow once-2 years over       119 - Benefit maximum for this time    M86 - Service denied because      259 - Frequency of service.
      age 24 without PA.            period or occurrence has been reached. payment already made for same-
                                                                           similar procedure within set time
                                                                           frame.                     N357 -
                                                                           Time frame requirements
                                                                           between this service-procedure-
                                                                           supply and a related service-
                                                                           procedure-supply have not been
                                                                           met

194   Adjustment processed to       3 - Co-payment Amount                  No Mapping Required                 20 - Accepted for processing.
      reflect increase in co-pay.

195   Optical goods less than       96 - Non-covered charge(s).            M79 - Missing-incomplete-invalid 454 - Procedure code for services
      $5.00 are non-covered.                                               charge                           rendered.

196   W4008 IV Pole not allowed 96 - Non-covered charge(s).                MA66 - Missing-incomplete-          585 - Denied Charge or Non-
      after January 31, 1992.                                              invalid principal procedure code.   covered Charge

                                                                              N303 - Missing-incomplete-
                                                                           invalid principal procedure date.

197   Refile on physicians CMS- 125 - Submission-billing error(s).         N34 - Incorrect claim form-format 481 - Claim-submission format is
      1500 claim format.                                                   for this service.                 invalid.




198   Refile on Hearing Aid form. 125 - Submission-billing error(s).       N34 - Incorrect claim form-format 481 - Claim-submission format is
                                                                           for this service.                 invalid.




                                                                        Page 29
                                                       EOB Code Crosswalk to HIPAA Standard Codes


199   Submit as an adjustment        16 - Claim-service lacks information        N29 - Missing documentation-        21 - Missing or invalid information
      with hysterectomy              which is needed for adjudication.           orders-notes-summary-report-                             297 - Medical
      statement, medical                                                         chart.                              notes-report.                    421
      records to include H&P,                                                                                        - Medical review attachment-
      operative report, path,                                                                                        information for service(s).
      summary and claim
      attached.

200   Provider name submitted        125 - Submission-billing error(s).          N256 - Missing-incomplete-           21 - Missing or invalid information.
      does not match provider                                                    invalid billing provider-supplier                            132 -
      number submitted.                                                          name.                                Entitys Medicaid provider id
                                                                                                  N257 - Missing-
                                                                                 incomplete-invalid billing provider-
                                                                                 supplier primary identifier.

201   Date of service is before     B7 - This provider was not certified-        No Mapping Required                 48 - Referral-authorization.
      provider eligibility date. To eligible to be paid for this procedure-                                           91 - Entity not eligible-not
      inquire, contact Division     service on this date of service.                                                 approved for dates of service.
      of Medical Assistance,
      Provider Enrollment, 2506
      Mail Service Center,
      Raleigh, NC 27699-2506.



202   Revenue code must be       125 - Submission-billing error(s).              M20 - Missing-incomplete-invalid 21 - Missing or invalid information.
      billed with a DME- medical                                                 HCPCS.                                                   507 -
      supply HCPC code.                                                                  M50 - Missing-incomplete- HCPCS
                                                                                 invalid revenue code(s)



203   Verify the dates of service. 125 - Submission-billing error(s).            MA31 - Missing-incomplete-          21 - Missing or invalid information.
                                                                                 invalid beginning and ending                                187 -
                                                                                 dates of the period billed.         Date(s) of service.
                                                                                                                           188 - Statement from-
                                                                                                                     through dates




                                                                              Page 30
                                                     EOB Code Crosswalk to HIPAA Standard Codes


204   Pre-mature delivery and-or 125 - Submission-billing error(s).           N228 - Incomplete-invalid           21 - Missing or invalid information.
      emergency C-section must                                                consent form                                                107 -
      show EDC on the                                                                                             Processed according to contract-
      sterilization consent form,.                                                                                plan provisions




205   No UPIN on claim. Refile     125 - Submission-billing error(s).         No Mapping Required                 21 - Missing or invalid information.
      with correct UPIN.                                                                                                                  133 -
                                                                                                                  Entitys UPIN




206   A handwritten or stamped     125 - Submission-billing error(s).         MA81 - Missing-incomplete-          21 - Missing or invalid information.
      provider signature                                                      invalid provider-supplier signature
      required.                                                                                                   466 - Entities original signature.




207   DME procedure not            96 - Non-covered charge(s).                MA66 - Missing-incomplete-          454 - Procedure code for services
      allowed after January 31,                                               invalid principal procedure code.   rendered.
      1992.                                                                                                       457 - Non-Covered Day(s)
                                                                              N303 - Missing-incomplete-
                                                                              invalid principal procedure date.

208   Resubmit for prior           197 - Precertification-authorization-      N54 - Claim information is          84 - Service not authorized.
      approved type of service.    notification absent.                       inconsistent with pre-certified-
                                                                              authorized services.
                                                                              N188 - The approved level of
                                                                              care does not match the
                                                                              procedure code submitted
209   Limited oral evaluation-     B15 - This service-procedure requires      N20 - Service not payable with      258 - Days-units for procedure-
      problem focused not          that a qualifying service-procedure be     other service rendered on the       revenue code.
      allowed same date of         received and covered. The qualifying       same date.
      service as dental exam.      other service-procedure has not been
                                   received-adjudicated.



                                                                           Page 31
                                                     EOB Code Crosswalk to HIPAA Standard Codes



210   Payment denied; there is      58 - Payment adjusted because          No Mapping Required                    344 - Documentation that provider
      no evidence that present      treatment was deemed by the payer to                                          of physical therapy is Medicare
      institution does not have     have been rendered in an inappropriate                                        Part B approved.
      appropriate medical           or invalid place of service.
      facilities for patients tx.

211   Dates of service not within 197 - Precertification-authorization-       N54 - Claim information is          187 - Date(s) of service.
      authorized time period.     notification absent.                        inconsistent with pre-certified-
                                                                              authorized services.
212   Disproportionate share     119 - Benefit maximum for this time          No Mapping Required                 259 - Frequency of service.
      hospital payment increase period or occurrence has been reached.
      of 5% for children under
      age 1 with charges greater
      than annual maximum or
      stays over 65 days.


213   No Prior Approval on file. 197 - Precertification-authorization-        N54 - Claim information is          84 - Service not authorized
      Contact Value Options at 1- notification absent.                        inconsistent with pre-certified-
      888-510-1150 for                                                        authorized services.
      confirmation.
214   Follow up care referred to 125 - Submission-billing error(s).           MA66 - Missing-incomplete-          21 - Missing or invalid information.
      Optometrist. Rebill using                                               invalid principal procedure code.   666 - Surgical Procedure Code
      code W9931, W9941 or
      W9951; or submit
      adjustment.


215   Send copy of claim,           16 - Claim-service lacks information      N29 - Missing documentation-        287 - Medical necessity for service.
      Certification of Need and     which is needed for adjudication.         orders-notes-summary-report-
      RA to DMA, Program                                                      chart.
      Integrity, Inpatient
      Psychiatric, 2515 Mail
      Service Center, Raleigh,
      NC, 27699-2515.




                                                                           Page 32
                                                     EOB Code Crosswalk to HIPAA Standard Codes

216   Lab services have been        18 - Duplicate claim-service.             M86 - Service denied because      259 - Frequency of service.
      billed and paid to a                                                    payment already made for same-
      Pathologist or an                                                       similar procedure within set time
      Independent lab.                                                        frame.

217   Code pertains to physician    16 - Claim-service lacks information      N225 - Incomplete-invalid          21 - Missing or invalid information.
      escort only. If billing for   which is needed for adjudication.         documentation-orders-notes-
      physician escort, please                                                summary-report-chart.
      note to and from
      destinations and time
      involved.
218   Cataract surgery follow-up    97 - The benefit for this service is      M80 - Not covered when             454 - Procedure code for services
      included in fee to surgeon.   included in the payment-allowance for     performed during the same          rendered.
                                    another service-procedure that has        session-date as a previously
                                    already been adjudicated.                 processed service for the patient.

219   Indicate number of miles      125 - Submission-billing error(s).        M22 - Missing-incomplete-invalid 21 - Missing or invalid information.
      outside base and-or cost-                                               number of miles traveled.                                    267 -
      mile.                                                                                                       Number of miles patient was
                                                                                                                  transported.
                                                                                                                              429 - Loaded miles and
                                                                                                                  charges for transport to nearest
                                                                                                                  facility with appropriate services
220   Resubmit as an                16 - Claim-service lacks information      N20 - Service not payable with      297 -Medical notes-report.
      adjustment with               which is needed for adjudication.         other service rendered on the       337 - Ambulance certification-
      ambulance call reports to                                               same date.                          documentation.
      justify same day one-way                                                N29 - Missing documentation-                           472- Ambulance
      and round trip transports                                               orders-notes-summary-report-        Run Sheet
                                                                              chart.
                                                                                      N56 - Procedure code
                                                                              billed is not correct-valid for the
                                                                              services billed or the date of
                                                                              service billed.

221   A new prior approval      197 - Precertification-authorization-         N54 - Claim information is         84 - Service not authorized.
      request must be submitted notification absent.                          inconsistent with pre-certified-
      for additional units.                                                   authorized services.
                                                                                                                   258 - Days-units for procedure-
                                                                                                                 revenue code.

                                                                           Page 33
                                                      EOB Code Crosswalk to HIPAA Standard Codes


222   Recipient name on file is 16 - Claim-service lacks information           MA36 - Missing-incomplete-        31 - Subscriber and policyholder
      not the same as on the    which is needed for adjudication.              invalid patient name              name mismatched
      statement consent. Attach
      note of verification to
      statement/consent that
      this is the same person &
      resubmit.

223   Maximum units have been       108 - Rent-purchase guidelines were        N362 - The number of Days or      483 - Maximum coverage amount
      used for this piece of        not met.                                   Units of Service exceeds our      met or exceeded for benefit period.
      equipment.                                                               acceptable maximum
224   Follow-up visits and          B15 - This service-procedure requires      N20 - Service not payable with    258 - Days-units for procedure-
      consults not allowed same     that a qualifying service-procedure be     other service rendered on the     revenue code.
      day as dialysis treatment.    received and covered. The qualifying       same date.
                                    other service-procedure has not been
                                    received-adjudicated.

225   Group-outpatient tx not       B15 - This service-procedure requires      N20 - Service not payable with    258 - Days-units for procedure-
      allowed same DOS as           that a qualifying service-procedure be     other service rendered on the     revenue code.
      hospital group therapy-       received and covered. The qualifying       same date.
      medication administration.    other service-procedure has not been
                                    received-adjudicated.

226   The Hysterectomy         16 - Claim-service lacks information            N3 - Missing consent form.        21 - Missing or invalid information.
      statement does not meet  which is needed for adjudication.                                                                    421 - Medical
      federal guidelines,                                                                                        review attachment-information for
      resubmit a completed new                                                                                   service(s).
      'Prior to my surgery'
      statement.

227   This service requires prior   197 - Precertification-authorization-      N54 - Claim information is         84 - Service not authorized.
      approval for your provider    notification absent.                       inconsistent with pre-certified-
      number,.                                                                 authorized services.
228   Service included in           97 - The benefit for this service is       M80 - Not covered when             454 - Procedure code for services
      previously paid               included in the payment-allowance for      performed during the same          rendered.
      cystourethroscopy code,.      another service-procedure that has         session-date as a previously
                                    already been adjudicated.                  processed service for the patient.



                                                                            Page 34
                                                   EOB Code Crosswalk to HIPAA Standard Codes

229   Previously paid procedure    97 - The benefit for this service is    M80 - Not covered when                 454 - Procedure code for services
      52005 is included in this    included in the payment-allowance for   performed during the same              rendered.
      service, please file an      another service-procedure that has      session-date as a previously
      adjustment.                  already been adjudicated.               processed service for the patient.
                                                                                                          N1 -
                                                                           Alert- You may appeal this
                                                                           decision in writing within the
                                                                           required time limits following
                                                                           receipt of this notice by following
                                                                           the instructions included in your
                                                                           contract or plan benefit
                                                                           documents
230   Previously paid procedure    97 - The benefit for this service is    M80 - Not covered when                 454 - Procedure code for services
      52000 is included in this    included in the payment-allowance for   performed during the same              rendered.
      service, please file an      another service-procedure that has      session-date as a previously
      adjustment.                  already been adjudicated.               processed service for the patient.
                                                                                                           N1 -
                                                                           Alert- You may appeal this
                                                                           decision in writing within the
                                                                           required time limits following
                                                                           receipt of this notice by
                                                                           following the instructions
                                                                           included in your contract or
                                                                           plan benefit documents


231   SAIOP is not allowed same    A1 - Claim-Service denied. At least one N20 - Service not payable with         259 - Frequency of service
      date of service as partial   Remark Code must be provided (may       other service rendered on the
      hospitalization and-or day   be comprised of either the Remittance same date.
      treatment                    Advice Remark Code or NCPDP Reject
                                   Reason Code.) This change to be
                                   effective 7-1-2010- Claim-Service
                                   denied. At least one Remark Code
                                   must be provided (may be comprised
                                   of either the NCPDP Reject Reason
                                   Code, or Remittance Advice Remark
                                   Code that is not an ALERT.)




                                                                       Page 35
                                                    EOB Code Crosswalk to HIPAA Standard Codes

232   Psychosocial rehab not       B15 - This service-procedure requires    N20 - Service not payable with    258 - Days-units for procedure-
      allowed same DOS as old      that a qualifying service-procedure be   other service rendered on the     revenue code.
      psych rehab procedure.       received and covered. The qualifying     same date.
                                   other service-procedure has not been
                                   received-adjudicated.

233   Interpretation and-or        97 - The benefit for this service is     M80 - Not covered when             454 - Procedure code for services
      professional component is included in the payment-allowance for       performed during the same          rendered.
      included in fee for service. another service-procedure that has       session-date as a previously
                                   already been adjudicated.                processed service for the patient.

234   Case management not          B15 - This service-procedure requires    N20 - Service not payable with    258 - Days-units for procedure-
      allowed same day as adult    that a qualifying service-procedure be   other service rendered on the     revenue code.
      chronically mentally ill,    received and covered. The qualifying     same date.
      child emotionally            other service-procedure has not been
      disturbed, substance         received-adjudicated.
      abuse or Willie M.,.

235   Service denied, recipients 16 - Claim-service lacks information       N3 - Missing consent form.        21 - Missing or invalid information.
      signature and-or signature which is needed for adjudication.                                                       468 - Patient signature
      date on sterilization                                                                                   source.                       492 -
      consent form has been                                                                                   Other Procedure Date.
      altered.

236   Resubmit claim w- invoice 16 - Claim-service lacks information        N26 - Missing itemized bill       294 - Supporting documentation.
      include recipient's name,  which is needed for adjudication.
      MID#, if medication, the
      name of the medication,
      dose, size vial-ampule and
      NDC# used, and the
      money amount per dose.


237   Total billed does not equal 125 - Submission-billing error(s).        M54 - Missing-incomplete-invalid 21 - Missing or invalid information.
      the sum of details billed.                                            total charges.                   187 - Date(s) of service.




                                                                        Page 36
                                                     EOB Code Crosswalk to HIPAA Standard Codes

238   Claim adjusted to reflect     76 - Disproportionate Share Adjustment. No Mapping Required                  104 - Processed according to plan
      disproportionate share                                                                                     provisions.
      rate.

239   Follow-up visits or           B15 - This service-procedure requires     N20 - Service not payable with     258 - Days-units for procedure-
      consults to be recouped.      that a qualifying service-procedure be    other service rendered on the      revenue code.
      Follow-up visit or consult    received and covered. The qualifying      same date.
      not allowed same date of      other service-procedure has not been
      service as dialysis           received-adjudicated.
      treatment.

240   Resubmit prior approved       198 - Payment Adjusted for exceeding      N54 - Claim information is         21 - Missing or invalid information.
      hours only.                   precertification- authorization           inconsistent with precertified-    674 - Authorization exceeded
                                                                              authorized services

241   UPIN on claim not a valid     125 - Submission-billing error(s).        MA130 - Your claim contains       21 - Missing or invalid information.
      UPIN. Contact prescriber                                                incomplete and-or invalid         133 - Entitys UPIN
      and refile claim with                                                   information, and no appeal rights
      correct UPIN.                                                           are afforded because the claim is
                                                                              unprocessable. Please submit a
                                                                              new claim with the complete-
                                                                              correct information.
                                                                              N31 - Missing-incomplete-invalid
                                                                              prescribing provider identifier

242   DME services paid only to     184 - The prescribing-ordering provider   N95 - This provider type -        91 - Entity not eligible-not
      DME enrolled providers.       is not eligible to prescribe-order the    provider specialty may not bill   approved for dates of service.
                                    service billed.                           this service.
243   Ultra Sound previously        18 - Duplicate claim-service.             M86 - Service denied because      259 - Frequency of service.
      paid in HX for this DOS. If                                             payment already made for same-
      this is a second Ultra                                                  similar procedure within set time
      Sound, submit as                                                        frame.
      adjustment with
      documentation.
244   Resubmit as an                16 - Claim-service lacks information      N29 - Missing documentation-       294 - Supporting documentation.
      adjustment with medical       which is needed for adjudication.         orders-notes-summary-report-       317 - Patients medical records.
      records attached                                                        chart.
                                                                              N163 - Medical Record does not
                                                                              support code billed per the code
                                                                              definition
                                                                           Page 37
                                                    EOB Code Crosswalk to HIPAA Standard Codes




245   Sterilization form missing- 16 - Claim-service lacks information       N3 - Missing consent form.         21 - Missing or invalid information.
      incomplete.                 which is needed for adjudication.
247   Records indicate epidural 125 - Submission-billing error(s).           N163 - Medical record does not     21 - Missing or invalid information.
      procedure performed,                                                   support code billed per the code    454 - Procedure code for
      please recode and                                                      definition                         services rendered
      resubmit.



248   Refile as adj. with          16 - Claim-service lacks information      M51 - Missing-incomplete-invalid 101 - Claim was processed as
      documentation of second      which is needed for adjudication.         procedure code(s).               adjustment to previous claim.
      ultra sound procedure                                                                       N29 -
      being performed same                                                   Missing documentation-orders-
      date of service.                                                       notes- summary- report- chart.

250   Over 6 hours of critical     16 - Claim-service lacks information      N362 - The number of Days or       187 - Date(s) of service.
      care billed for same date    which is needed for adjudication.         Units of Service exceeds our         259 - Frequency of service.
      of service. Resubmit as an                                             acceptable maximum.                   294 - Supporting documentation.
      adjustment with                                                          N393 - Missing progress notes-
      documentation of time                                                  report.
      (i.e., ICU record, physician                                                 N435 - Exceeds number-
      progress notes)                                                        frequency approved -allowed
                                                                             within time period without support
                                                                             documentation.

251   Resubmit as an               16 - Claim-service lacks information      N29 - Missing documentation-       262 - Type of surgery-service for
      adjustment with              which is needed for adjudication          orders-notes-summary-report-       which anesthesia was
      anesthesia records                                                     chart                              administered.
                                                                                                                 294 - Supporting documentation
252   Full recoup due to invalid 16 - Claim-service lacks information        N225 - Incomplete-invalid          21 - Missing or invalid information.
      consent form or              which is needed for adjudication.         documentation-orders-notes-         107 - Processed according to
      sterilization guidelines not                                           summary-report-chart.              contract-plan provisions.
      met.                                                                                                      666 - Surgical Procedure Code




                                                                          Page 38
                                                   EOB Code Crosswalk to HIPAA Standard Codes



253   Adjustment denied, please    A1 - Claim-Service denied. At least one MA91 - This determination is the    101 - Claim was processed as
      check your R-A's for         Remark Code must be provided (may       result of the appeal you filed.     adjustment to previous claim.
      previous adjustment of       be comprised of either the Remittance
      this claim.                  Advice Remark Code or NCPDP Reject
                                   Reason Code.) This change to be
                                   effective 7-1-2010- Claim-Service
                                   denied. At least one Remark Code
                                   must be provided (may be comprised
                                   of either the NCPDP Reject Reason
                                   Code, or Remittance Advice Remark
                                   Code that is not an ALERT.)


254   X-ray w-o contrast not   16 - Claim-service lacks information         M118 - Alert- Letter to follow     101 - Claim was processed as
      allowed same DOS as non- which is needed for adjudication.            containing further information     adjustment to previous claim.
      ionic contrast media.

255   Please indicate or correct 23 - The impact of prior payer(s)          MA34 - Missing-incomplete-         21 - Missing or invalid information.
      the number of co-ins or      adjudication including payments and-or   invalid number of coinsurance       458 - Coinsurance Day(s).
      lifetime reserve days billed adjustments.                             days during the billing period.       459 - Lifetime Reserve Day(s)
      to correspond with monies
      on the voucher, and                                                      MA35 - Missing-incomplete-
      resubmit as a new claim.                                              invalid number of lifetime reserve
                                                                            days.
256   Claim cannot be              A1 - Claim-Service denied. At least      MA130 - Your claim contains        1 - For more detailed information,
      processed. Explanation to    one Remark Code must be provided         incomplete and-or invalid          see remittance advice.
      follow.                      (may be comprised of either the          information, and no appeal rights            104 - Processed
                                   Remittance Advice Remark Code or         are afforded because the claim is according to plan provisions.
                                   NCPDP Reject Reason Code.) This          unprocessable. Please submit a
                                   change to be effective 7-1-2010-         new claim with the complete-
                                   Claim-Service denied. At least one       correct information.
                                   Remark Code must be provided
257   Refile as an adjustment      16 - Claim-service lacks information     N29 -Missing documentation-        262 - Type of surgery-service for
      with itemized statement      which is needed for adjudication.        orders-notes-summary-report-       which anesthesia was
      attached                                                              chart.                             administered.
                                                                                                                 294 -Supporting documentation.




                                                                       Page 39
                                                    EOB Code Crosswalk to HIPAA Standard Codes


258   Adjustment referred to      133 - The disposition of this claim-      N10 - Claim-service adjusted       258 - Days-units for procedure-
      DMA for eligibility         service is pending further review.        based on the findings of a review revenue code.
      determination. Do not                                                 organization-professional consult-
      resubmit.                                                             manual adjudication-medical or
                                                                            dental advisor.
                                                                                        N185 - Alert- Do not
                                                                            resubmit this claim-service


259   Non-ionic contrast media    119 - Benefit maximum for this time    M86 - Service denied because      259 - Frequency of service.
      allowed 4 units per day.    period or occurrence has been reached. payment already made for same-
                                                                         similar procedure within set time                           612 -
                                                                         frame.                     N362 - Per Day Limit Amount
                                                                         The number of Days or Units of
                                                                         Service exceeds our acceptable
                                                                         maximum

260   Non-ionic contrast media    B15 - This service-procedure requires     N20 - Service not payable with    258 - Days-units for procedure-
      not allowed same DOS as     that a qualifying service-procedure be    other service rendered on the     revenue code.
      x-ray w-o contrast.         received and covered. The qualifying      same date.
                                  other service-procedure has not been
                                  received-adjudicated.

261   Removal and insertion of    97 - The benefit for this service is      M80 - Not covered when             454 - Procedure code for services
      Norplant system included    included in the payment-allowance for     performed during the same          rendered.
      in procedure W5133.         another service-procedure that has        session-date as a previously
                                  already been adjudicated.                 processed service for the patient.

262   Procedure includes fee for 97 - The benefit for this service is       M80 - Not covered when             454 - Procedure code for services
      removal and insertion of   included in the payment-allowance for      performed during the same          rendered.
      norplant system.           another service-procedure that has         session-date as a previously
                                 already been adjudicated.                  processed service for the patient.

263   Adjustment denied, claim    193 - Original payment decision is        N381 - Consult our contractual      101 - Claim was processed as
      paid correctly.             being maintained. This claim was          agreement for restrictions-billing- adjustment to previous claim.
                                  processed properly the first time         payment information related to                           107 -
                                                                            these charges                       Processed according to contract-
                                                                                                                plan provisions.


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                                                    EOB Code Crosswalk to HIPAA Standard Codes




264   Adjustment denied, claim     A1 - Claim-Service denied. At least one MA91 - This determination is the        101 - Claim was processed as
      denied correctly,.           Remark Code must be provided (may       result of the appeal you filed.         adjustment to previous claim.
                                   be comprised of either the Remittance
                                   Advice Remark Code or NCPDP Reject
                                   Reason Code.) This change to be
                                   effective 7-1-2010- Claim-Service
                                   denied. At least one Remark Code
                                   must be provided (may be comprised
                                   of either the NCPDP Reject Reason
                                   Code, or Remittance Advice Remark
                                   Code that is not an ALERT.)


265   Adjustment must be filed     125 - Submission-billing error(s).        N34 - Incorrect claim form-format 21 - Missing or invalid information.
      on EDS adjustment                                                      for this service.
      request form.




266   Adjustment denied,         125 - Submission-billing error(s).          MA130 - Your claim contains       21 - Missing or invalid information.
      complete all blanks on the                                             incomplete and-or invalid
      adjustment form and                                                    information, and no appeal rights
      resubmit.                                                              are afforded because the claim is   294 - Supporting documentation.
                                                                             unprocessable. Please submit a
                                                                             new claim with the complete-
                                                                             correct information.

267   Resubmit stating specific    16 - Claim-service lacks information      N1 - Alert- You may appeal this       21 - Missing or invalid information.
      reason for adjustment.       which is needed for adjudication.         decision in writing within the
                                                                             required time limits following
                                                                             receipt of this notice by following
                                                                             the instructions included in your
                                                                             contract or plan benefit
                                                                             documents




                                                                          Page 41
                                                    EOB Code Crosswalk to HIPAA Standard Codes



268   Refile adjustment with       16 - Claim-service lacks information        N1 - Alert- You may appeal this       21 - Missing or invalid information.
      DMA-5016 form and all        which is needed for adjudication.           decision in writing within the
      related RA's.                                                            required time limits following
                                                                               receipt of this notice by following
                                                                               the instructions included in your
                                                                               contract or plan benefit
                                                                               documents.
                                                                                N29 - Missing documentation-
                                                                               orders-notes-summary-report-
                                                                               chart.
269   Refile adjustment with      16 - Claim-service lacks information         M127 - Missing patient medical        101 - Claim was processed as
      medical records. Please     which is needed for adjudication.            record for this service.              adjustment to previous claim.
      resubmit with necessary                                                                                                          123 - Additional
      information along with a                                                                                       information requested from entity.
      copy of the original claims                                                                                                     421 - Medical
      RA.                                                                                                            review attachment-information for
                                                                                                                     service(s).
270   Billing provider is not      38 - Services not provided or               N52 - Patient not enrolled in the     93 - Entity is not selected primary
      recipient's Carolina         authorized by designated (network-          billing providers managed care        care provider.
      Access PCP.                  primary care) providers                     plan on the date of service.                           252 - Authorization-
      Authorization is missing                                                                                       certification number
      or unresolved. Contact
      PCP for authorization or
      EDS Prov Svcs if
      authorization is correct

271   Refile adjustment with all   148 - Information from another provider N29 - Missing documentation-         101 - Claim was processed as
      related Medicare             was not provided or was insufficient-   orders- notes- summary- report-      adjustment to previous claim.
      vouchers. Resubmit with      incomplete.                             chart.                                            123 - Additional
      necessary information                                                                                     information requested from entity.
      along with a copy of                                                                                                           285 -
      original claims RA.                                                                                       Vouchers-explanation of benefits
                                                                                                                (EOB).
272   Adjustment request           138 - Claim-service denied. Appeal          M51 - Missing-incomplete-invalid 101 - Claim was processed as
      denied, adjustments are      procedures not followed or time limits      procedure code(s).               adjustment to previous claim.
      not processed for rate       not met.
      changes.


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                                                      EOB Code Crosswalk to HIPAA Standard Codes



273   Full recoupment, per your    45 - Charge exceeds fee schedule-          MA67 - Correction to a prior       101 - Claim was processed as
      request.                     maximum allowable or contracted-           claim.                             adjustment to previous claim.
                                   legislated fee arrangement. (Use
                                   Group Codes PR or CO depending
                                   upon liability).
274   Full recoupment, resubmit 45 - Charge exceeds fee schedule-             MA67 - Correction to a prior       101 - Claim was processed as
      as new day claim.            maximum allowable or contracted-           claim.                             adjustment to previous claim.
                                   legislated fee arrangement. (Use
                                   Group Codes PR or CO depending
                                   upon liability).
275   Full recoupment, claim       45 - Charge exceeds fee schedule-          MA67 - Correction to a prior       101 - Claim was processed as
      has been resubmitted.        maximum allowable or contracted-           claim.                             adjustment to previous claim.
                                   legislated fee arrangement. (Use
                                   Group Codes PR or CO depending
                                   upon liability).
276   Full recoupment per DMA 45 - Charge exceeds fee schedule-               MA67 - Correction to a prior       101 - Claim was processed as
      memo.                        maximum allowable or contracted-           claim.                             adjustment to previous claim.
                                   legislated fee arrangement. (Use
                                   Group Codes PR or CO depending
                                   upon liability).
277   Full recoupment, paid to     45 - Charge exceeds fee schedule-          MA67 - Correction to a prior       101 - Claim was processed as
      wrong provider.              maximum allowable or contracted-           claim.                             adjustment to previous claim.
                                   legislated fee arrangement. (Use
                                   Group Codes PR or CO depending
                                   upon liability).
278   Full recoupment, paid for 45 - Charge exceeds fee schedule-             MA67 - Correction to a prior       101 - Claim was processed as
      wrong recipient.             maximum allowable or contracted-           claim.                             adjustment to previous claim.
                                   legislated fee arrangement. (Use
                                   Group Codes PR or CO depending
                                   upon liability).
279   No patient liability on elig 142 - Monthly Medicaid patient liability   N58 - Missing-incomplete-invalid   21 - Missing or invalid information.
      file.                        amount.                                    patient liability amount.
280   Full recoupment per          45 - Charge exceeds fee schedule-          MA67 - Correction to a prior       101 - Claim was processed as
      Medical or Policy review.    maximum allowable or contracted-           claim.                             adjustment to previous claim.
                                   legislated fee arrangement. (Use
                                   Group Codes PR or CO depending
                                   upon liability).



                                                                          Page 43
                                                    EOB Code Crosswalk to HIPAA Standard Codes



281   Full recoupment, duplicate 18 - Duplicate claim-service.             M86 - Service denied because      54 - Duplicate of a previously
      payment.                                                             payment already made for same- processed claim-line.
                                                                           similar procedure within set time
                                                                           frame.

282   Patient status missing or    125 - Submission-billing error(s).      MA43 - Missing-incomplete-         18 - Entity received claim-
      invalid.                                                             invalid patient status.            encounter, but returned invalid
                                                                                                              status.

                                                                                                                    21 - Missing or invalid
                                                                                                              information.

283   Service code missing or      125 - Submission-billing error(s).      M51 - Missing-incomplete-invalid 21 - Missing or invalid information.
      invalid.                                                             procedure code(s).
                                                                              N188 - The approved level of
                                                                           care does not match the
                                                                           procedure code submitted.


284   Dispensing date is before B5 - Coverage-program guidelines           No Mapping Required                107 - Processed according to
      NDC number was placed       were not met or were exceeded.                                              contract-plan provisions.
      on market by
      manufacturer.
285   Adjustment denied-          125 - Submission-billing error(s).       N58 - Missing-incomplete-invalid   21 - Missing or invalid information.
      change in patient liability                                          patient liability amount.
      should have been on claim
      before submission.



286   Incorrect authorization      165 - Payment denied -reduced for       MA130 - Your claim contains       252 - Authorization-certification
      number on claim form.        absence of, or exceeded referral        incomplete and-or invalid         number.
      Verify number and refile                                             information, and no appeal rights
      claim.                                                               are afforded because the claim is          276 - UB04-HCFA-1450-
                                                                           unprocessable. Please submit a 1500 claim form
                                                                           new claim with the complete-
                                                                           correct information.




                                                                        Page 44
                                                     EOB Code Crosswalk to HIPAA Standard Codes


287   Adjustment denied,           125 - Submission-billing error(s).         N1 - Alert - You may appeal      101 - Claim was processed as
      reference only one claim                                                this decision in writing within adjustment to previous claim.
      per form. Refile                                                        the required time limits
      adjustments separately.                                                 following receipt of this notice
                                                                              by following the instructions
                                                                              included in your contract or
                                                                              plan benefit documents.

                                                                                                N61 - Rebill
                                                                              services on separate claims.
288   Adjustment denied; DMA       148 - Information from another provider N61 - Rebill services on separate 275 - Claim
      files indicate commercial    was not provided or was insufficient-   claims.
      insurance. Refile with       incomplete.
      insurance payment-denial
      voucher.

289   Emergency authorization      197 - Precertification-authorization-      N54 - Claim information is           25 - Entity not approved.
      not valid for Carolina       notification absent.                       inconsistent with pre-certified-                      48 - Referral-
      Access recipient.                                                       authorized services.                 authorization.

290   RC code does not match       197 - Precertification-authorization-      N54 - Claim information is           21 - Missing or invalid information.
      DME prior approval           notification absent.                       inconsistent with pre-certified-
      number.                                                                 authorized services.
292   Qualified Medicare           22 - This care may be covered by           MA04 - Secondary payment             107 - Processed according to
      beneficiary-MQB recipient.   another payer per coordination of          cannot be considered without the     contract-plan provisions.
      Medicare payment must        benefits.                                  identity of or payment information                116 - Claim
      be indicated, either as                                                 from the primary payer. The          submitted to incorrect payer.
      Medicare crossover for                                                  information was either not
      DOS prior to 10-1-02 or                                                 reported or was illegible.            655 - Total Medicare Paid
      Third Party if 10-1-02 or                                                                                    Amount
      after.                                                                  N192 - Patient is a Medicaid-
                                                                              Qualified Medicare Beneficiary.

                                                                                       N381 - Consult our
                                                                              contractual agreement for
                                                                              restrictions-billing-payment
                                                                              information related to these
                                                                              charges


                                                                           Page 45
                                                     EOB Code Crosswalk to HIPAA Standard Codes
293   Only one unit of service     125 - Submission-billing error(s).         N63 - Rebill services on separate 259 - Frequency of service.
      allowed per detail, units                                               claim lines.
      changed to facilitate
      processing.



294   Resubmit prior approved      197 - Precertification-authorization-      N54 - Claim information is       187 - Date(s) of service.
      dates of service only.       notification absent.                       inconsistent with pre-certified-
                                                                              authorized services.
295   Number of miles billed is   125 - Submission-billing error(s).          M22 - Missing-incomplete-invalid 267 - Number of miles patient was
      excessive according to                                                  number of miles traveled.        transported.
      point of pick up and
      destination point listed on
      your claim. Please correct
      mileage and resubmit
      claim.
296   Your claim is being split to 101 - Predetermination: anticipated        MA15 - Alert- Your claim has       72 - Claim contains split payment.
      facilitate processing; It will payment upon completion of services      been separated to expedite
      be resubmitted for you as or claim adjudication.                        handling. You will receive a
      multiple claims. Please                                                 separate notice for the other
      watch for these claims on                                               services reported.
      future R-A‟s.                                                                             N185 - Alert-
                                                                              Do not resubmit this claim-service


297   Claim denied- Will be paid   101 - Predetermination: anticipated        N381 - Consult our contractual        3 - Claim has been adjudicated
      as a financial item on       payment upon completion of services        agreement for restrictions-billing-   and is awaiting payment cycle.
      future remittance advice.    or claim adjudication.                     payment information related to
                                                                              these charges
298   Catastrophic providers       109 - Claim not covered by this payer-     N95 - This provider type -            91 - Entity not eligible-not
      must indicate Medicare       contractor. You must send the claim to     provider specialty may not bill       approved for dates of service.
      payment for services to      the correct payer-contractor.              this service.
      catastrophic recipients,
      either as crossover if DOS
      is prior to 10-1-02 or Third
      Party if 10-1-02 or after.




                                                                           Page 46
                                                      EOB Code Crosswalk to HIPAA Standard Codes



299   Payment denied, no        150 - Payment adjusted because the      N29 - Missing documentation-            21 - Missing or invalid information.
      documentation of services payer deems the information submitted orders-notes-summary-report-
      rendered.                 does not support this level of service. chart.
                                                                                                                   294 - Supporting documentation.

300   Time billed is not             152 - Payment adjusted because the      MA130 - Your claim contains       21 - Missing or invalid information.
      substantiated by medical       payer deems the information submitted incomplete and-or invalid
      records. Time-units            does not support this length of service information, and no appeal rights
      reduced to match time                                                  are afforded because the claim is              476 - Missing or
      documented ( up to 3                                                   unprocessable. Please submit a invalid units of service
      hours).                                                                new claim with the complete-
                                                                             correct information.

301   Physician visit not allowed    B15 - This service-procedure requires    N20 - Service not payable with    258 - Days-units for procedure-
      same day as Health Check       that a qualifying service-procedure be   other service rendered on the     revenue code.
      screen by same provider        received and covered. The qualifying     same date.
      or member of same group.       other service-procedure has not been                                                        294 -
       Resubmit as an                received-adjudicated.                                                      Supporting documentation.
      adjustment with
      documentation supporting
      related services.


302   Payment reduced by             23 - The impact of prior payer(s)      N192 - Patient is a Medicaid-       107 - Processed according to
      negative Medicare              adjudication including payments and-or Qualified Medicare Beneficiary.     contract-plan provisions.
      reimbursement.                 adjustments.                           N381 - Consult our contractual
                                                                            agreement for restrictions-billing-
                                                                            payment information related to
                                                                            these charges

303   Initial reline or adjustment   119 - Benefit maximum for this time    M86 - Service denied because      259 - Frequency of service.
      of complete upper              period or occurrence has been reached. payment already made for same-
      dentures not allowed until                                            similar procedure within set time
      6 months after receipt of                                             frame.
      dentures per state limit.




                                                                          Page 47
                                                      EOB Code Crosswalk to HIPAA Standard Codes



304   Initial reline or adjustment 119 - Benefit maximum for this time        M86 - Service denied because      259 - Frequency of service.
      of partial upper dentures    period or occurrence has been reached.     payment already made for same-
      not allowed until 6 months                                              similar procedure within set time
      after receipt of dentures                                               frame.
      per state limit.


305   Panorex not allowed in         B15 - This service-procedure requires    M86 - Service denied because      258 - Days-units for procedure-
      conjunction with full          that a qualifying service-procedure be   payment already made for same- revenue code.
      mouth series.                  received and covered. The qualifying     similar procedure within set time
                                     other service-procedure has not been     frame.
                                     received-adjudicated.

306   Core build up, pin             B15 - This service-procedure requires    N20 - Service not payable with    258 - Days-units for procedure-
      retention, and composite       that a qualifying service-procedure be   other service rendered on the     revenue code.
      or amalgam buildup not         received and covered. The qualifying     same date.
      allowed on the same date       other service-procedure has not been
      of service.                    received-adjudicated.

307   Initial reline or adjustment   119 - Benefit maximum for this time    M86 - Service denied because      259 - Frequency of service.
      of complete lower              period or occurrence has been reached. payment already made for same-
      dentures not allowed until                                            similar procedure within set time
      6 months after receipt of                                             frame.
      dentures per state limit.


308   Related Service on same        B15 - This service-procedure requires    M76 - Missing-incomplete-invalid 258 - Days-units for procedure-
      day as Health Check            that a qualifying service-procedure be   diagnosis or condition.          revenue code.
      screen not supported by        received and covered. The qualifying
      diagnosis.                     other service-procedure has not been
                                     received-adjudicated.

309   Service is included in         97 - The benefit for this service is     M80 - Not covered when             454 - Procedure code for services
      CORE.                          included in the payment-allowance for    performed during the same          rendered.
                                     another service-procedure that has       session-date as a previously
                                     already been adjudicated.                processed service for the patient.




                                                                          Page 48
                                                    EOB Code Crosswalk to HIPAA Standard Codes

310   Hospital and psychiatric     B15 - This service-procedure requires    M2 - Not paid separately when     258 - Days-units for procedure-
      visits not allowed on the    that a qualifying service-procedure be   the patient is an inpatient.      revenue code.
      same date of service.        received and covered. The qualifying
                                   other service-procedure has not been
                                   received-adjudicated.

311   Initial reline or adjustment 119 - Benefit maximum for this time      M86 - Service denied because      259 - Frequency of service.
      of partial lower dentures    period or occurrence has been reached.   payment already made for same-
      not allowed until 6 months                                            similar procedure within set time
      after receipt of dentures                                             frame.
      per state limit.


312   Surgery fee includes         97 - The benefit for this service is     M80 - Not covered when             454 - Procedure code for services
      charges for casting-         included in the payment-allowance for    performed during the same          rendered.
      bracing.                     another service-procedure that has       session-date as a previously
                                   already been adjudicated.                processed service for the patient.

313   Surgery fee includes cast    97 - The benefit for this service is     M80 - Not covered when             454 - Procedure code for services
      fee.                         included in the payment-allowance for    performed during the same          rendered.
                                   another service-procedure that has       session-date as a previously
                                   already been adjudicated.                processed service for the patient.

314   Surgery fee includes cast    97 - The benefit for this service is     M80 - Not covered when             454 - Procedure code for services
      fee.                         included in the payment-allowance for    performed during the same          rendered.
                                   another service-procedure that has       session-date as a previously
                                   already been adjudicated.                processed service for the patient.

315   Surgery fee includes cast    97 - The benefit for this service is     M80 - Not covered when             454 - Procedure code for services
      fee.                         included in the payment-allowance for    performed during the same          rendered.
                                   another service-procedure that has       session-date as a previously
                                   already been adjudicated.                processed service for the patient.

316   Special services denied,    125 - Submission-billing error(s).        N188 - The approved level of      21 - Missing or invalid information.
      circumstances for use of                                              care does not match the
      this procedure-modifier                                               procedure code submitted.
      combination are not                                                     N225 - Incomplete-invalid        453 - Procedure Code
      substantiated on the claim-                                           documentation-orders-notes-       modifier(s) for service(s) rendered.
      records.                                                              summary-report-chart


                                                                        Page 49
                                                      EOB Code Crosswalk to HIPAA Standard Codes

317   File adjustment using CBC 125 - Submission-billing error(s).            MA66 - Missing-incomplete-          21 - Missing or invalid information.
      code that includes all                                                  invalid principal procedure code.
      components billed and
      combine charges.



318   Initial and or established     97 - The benefit for this service is     M80 - Not covered when               454 - Procedure code for services
      office visit included in fee   included in the payment-allowance for    performed during the same            rendered.
      for service. Resubmit as       another service-procedure that has       session-date as a previously
      an adjustment.                 already been adjudicated.                processed service for the patient.
                                                                                                              N1 -
                                                                              Alert- You may appeal this
                                                                              decision in writing within the
                                                                              required time limits following
                                                                              receipt of this notice by following
                                                                              the instructions included in your
                                                                              contract or plan benefit
                                                                              documents
319   Point of origin code           125 - Submission-billing error(s).       MA42 - Missing-incomplete-           21 - Missing or invalid information.
      submitted is missing or is                                              invalid admission source.
      not in accordance with
      medicaid policy. Rebill                                                                                        229 - Hospital admission source.
      with correct source of
      admission code. Refer to
      UB manual.
320   Psychiatric and hospital       B15 - This service-procedure requires    M2 - Not paid separately when       258 - Days-units for procedure-
      visits not allowed on the      that a qualifying service-procedure be   the patient is an inpatient.        revenue code.
      same DOS.                      received and covered. The qualifying
                                     other service-procedure has not been
                                     received-adjudicated.

321   Use 99025 if billing estab  125 - Submission-billing error(s).          MA66 - Missing-incomplete-          21 - Missing or invalid information.
      off visit or follow-up                                                  invalid principal procedure code.
      consult w an asterisk
      surgical procedure. If
      billing inpat or outpat
      consult w asterisk surgical
      procedure, submit
      adjustment.
                                                                          Page 50
                                                     EOB Code Crosswalk to HIPAA Standard Codes

322   Total ob package paid.        97 - The benefit for this service is     M80 - Not covered when             454 - Procedure code for services
      routine office visits, labs   included in the payment-allowance for    performed during the same          rendered.
      or consultations included     another service-procedure that has       session-date as a previously
      in total ob package will be   already been adjudicated.                processed service for the patient.
      recouped.

323   Hospital-office visits not    B15 - This service-procedure requires    M2 - Not paid separately when       258 - Days-units for procedure-
      allowed same date of          that a qualifying service-procedure be   the patient is an inpatient.        revenue code.
      service .                     received and covered. The qualifying
                                    other service-procedure has not been
                                    received-adjudicated.

324   Office- hospital visits not   B15 - This service-procedure requires    M2 - Not paid separately when       258 - Days-units for procedure-
      allowed same date of          that a qualifying service-procedure be   the patient is an inpatient.        revenue code.
      service .                     received and covered. The qualifying
                                    other service-procedure has not been
                                    received-adjudicated.

325   Procedure, procedure-         96 - Non-covered charge(s).              MA66 - Missing-incomplete-          454 - Procedure code for services
      modifier combination or                                                invalid principal procedure code.   rendered.
      rate not covered for this
      date of service .                                                          N188 - The approved level of
                                                                             care does not match the
                                                                             procedure code submitted
                                                                                               N301 - Missing-
                                                                             incomplete-invalid procedure
                                                                             date(s).
326   A valid date of denial must 125 - Submission-billing error(s).         MA130 - Your claim contains         21 - Missing or invalid information.
      accompany occurrence                                                   incomplete and-or invalid                                    461 -
      code 24. Correct and                                                   information, and no appeal rights   NUBC occurrence code(s) and
      resubmit as a new claim.                                               are afforded because the claim is   date(s).
                                                                             unprocessable. Please submit a
                                                                             new claim with the complete-              462 - NUBC Occurrence
                                                                             correct information.                Span Code(s) and Date(s).

327   Code multiple lab tests on 97 - The benefit for this service is        M80 - Not covered when             454 - Procedure code for services
      the same day to equivalent included in the payment-allowance for       performed during the same          rendered.
      panel code.                another service-procedure that has          session-date as a previously
                                 already been adjudicated.                   processed service for the patient.


                                                                         Page 51
                                                    EOB Code Crosswalk to HIPAA Standard Codes



328   Code multiple panel test     97 - The benefit for this service is     M80 - Not covered when             454 - Procedure code for services
      codes on same day to         included in the payment-allowance for    performed during the same          rendered.
      equivalent panel code.       another service-procedure that has       session-date as a previously
                                   already been adjudicated.                processed service for the patient.

329   Prior to 6-1-93, only one    119 - Benefit maximum for this time    M86 - Service denied because      259 - Frequency of service.
      modality is allowed per      period or occurrence has been reached. payment already made for same-
      day.                                                                similar procedure within set time
                                                                          frame.                            442 - Modalities of service.

                                                                                                                                            612
                                                                                                              - Per Day Limit Amount
330   Miscellaneous charges not B15 - This service-procedure requires       N20 - Service not payable with    258 - Days-units for procedure-
      allowed with prolonged     that a qualifying service-procedure be     other service rendered on the     revenue code.
      services of critical care. received and covered. The qualifying       same date.
                                 other service-procedure has not been
                                 received-adjudicated.

331   Prior to 6-1-93, each        B15 - This service-procedure requires    N20 - Service not payable with    258 - Days-units for procedure-
      additional physical          that a qualifying service-procedure be   other service rendered on the     revenue code.
      medicine treatment is not    received and covered. The qualifying     same date.                        442 - Modalities of service.
      allowed with modalities.     other service-procedure has not been
                                   received-adjudicated.

332   EEG-ECG-EKG recordings       97 - The benefit for this service is     M80 - Not covered when             454 - Procedure code for services
      included in circadian        included in the payment-allowance for    performed during the same          rendered.
      respiratory pattern          another service-procedure that has       session-date as a previously
      recording.                   already been adjudicated.                processed service for the patient.

333   Machine charge denied,       108 - Rent-purchase guidelines were      No Mapping Required               21 - Missing or invalid information.
      hospital owned equip.        not met.

334   Initial-established office   97 - The benefit for this service is     M80 - Not covered when             454 - Procedure code for services
      visit included in fee for    included in the payment-allowance for    performed during the same          rendered.
      service.                     another service-procedure that has       session-date as a previously
                                   already been adjudicated.                processed service for the patient.




                                                                         Page 52
                                                     EOB Code Crosswalk to HIPAA Standard Codes


335   Culdoscopy with biopsy        97 - The benefit for this service is     M80 - Not covered when             454 - Procedure code for services
      included in colposcopy        included in the payment-allowance for    performed during the same          rendered.
      with biopsy.                  another service-procedure that has       session-date as a previously
                                    already been adjudicated.                processed service for the patient.

336   Physician owned               108 - Rent-purchase guidelines were      No Mapping Required               21 - Missing or invalid information.
      equipment - machine           not met.
      charge denied.
337   Critical care and ICU         B15 - This service-procedure requires    N20 - Service not payable with    258 - Days-units for procedure-
      follow-up not allowed         that a qualifying service-procedure be   other service rendered on the     revenue code.
      same day.                     received and covered. The qualifying     same date.
                                    other service-procedure has not been
                                    received-adjudicated.

338   Biopsy of cervix included 97 - The benefit for this service is         M80 - Not covered when             454 - Procedure code for services
      in colposcopy-culdoscopy. included in the payment-allowance for        performed during the same          rendered.
                                another service-procedure that has           session-date as a previously
                                already been adjudicated.                    processed service for the patient.

339   ICU follow-up and critical B15 - This service-procedure requires       N20 - Service not payable with    258 - Days-units for procedure-
      care not allowed same day. that a qualifying service-procedure be      other service rendered on the     revenue code.
                                 received and covered. The qualifying        same date.
                                 other service-procedure has not been
                                 received-adjudicated.

340   Dilation of cervical canal-   97 - The benefit for this service is     M80 - Not covered when             454 - Procedure code for services
      dilation and curettage        included in the payment-allowance for    performed during the same          rendered.
      included in biopsy of         another service-procedure that has       session-date as a previously
      cervix, circumferential       already been adjudicated.                processed service for the patient.
      cone with or without
      dilation and curettage.

341   Health check screen not       B15 - This service-procedure requires    N20 - Service not payable with    258 - Days-units for procedure-
      allowed on same day as        that a qualifying service-procedure be   other service rendered on the     revenue code.
      related service by the        received and covered. The qualifying     same date.
      same or different health      other service-procedure has not been
      department.                   received-adjudicated.



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                                                   EOB Code Crosswalk to HIPAA Standard Codes

342   Dacryocystography           97 - The benefit for this service is    M80 - Not covered when             454 - Procedure code for services
      includes injection of       included in the payment-allowance for   performed during the same          rendered.
      contrast medium.            another service-procedure that has      session-date as a previously
                                  already been adjudicated.               processed service for the patient.

343   Colposcopy-culdoscopy     97 - The benefit for this service is      M80 - Not covered when             454 - Procedure code for services
      includes biopsy. resubmit included in the payment-allowance for     performed during the same          rendered.
      as an adjustment.         another service-procedure that has        session-date as a previously
                                already been adjudicated.                 processed service for the patient.

                                                                          N1 - Alert- You may appeal this
                                                                          decision in writing within the
                                                                          required time limits following
                                                                          receipt of this notice by following
                                                                          the instructions included in your
                                                                          contract or plan benefit
                                                                          documents
344   Use established eye exam    125 - Submission-billing error(s).      MA66 - Missing-incomplete-            21 - Missing or invalid information.
      code.                                                               invalid principal procedure code.




345   Charges for casting-        97 - The benefit for this service is    M80 - Not covered when             454 - Procedure code for services
      bracing is included in      included in the payment-allowance for   performed during the same          rendered.
      surgery fee.                another service-procedure that has      session-date as a previously
                                  already been adjudicated.               processed service for the patient.

346   Charges for cast included   97 - The benefit for this service is    M80 - Not covered when             454 - Procedure code for services
      in surgery fee.             included in the payment-allowance for   performed during the same          rendered.
                                  another service-procedure that has      session-date as a previously
                                  already been adjudicated.               processed service for the patient.

347   Charges for cast included   97 - The benefit for this service is    M80 - Not covered when             454 - Procedure code for services
      in surgery fee.             included in the payment-allowance for   performed during the same          rendered.
                                  another service-procedure that has      session-date as a previously
                                  already been adjudicated.               processed service for the patient.



                                                                       Page 54
                                                     EOB Code Crosswalk to HIPAA Standard Codes




348   Charges for cast included     97 - The benefit for this service is     M80 - Not covered when             454 - Procedure code for services
      in surgery fee.               included in the payment-allowance for    performed during the same          rendered.
                                    another service-procedure that has       session-date as a previously
                                    already been adjudicated.                processed service for the patient.

349   Health check screen and       B15 - This service-procedure requires    M51 - Missing-incomplete-invalid 258 - Days-units for procedure-
      related service not allowed   that a qualifying service-procedure be   procedure code(s).               revenue code.
      same day, same provider       received and covered. The qualifying
      or member of same group.      other service-procedure has not been       N20 - Service not payable with
       Resubmit as an               received-adjudicated.                    other service rendered on the
      adjustment with                                                        same date.
      documentation supporting
      related services.


350   Daily and -or weekly          18 - Duplicate claim-service.            M86 - Service denied because      54 - Duplicate of a previously
      cobalt therapy cannot be                                               payment already made for same- processed claim-line.
      billed in duplicate.                                                   similar procedure within set time
                                                                             frame.

351   Prophylaxis w-fluoride fee    97 - The benefit for this service is     M80 - Not covered when             454 - Procedure code for services
      includes prophylaxis          included in the payment-allowance for    performed during the same          rendered.
      charges.                      another service-procedure that has       session-date as a previously
                                    already been adjudicated.                processed service for the patient.

352   Chemonucleolysis and          119 - Benefit maximum for this time    M86 - Service denied because      259 - Frequency of service.
      laminectomy cannot be         period or occurrence has been reached. payment already made for same-
      billed within one year of                                            similar procedure within set time
      each other.                                                          frame.                     N357 -
                                                                           Time frame requirements
                                                                           between this service-procedure-
                                                                           supply and a related service-
                                                                           procedure-supply have not been
                                                                           met.




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                                                     EOB Code Crosswalk to HIPAA Standard Codes




353   Antepartum, package can       97 - The benefit for this service is    M80 - Not covered when              259 - Frequency of service.
      be billed only once in 300    included in the payment-allowance for   performed during the same                               454 -
      days prior to delivery.       another service-procedure that has      session-date as a previously       Procedure code for services
      Laboratory work is            already been adjudicated.               processed service for the patient. rendered.
      included in package fee.


354   Home photo therapy unit       119 - Benefit maximum for this time    M86 - Service denied because       259 - Frequency of service.
      allowed once weekly.          period or occurrence has been reached. payment already made for same-
                                                                           similar procedure within set time
                                                                           frame.                      N362 -
                                                                            The number of Days or Units of
                                                                           Service exceeds our acceptable
                                                                           maximum

355   Prolonged services and       B15 - This service-procedure requires    N20 - Service not payable with     258 - Days-units for procedure-
      crit care not allowed with that a qualifying service-procedure be     other service rendered on the      revenue code.
      daily care or misc charges . received and covered. The qualifying     same date.
                                   other service-procedure has not been
                                   received-adjudicated.

356   Mapped attending              A1 - Claim-Service denied. At least one N253 - Missing-incomplete-         91 - Entity not eligible-not
      provider ID is not eligible   Remark Code must be provided (may       invalid attending provider primary approved for dates of service.
      on service date               be comprised of either the Remittance identifier.                            562 - Entitys National Provider
                                    Advice Remark Code or NCPDP Reject                                         Identifier (NPI)
                                    Reason Code.) This change to be
                                    effective 7-1-2010- Claim-Service
                                    denied. At least one Remark Code
                                    must be provided (may be comprised
                                    of either the NCPDP Reject Reason
                                    Code, or Remittance Advice Remark
                                    Code that is not an ALERT.)




                                                                         Page 56
                                                   EOB Code Crosswalk to HIPAA Standard Codes


357   Maternity charge allowed    119 - Benefit maximum for this time    M86 - Service denied because       259 - Frequency of service.
      only once per gestation     period or occurrence has been reached. payment already made for same-
      period. Resubmit as an                                             similar procedure within set time
      adjustment with medical                                            frame.
      records to support                                                 N435 - Exceeds number-
      multiple/reoccurring                                               frequency approved -allowed
      gestation                                                          within time period without support
                                                                         documentation.

358   Only one nail debridement 119 - Benefit maximum for this time    M86 - Service denied because       259 - Frequency of service.
      allowed-60 day period.    period or occurrence has been reached. payment already made for same-
                                                                       similar procedure within set time
                                                                       frame
359   Individual components     97 - The benefit for this service is   M80 - Not covered when             454 - Procedure code for services
      recouped. Hematology      included in the payment-allowance for performed during the same           rendered.
      panel that includes       another service-procedure that has     session-date as a previously
      components already paid. already been adjudicated.               processed service for the patient.


360   Carbon dioxide              97 - The benefit for this service is     M80 - Not covered when             454 - Procedure code for services
      determination included in   included in the payment-allowance for    performed during the same          rendered.
      fee for service.            another service-procedure that has       session-date as a previously
                                  already been adjudicated.                processed service for the patient.

361   Labs included in adult      97 - The benefit for this service is     M80 - Not covered when             454 - Procedure code for services
      health screening.           included in the payment-allowance for    performed during the same          rendered.
                                  another service-procedure that has       session-date as a previously
                                  already been adjudicated.                processed service for the patient.

362   Bitewings already billed    119 - Benefit maximum for this time      M86 - Service denied because      259 - Frequency of service.
      within 364 days not as      period has been reached.                 payment already made for same-             483 - Maximum coverage
      components of a full                                                 similar procedure within set time amount met or exceeded for
      mouth survey.                                                        frame.                            benefit period.
                                                                             N59 - Alert- Please refer to
                                                                           your provider manual for
                                                                           additional program and provider
                                                                           information



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                                                    EOB Code Crosswalk to HIPAA Standard Codes

363   Not in accordance with       B5 - Coverage-program guidelines         No Mapping Required               21 - Missing or invalid information.
      medical policy guidelines.   were not met or were exceeded.

364   Not in accordance with       B5 - Coverage-program guidelines         No Mapping Required               21 - Missing or invalid information.
      medical policy guidelines.   were not met or were exceeded.

365   Office visit and-or        97 - The benefit for this service is       M80 - Not covered when             454 - Procedure code for services
      consultations are included included in the payment-allowance for      performed during the same          rendered.
      in eye exam.               another service-procedure that has         session-date as a previously
                                 already been adjudicated.                  processed service for the patient.

366   Delivery (with or without    97 - The benefit for this service is     M80 - Not covered when             454 - Procedure code for services
      postpartum care) is          included in the payment-allowance for    performed during the same          rendered.
      included in total ob         another service-procedure that has       session-date as a previously
      package.                     already been adjudicated.                processed service for the patient.

367   Semen analysis included      97 - The benefit for this service is     M80 - Not covered when             454 - Procedure code for services
      in fee for sterilization.    included in the payment-allowance for    performed during the same          rendered.
                                   another service-procedure that has       session-date as a previously
                                   already been adjudicated.                processed service for the patient.

368   Multiple consultations not   B15 - This service-procedure requires    N20 - Service not payable with    258 - Days-units for procedure-
      allowed same DOS, same       that a qualifying service-procedure be   other service rendered on the     revenue code.
      provider specialty.          received and covered. The qualifying     same date.
                                   other service-procedure has not been
                                   received-adjudicated.

369   Multiple office visits not   B15 - This service-procedure requires    N20 - Service not payable with    258 - Days-units for procedure-
      allowed same DOS, same       that a qualifying service-procedure be   other service rendered on the     revenue code.
      provider specialty.          received and covered. The qualifying     same date.
                                   other service-procedure has not been
                                   received-adjudicated.

370   Multiple hospital visits not B15 - This service-procedure requires    N20 - Service not payable with    258 - Days-units for procedure-
      allowed same DOS, same that a qualifying service-procedure be         other service rendered on the     revenue code.
      provider specialty.          received and covered. The qualifying     same date.
                                   other service-procedure has not been
                                   received-adjudicated.



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                                                    EOB Code Crosswalk to HIPAA Standard Codes



371   Supplies are included in     97 - The benefit for this service is     M80 - Not covered when             454 - Procedure code for services
      fee for surgery.             included in the payment-allowance for    performed during the same          rendered.
                                   another service-procedure that has       session-date as a previously
                                   already been adjudicated.                processed service for the patient.

372   One supply allowed per       119 - Benefit maximum for this time    M86 - Service denied because      259 - Frequency of service.
      date of service.             period or occurrence has been reached. payment already made for same-
                                                                          similar procedure within set time                             612 -
                                                                          frame.                            Per Day Limit Amount

373   Consults and hospital        B15 - This service-procedure requires    M2 - Not paid separately when     258 - Days-units for procedure-
      visits not allowed same      that a qualifying service-procedure be   the patient is an inpatient.      revenue code.
      DOS, same provider           received and covered. The qualifying
      specialty.                   other service-procedure has not been
                                   received-adjudicated.

374   Consults and office visits   B15 - This service-procedure requires    N20 - Service not payable with    258 - Days-units for procedure-
      not allowed same DOS,        that a qualifying service-procedure be   other service rendered on the     revenue code.
      same provider specialty.     received and covered. The qualifying     same date.
                                   other service-procedure has not been
                                   received-adjudicated.

375   Exploratory laparotomy       97 - The benefit for this service is     M80 - Not covered when             454 - Procedure code for services
      included in fee for surgery. included in the payment-allowance for    performed during the same          rendered.
                                   another service-procedure that has       session-date as a previously
                                   already been adjudicated.                processed service for the patient.

376   Routine labs are included    97 - The benefit for this service is     M80 - Not covered when             454 - Procedure code for services
      in dialysis fees.            included in the payment-allowance for    performed during the same          rendered.
                                   another service-procedure that has       session-date as a previously
                                   already been adjudicated.                processed service for the patient.

377   Routine labs included in     97 - The benefit for this service is     M80 - Not covered when             454 - Procedure code for services
      dialysis fees.               included in the payment-allowance for    performed during the same          rendered.
                                   another service-procedure that has       session-date as a previously
                                   already been adjudicated.                processed service for the patient.




                                                                        Page 59
                                                    EOB Code Crosswalk to HIPAA Standard Codes

378   Professional monthly fee    B15 - This service-procedure requires       M86 - Service denied because      258 - Days-units for procedure-
      not allowed with retraining that a qualifying service-procedure be      payment already made for same- revenue code.
      fee.                        received and covered. The qualifying        similar procedure within set time
                                  other service-procedure has not been        frame.
                                  received-adjudicated.

379   History shows total ob       97 - The benefit for this service is       M80 - Not covered when             454 - Procedure code for services
      package billed which         included in the payment-allowance for      performed during the same          rendered.
      includes labs consulations   another service-procedure that has         session-date as a previously
      and office visits.           already been adjudicated.                  processed service for the patient.

380   Supplies not allowed with    B15 - This service-procedure requires      N20 - Service not payable with       258 - Days-units for procedure-
      Health Check fee.            that a qualifying service-procedure be     other service rendered on the        revenue code.
                                   received and covered. The qualifying       same date.
                                   other service-procedure has not been
                                   received-adjudicated.

381   Health Check                 B15 - This service-procedure requires      M86 - Service denied because      258 - Days-units for procedure-
      reimbursement not            that a qualifying service-procedure be     payment already made for same- revenue code.
      allowed on same day of       received and covered. The qualifying       similar procedure within set time
      service as supplies paid     other service-procedure has not been       frame.
      previously.                  received-adjudicated.

382   Operative records            125 - Submission-billing error(s). At      MA130 - Your claim contains       21 - Missing or invalid information.
      received have no DOS-or      least one Remark Code must be              incomplete and-or invalid                                 187 -
      conflicting DOS, correct     provided (may be comprised of either       information, and no appeal rights Date(s) of service.
      claim/records and            the Remittance Advice Remark Code          are afforded because the claim is    298 - Operative report.
      resubmit both as an          or NCPDP Reject Reason Code.)              unprocessable. Please submit a
      adjustment                                                              new claim with the complete-
                                                                              correct information.

383   Salpingo-oophorectomy        97 - The benefit for this service is       M80 - Not covered when               287 - Medical necessity for
      included in hysterectomy     included in the payment-allowance for      performed during the same            service.
      code. Resubmit as an         another service-procedure that has         session-date as a previously          294 - Supporting documentation.
      adjustment with              already been adjudicated.                  processed service for the patient.   454 - Procedure code for services
      appropriate medical                                                                                          rendered.
      records




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                                                    EOB Code Crosswalk to HIPAA Standard Codes




384   Circadian respiratory         97 - The benefit for this service is    M80 - Not covered when             454 - Procedure code for services
      pattern includes EEG,         included in the payment-allowance for   performed during the same          rendered.
      ECG, and EKG recording.       another service-procedure that has      session-date as a previously
      Resubmit as an                already been adjudicated.               processed service for the patient.
      adjustment.
385   I&D included in               97 - The benefit for this service is    M80 - Not covered when             454 - Procedure code for services
      appendectomy.                 included in the payment-allowance for   performed during the same          rendered.
                                    another service-procedure that has      session-date as a previously
                                    already been adjudicated.               processed service for the patient.

386   Office visit-consult already 18 - Duplicate claim-service.            M86 - Service denied because      54 - Duplicate of a previously
      paid in history. Resubmit                                             payment already made for same- processed claim-line.
      as an adjustment.                                                     similar procedure within set time
                                                                            frame.

387   Daily and-or weekly cobalt 18 - Duplicate claim-service.              M86 - Service denied because      54 - Duplicate of a previously
      therapy cannot be billed in                                           payment already made for same- processed claim-line.
      duplicate.                                                            similar procedure within set time
                                                                            frame.

388   Periodontal scaling and       97 - The benefit for this service is    M80 - Not covered when             454 - Procedure code for services
      root planning, full month     included in the payment-allowance for   performed during the same          rendered.
      debridement to enable         another service-procedure that has      session-date as a previously
      comprehensive                 already been adjudicated.               processed service for the patient.
      periodontal eval & DX &
      periodontal maintenance
      included in fee for
      periodontal surgery.




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                                                    EOB Code Crosswalk to HIPAA Standard Codes


389   Adult health screening     97 - The benefit for this service is       M80 - Not covered when             454 - Procedure code for services
      includes labs, resubmit as included in the payment-allowance for      performed during the same          rendered.
      an adjustment.             another service-procedure that has         session-date as a previously
                                 already been adjudicated.                  processed service for the patient.

                                                                              N1 - Alert - You may appeal
                                                                            this decision in writing within the
                                                                            required time limits following
                                                                            receipt of this notice by following
                                                                            the instructions included in your
                                                                            contract or plan benefit
                                                                            documents
390   Hospital visits and          B15 - This service-procedure requires    M2 - Not paid separately when         258 - Days-units for procedure-
      consults not allowed same    that a qualifying service-procedure be   the patient is an inpatient.          revenue code.
      DOS, same provider           received and covered. The qualifying
      specialty.                   other service-procedure has not been
                                   received-adjudicated.

391   Fetal monitoring denied,     18 - Duplicate claim-service.            M86 - Service denied because      54 - Duplicate of a previously
      reimbursement has been                                                payment already made for same- processed claim-line.
      made to hospital.                                                     similar procedure within set time
                                                                            frame.

392   Evaluation not allowed       B15 - This service-procedure requires    M2 - Not paid separately when         258 - Days-units for procedure-
      same day as diagnostic       that a qualifying service-procedure be   the patient is an inpatient.          revenue code.
      assessment detox initial     received and covered. The qualifying
      evaluation hosp.             other service-procedure has not been
      Admission WAIS bender.       received-adjudicated.


393   Dacyacystography             97 - The benefit for this service is     M80 - Not covered when             454 - Procedure code for services
      includes injection of        included in the payment-allowance for    performed during the same          rendered.
      contrast medium resubmit     another service-procedure that has       session-date as a previously
      as an adjustment.            already been adjudicated.                processed service for the patient.

394   Not in accordance with       B5 - Coverage-program guidelines         No Mapping Required                   258 - Days-units for procedure-
      medical policy guidelines.   were not met or were exceeded.                                                 revenue code.



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                                                     EOB Code Crosswalk to HIPAA Standard Codes




395   Delivery of placenta,         97 - The benefit for this service is     M80 - Not covered when             454 - Procedure code for services
      external cephalic version ,   included in the payment-allowance for    performed during the same          rendered.
      or special miscellaneous      another service-procedure that has       session-date as a previously
      services are included in      already been adjudicated.                processed service for the patient.
      the fee for delivery.

396   Carbon dioxide                97 - The benefit for this service is     M80 - Not covered when             454 - Procedure code for services
      determination included in     included in the payment-allowance for    performed during the same          rendered.
      fee for service.              another service-procedure that has       session-date as a previously
                                    already been adjudicated.                processed service for the patient.

397   Dilation and curettage        97 - The benefit for this service is     M80 - Not covered when           454 - Procedure code for services
      included in biopsy of         included in the payment-allowance for    performed during the same        rendered.
      cervix, circumferential       another service-procedure that has       session-date as a previously
      cone with or without D&C.     already been adjudicated.                processed service for the
      Resubmit as an                                                         patient.
      adjustment.                                                                     N1 - Alert- You may
                                                                             appeal this decision in writing
                                                                             within the required time limits
                                                                             following receipt of this notice
                                                                             by following the instructions
                                                                             included in your contract or
                                                                             plan benefit documents


398   Immunizations covered         6 - The procedure-revenue code is        No Mapping Required               91 - Entity not eligible-not
      only in health check for      inconsistent with the patients age.                                        approved for dates of service.
      recipients under 21.

399   Office visits and consults    B15 - This service-procedure requires    N20 - Service not payable with    258 - Days-units for procedure-
      not allowed same DOS          that a qualifying service-procedure be   other service rendered on the     revenue code.
      same provider specialty.      received and covered. The qualifying     same date.
                                    other service-procedure has not been
                                    received-adjudicated.




                                                                          Page 63
                                                    EOB Code Crosswalk to HIPAA Standard Codes



400   Admission- medical visits-   B15 - This service-procedure requires    N20 - Service not payable with   258 - Days-units for procedure-
      observation unit not         that a qualifying service-procedure be   other service rendered on the    revenue code.
      allowed same date of         received and covered. The qualifying     same date.
      service.                     other service-procedure has not been
                                   received-adjudicated.

401   Medical visits-              B15 - This service-procedure requires    N20 - Service not payable with   258 - Days-units for procedure-
      observation unit not         that a qualifying service-procedure be   other service rendered on the    revenue code.
      allowed same date of         received and covered. The qualifying     same date.
      service.                     other service-procedure has not been
                                   received-adjudicated.

402   Observation unit- medical    B15 - This service-procedure requires    N20 - Service not payable with   258 - Days-units for procedure-
      visits not allowed same      that a qualifying service-procedure be   other service rendered on the    revenue code.
      date of service.             received and covered. The qualifying     same date.
                                   other service-procedure has not been
                                   received-adjudicated.

403   Medical visits- admission    B15 - This service-procedure requires    N20 - Service not payable with   258 - Days-units for procedure-
      not allowed same day as      that a qualifying service-procedure be   other service rendered on the    revenue code.
      initial observation.         received and covered. The qualifying     same date.
                                   other service-procedure has not been
                                   received-adjudicated.

404   Personal care service not B15 - This service-procedure requires       N20 - Service not payable with   258 - Days-units for procedure-
      allowed same day as        that a qualifying service-procedure be     other service rendered on the    revenue code.
      Home Health aide services. received and covered. The qualifying       same date.
                                 other service-procedure has not been
                                 received-adjudicated.

405   Home health aide services B15 - This service-procedure requires       N20 - Service not payable with   258 - Days-units for procedure-
      not allowed same day as   that a qualifying service-procedure be      other service rendered on the    revenue code.
      personal care service.    received and covered. The qualifying        same date.
                                other service-procedure has not been
                                received-adjudicated.




                                                                        Page 64
                                                    EOB Code Crosswalk to HIPAA Standard Codes


406   Initial hospital care not    B15 - This service-procedure requires    N20 - Service not payable with    258 - Days-units for procedure-
      allowed same DOS as          that a qualifying service-procedure be   other service rendered on the     revenue code.
      dental exam.                 received and covered. The qualifying     same date.
                                   other service-procedure has not been
                                   received-adjudicated.

407   Medical visits- epidural     B15 - This service-procedure requires    N20 - Service not payable with    258 - Days-units for procedure-
      follow-up not allowed on     that a qualifying service-procedure be   other service rendered on the     revenue code.
      the same DOS.                received and covered. The qualifying     same date.
                                   other service-procedure has not been
                                   received-adjudicated.

408   Follow up for both eyes    18 - Duplicate claim-service.              M86 - Service denied because      54 - Duplicate of a previously
      has been billed, Y5575 not                                            payment already made for same- processed claim-line.
      allowed.                                                              similar procedure within set time
                                                                            frame.

409   Epidural follow-up-          B15 - This service-procedure requires    N20 - Service not payable with    258 - Days-units for procedure-
      medical visits not allowed   that a qualifying service-procedure be   other service rendered on the     revenue code.
      on the same date of          received and covered. The qualifying     same date.
      service.                     other service-procedure has not been
                                   received-adjudicated.

410   Panel partially paid on      97 - The benefit for this service is     M86 - Service denied because      454 - Procedure code for services
      previous claim or detail.    included in the payment-allowance for    payment already made for same- rendered.
                                   another service-procedure that has       similar procedure within set time
                                   already been adjudicated.                frame.

411   Panel partially paid on      97 - The benefit for this service is     M80 - Not covered when             454 - Procedure code for services
      previous claim detail.       included in the payment-allowance for    performed during the same          rendered.
                                   another service-procedure that has       session-date as a previously
                                   already been adjudicated.                processed service for the patient.

412   Blood gases included in      97 - The benefit for this service is     M80 - Not covered when             454 - Procedure code for services
      fee for service.             included in the payment-allowance for    performed during the same          rendered.
                                   another service-procedure that has       session-date as a previously
                                   already been adjudicated.                processed service for the patient.



                                                                        Page 65
                                                      EOB Code Crosswalk to HIPAA Standard Codes



413   Blood gases included in        97 - The benefit for this service is     M80 - Not covered when             454 - Procedure code for services
      fee for service.               included in the payment-allowance for    performed during the same          rendered.
                                     another service-procedure that has       session-date as a previously
                                     already been adjudicated.                processed service for the patient.

414   Routine-continuous home        B15 - This service-procedure requires    N20 - Service not payable with    258 - Days-units for procedure-
      care inpatient respite care-   that a qualifying service-procedure be   other service rendered on the     revenue code.
      general inpatient care not     received and covered. The qualifying     same date.
      allowed same date of           other service-procedure has not been
      service .                      received-adjudicated.

415   Continuous home care-          B15 - This service-procedure requires    N20 - Service not payable with    258 - Days-units for procedure-
      inpatient respite care-        that a qualifying service-procedure be   other service rendered on the     revenue code.
      general inpatient care not     received and covered. The qualifying     same date.
      allowed same date of           other service-procedure has not been
      service .                      received-adjudicated.

416   Routine home care-             B15 - This service-procedure requires    N20 - Service not payable with    258 - Days-units for procedure-
      general respite care-          that a qualifying service-procedure be   other service rendered on the     revenue code.
      general inpatient care         received and covered. The qualifying     same date.
      cannot be billed on same       other service-procedure has not been
      date of service as             received-adjudicated.
      continuous home care.

417   Routine home care-             B15 - This service-procedure requires    M2 - Not paid separately when     258 - Days-units for procedure-
      inpatient respite care-        that a qualifying service-procedure be   the patient is an inpatient.      revenue code.
      general inpatient care not     received and covered. The qualifying
      allowed same date of           other service-procedure has not been
      service as continuous          received-adjudicated.
      home care.
418   General inpatient care not     B15 - This service-procedure requires    M2 - Not paid separately when     258 - Days-units for procedure-
      allowed same day as            that a qualifying service-procedure be   the patient is an inpatient.      revenue code.
      routine home care-             received and covered. The qualifying
      continuous home care-          other service-procedure has not been
      inpatient respite care-        received-adjudicated.
      hospice- LTC.



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419   Routine home care-           B15 - This service-procedure requires      N20 - Service not payable with     258 - Days-units for procedure-
      continuous home care-        that a qualifying service-procedure be     other service rendered on the      revenue code.
      general inpatient care-      received and covered. The qualifying       same date.
      hospice-LTC not allowed      other service-procedure has not been
      same day as inpatient        received-adjudicated.
      respite care.
420   Routine home care-           B15 - This service-procedure requires      N20 - Service not payable with     258 - Days-units for procedure-
      continuous home care-        that a qualifying service-procedure be     other service rendered on the      revenue code.
      inpatient respite care-      received and covered. The qualifying       same date.
      hospice- LTC not allowed     other service-procedure has not been
      same day as general inp      received-adjudicated.
      care.
421   Inpatient respite care not   B15 - This service-procedure requires      N20 - Service not payable with     258 - Days-units for procedure-
      allowed same day as          that a qualifying service-procedure be     other service rendered on the      revenue code.
      routine home care-           received and covered. The qualifying       same date.
      continuous home care-        other service-procedure has not been
      general inpatient care-      received-adjudicated.
      hospice- LTC.
422   Only one routine home        119 - Benefit maximum for this time    M86 - Service denied because      259 - Frequency of service.
      care allowed per day.        period or occurrence has been reached. payment already made for same-
                                                                          similar procedure within set time                             612 -
                                                                          frame.                            Per Day Limit Amount

423   Only one inpatient general 119 - Benefit maximum for this time    M86 - Service denied because      259 - Frequency of service.
      care allowed per day.      period or occurrence has been reached. payment already made for same-
                                                                        similar procedure within set time                             612 -
                                                                        frame.                            Per Day Limit Amount

424   Date of service on claim     125 - Submission-billing error(s). At      N3 - Missing consent form          187 - Date(s) of service.
      and consent form differ.     least one Remark Code must be                                                  21 - Missing or invalid information.
      Correct and resubmit as      provided (may be comprised of either                                          Note- At least one other status
      adjustment with claim and    the Remittance Advice Remark Code                                             code is required to identify the
      consent attached.            or NCPDP Reject Reason Code.)                                                 missing or invalid information.

425   Illegible consent form       16 - Claim-service lacks information       N3 - Missing consent form.          123 - Additional information
      received, resubmit legible   which is needed for adjudication.                         N205 -               requested from entity.
      consent form                                                            Information provided was illegible.



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                                                     EOB Code Crosswalk to HIPAA Standard Codes



427   Physicians initials are not   16 - Claim-service lacks information      MA70 - Missing-incomplete-        21 - Missing or invalid information.
      acceptable on the             which is needed for adjudication.         invalid provider representative                  466 - Entities original
      sterilization consent form                                              signature                         signature.                       467 -
      and-or the physicians full                                                                     MA71 -      Entity signature date.
      signature must be dated                                                 Missing-incomplete-invalid
      on the date of surgery or                                               provider representative signature
      after.                                                                  date.

428   Admission type 2-urgent       125 - Submission-billing error(s).        MA41 - Missing-incomplete-         21 - Missing or invalid information.
      not acceptable for                                                      invalid admission type.
      inpatient    psychiatric
      admission.



429   Screening not allowed         B15 - This service-procedure requires     N20 - Service not payable with     258 - Days-units for procedure-
      same day as diagnostic        that a qualifying service-procedure be    other service rendered on the      revenue code.
      assessment, detox initial     received and covered. The qualifying      same date.
      evaluation, hosp              other service-procedure has not been
      admission wais bender.        received-adjudicated.


430   Claim referred to the       133 - The disposition of this claim-        N185 - Alert- Do not resubmit      421 - Medical review attachment-
      division of medical         service is pending further review.          this claim-service                 information for service(s)
      assistance for processing
      information. The claim will
      be resubmitted for you.


431   Outpatient Treatment not      B15 - This service-procedure requires     M2 - Not paid separately when      258 - Days-units for procedure-
      allowed same day as           that a qualifying service-procedure be    the patient is an inpatient.       revenue code.
      therapy, crisis               received and covered. The qualifying
      management, medication        other service-procedure has not been
      administration or hospital    received-adjudicated.
      visits.




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                                                      EOB Code Crosswalk to HIPAA Standard Codes


432   Health check screening        B15 - This service-procedure requires    N20 - Service not payable with     258 - Days-units for procedure-
      not allowed on the same       that a qualifying service-procedure be   other service rendered on the      revenue code.
      day as vision and hearing     received and covered. The qualifying     same date.
      screenings.                   other service-procedure has not been
                                    received-adjudicated.

433   Vision-hearing screen not B15 - This service-procedure requires        N20 - Service not payable with     258 - Days-units for procedure-
      allowed on the same day    that a qualifying service-procedure be      other service rendered on the      revenue code.
      as Health Check screening. received and covered. The qualifying        same date.
                                 other service-procedure has not been
                                 received-adjudicated.

434   Components of code            97 - The benefit for this service is     M80 - Not covered when             454 - Procedure code for services
      52285 have been billed        included in the payment-allowance for    performed during the same          rendered.
      and paid separately-file      another service-procedure that has       session-date as a previously
      adjustment if necessary.      already been adjudicated.                processed service for the patient.


435   Combine codes-charges         125 - Submission-billing error(s).       MA66 - Missing-incomplete-         21 - Missing or invalid information.
      and bill to the all inclusive                                          invalid principal procedure code
      code 52285.                                                            or date.




436   SAIOP is not allowed same     A1 - Claim-Service denied. At least one N20 - Service not payable with      259 - Frequency of service
      date of service as partial    Remark Code must be provided (may       other service rendered on the
      hospitalization and-or day    be comprised of either the Remittance same date.
      treatment                     Advice Remark Code or NCPDP Reject
                                    Reason Code.) This change to be
                                    effective 7-1-2010- Claim-Service
                                    denied. At least one Remark Code
                                    must be provided (may be comprised
                                    of either the NCPDP Reject Reason
                                    Code, or Remittance Advice Remark
                                    Code that is not an ALERT.)




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                                                    EOB Code Crosswalk to HIPAA Standard Codes


437   90742 and related            B15 - This service-procedure requires     N20 - Service not payable with       258 - Days-units for procedure-
      vaccines ( hibg, rig, tig,   that a qualifying service-procedure be    other service rendered on the        revenue code.
      vzig ) are not allowed on    received and covered. The qualifying      same date.
      the same date of service.    other service-procedure has not been
                                   received-adjudicated.

438   The date associated with  22 - This care may be covered by             MA04 - Secondary payment             85 - Entity not primary.
      occurrence code indicates another payer per coordination of            cannot be considered without the     116 - Claim submitted to
      this claim must be        benefits.                                    identity of or payment information   incorrect payer.
      submitted to primary                                                   from the primary payer. The                461 - NUBC occurrence
      payer.                                                                 information was either not           code(s) and date(s).
                                                                             reported or was illegible.

439   Information on value code- 125 - Submission-billing error(s).          M49 - Missing-incomplete-invalid 21 - Missing or invalid information.
      value amount is missing                                                value code(s) or amount(s).
      or incomplete. Rebill with
      complete value code data.                                                                                  123 - Additional information
      Refer to UB manual.                                                                                      requested from entity.
                                                                                                                     463 - NUBC value code(s)
                                                                                                               and-or amount(s).
440   Suspect dupe-exact           18 - Duplicate claim-service.             M86 - Service denied because      54 - Duplicate of a previously
      service dated 4 digit                                                  payment already made for same- processed claim-line.
      procedure, prof. sys plug.                                             similar procedure within set time
                                                                             frame.

441   Suspect dupe-exact           18 - Duplicate claim-service.             M86 - Service denied because      54 - Duplicate of a previously
      service date, billed                                                   payment already made for same- processed claim-line.
      amount inst sys plug.                                                  similar procedure within set time
                                                                             frame.

442   Out patient charges are      97 - The benefit for this service is      M80 - Not covered when             454 - Procedure code for services
      included in inpatient        included in the payment-allowance for     performed during the same          rendered.
      reimbursement.               another service-procedure that has        session-date as a previously
                                   already been adjudicated.                 processed service for the patient.

443   Inpatient claim paid,        16 - Claim-service lacks information      M2 - Not paid separately when        258 - Days-units for procedure-
      previously paid outpatient   which is needed for adjudication.         the patient is an inpatient.         revenue code.
      claim will be recouped.



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                                                     EOB Code Crosswalk to HIPAA Standard Codes



444   Medical screening exam        B15 - This service-procedure requires    M2 - Not paid separately when      258 - Days-units for procedure-
      fee denied due to inpatient   that a qualifying service-procedure be   the patient is an inpatient.       revenue code.
      claim paid in history for     received and covered. The qualifying
      the same date of service.     other service-procedure has not been                             M86 -
                                    received-adjudicated.                    Service denied because payment
                                                                             already made for same-similar
                                                                             procedure within set time frame.

445   HIT services not allowed      B15 - This service-procedure requires    M2 - Not paid separately when      258 - Days-units for procedure-
      same day as inpatient         that a qualifying service-procedure be   the patient is an inpatient.       revenue code.
      service.                      received and covered. The qualifying
                                    other service-procedure has not been
                                    received-adjudicated.

446   Suspect duplicate-            18 - Duplicate claim-service.            M86 - Service denied because      54 - Duplicate of a previously
      overlapping DOS-same                                                   payment already made for same- processed claim-line.
      proc. code-prof.                                                       similar procedure within set time
                                                                             frame.

447   Inpatient claim paid;      169 - Payment adjusted because an           M2 - Not paid separately when      258 - Days-units for procedure-
      previously paid medical    alternate benefit has been provided         the patient is an inpatient.       revenue code.
      screening exam fee will be
      recouped.

448   Inpatient services paid;      169 - Payment adjusted because an        M2 - Not paid separately when      258 - Days-units for procedure-
      previously paid HIT           alternate benefit has been provided      the patient is an inpatient.       revenue code.
      services will be recouped.

449   HIV Case Management           97 - The benefit for this service is     M2 - Not paid separately when      454 - Procedure code for services
      denied due to inpatient       included in the payment-allowance for    the patient is an inpatient.       rendered.
      claim paid with same date     another service-procedure that has
      of service. Case              already been adjudicated.
      management fee is
      included in the hospital
      inpatient per diem.




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                                                    EOB Code Crosswalk to HIPAA Standard Codes

450   Less severe dupe prof sys 18 - Duplicate claim-service.               M86 - Service denied because      54 - Duplicate of a previously
      plug.                                                                 payment already made for same- processed claim-line.
                                                                            similar procedure within set time
                                                                            frame.

451   Less severe dupe same        18 - Duplicate claim-service.            M86 - Service denied because      54 - Duplicate of a previously
      hour prof sys plug.                                                   payment already made for same- processed claim-line.
                                                                            similar procedure within set time
                                                                            frame.

452   Nursing home claim          152 - Payment adjusted because the      M2 - Not paid separately when        21 - Missing or invalid information.
      denied. Patient was         payer deems the information submitted the patient is an inpatient.
      inpatient for some of these does not support this length of service
      date of service. Rebill for                                                                                56 - Awaiting eligibility
      covered days only.                                                                                       determination.
      Correct and resubmit as a
      new claim.

453   Less severe dupe same       18 - Duplicate claim-service.             M86 - Service denied because      54 - Duplicate of a previously
      provider 4 digit procedure,                                           payment already made for same- processed claim-line.
      same service date, prof                                               similar procedure within set time
      sys plug.                                                             frame.

454   Debridement only allowed 107 - The related or qualifying claim-       N19 - Procedure code incidental    454 - Procedure code for services
      when billed on the same     service was not identified on this claim. to primary procedure.              rendered.
      day as surgical cleaning of                                                    N161 - This drug-
      skin.                                                                 service-supply is covered only
                                                                            when the associated service is
                                                                            covered.

455   Biopsy of skin only          107 - The related or qualifying claim-    N161 - This drug-service-supply   454 - Procedure code for services
      allowed when billed on the   service was not identified on this claim. is covered only when the          rendered.
      same day as biopsy of                                                  associated service is covered.
      skin lesion.
456   Each additional ten          107 - The related or qualifying claim-    N161 - This drug-service-supply   454 - Procedure code for services
      lesions only allowed on      service was not identified on this claim. is covered only when the          rendered.
      same date of service as                                                associated service is covered.
      removal of skin tags up to
      and including 15 lesions.


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                                                    EOB Code Crosswalk to HIPAA Standard Codes



457   Avulsions of nail plate      107 - The related or qualifying claim-    N19 - Procedure code incidental   454 - Procedure code for services
      only allowed when billed     service was not identified on this claim. to primary procedure.             rendered.
      on the same day as                                                              N161 - This drug-
      removal of nail.                                                       service-supply is covered only
                                                                             when the associated service is
                                                                             covered.

458   Less severe duplicate.   18 - Duplicate claim-service.               M86 - Service denied because      54 - Duplicate of a previously
      Same procedure code prof                                             payment already made for same- processed claim-line.
      -dental.                                                             similar procedure within set time
                                                                           frame.

459   Less severe dupe-same        18 - Duplicate claim-service.           M86 - Service denied because      54 - Duplicate of a previously
      DOS-same admit hour.                                                 payment already made for same- processed claim-line.
                                                                           similar procedure within set time
                                                                           frame.

460   Exact dupe prof sys plug.    18 - Duplicate claim-service.           M86 - Service denied because      54 - Duplicate of a previously
                                                                           payment already made for same- processed claim-line.
                                                                           similar procedure within set time
                                                                           frame.

461   Exact dupe same hour         18 - Duplicate claim-service.           M86 - Service denied because      54 - Duplicate of a previously
      prof sys plug.                                                       payment already made for same- processed claim-line.
                                                                           similar procedure within set time
                                                                           frame.

462   Inpatient claim must         97 - The benefit for this service is    M2 - Not paid separately when       454 - Procedure code for services
      include out patient          included in the payment-allowance for   the patient is an inpatient.        rendered.
      charges incurred within 24   another service-procedure that has
      hrs of admission.            already been adjudicated.
      Outpatient charges billed
      separately have been
      denied or recouped.
      Correct and resubmit
      inpatient claim.



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                                                      EOB Code Crosswalk to HIPAA Standard Codes

463   Tattooing only allowed         107 - The related or qualifying claim-    N19 - Procedure code incidental 465 - Principal Procedure Code for
      when billed on the same        service was not identified on this claim. to primary procedure.             Service(s) Rendered.
      day as correct skin color                                                        N161 - This drug-service-
      defects.                                                                 supply is covered only when the
                                                                               associated service is covered.

464   Each additional 100 sq cm 107 - The related or qualifying claim-     N19 - Procedure code incidental       454 - Procedure code for services
      only allowed when billed   service was not identified on this claim. to primary procedure.                 rendered.
      on the same day as split                                                                N161 - This
      graft 100 sq cm or less.                                             drug-service-supply is covered
                                                                           only when the associated service
                                                                           is covered.
465   Outpt charges within 24    B15 - This service-procedure requires M2 - Not paid separately when             454 - Procedure code for services
      hrs of admit not paid      that a qualifying service-procedure be    the patient is an inpatient.          rendered.
      separately. Add charges    received and covered. The qualifying
      to inpt claim & resubmit   other service-procedure has not been
      replacement claim. If mult received-adjudicated.
      encounter, bill others not
      24 hrs of admit, separately.


466   Full thickness graft, each     107 - The related or qualifying claim-    N19 - Procedure code incidental   454 - Procedure code for services
      add‟l 20 sq cm must bill       service was not identified on this claim. to primary procedure.             rendered.
      with 20 sq cm or less.                                                              N161 - This drug-
                                                                               service-supply is covered only
                                                                               when the associated service is
                                                                               covered.

467   Suspect duplicate,             18 - Duplicate claim-service.           M86 - Service denied because      54 - Duplicate of a previously
      overlapping dates of                                                   payment already made for same- processed claim-line.
      service.                                                               similar procedure within set time
                                                                             frame.

468   Each additional four       107 - The related or qualifying claim-      N19 - Procedure code incidental 454 - Procedure code for services
      lesions or less only       service was not identified on this claim.   to primary procedure.              rendered.
      allowed when billed on the                                                              N161 - This drug-
      same day as abrasions;                                                 service-supply is covered only
      single lesion.                                                         when the associated service is
                                                                             covered.


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469   Suspect duplicate,            18 - Duplicate claim-service.        M86 - Service denied because      54 - Duplicate of a previously
      overlapping dates of                                               payment already made for same- processed claim-line.
      service inst.                                                      similar procedure within set time
                                                                         frame.

470   Suspect duplicate,            18 - Duplicate claim-service.        M86 - Service denied because      54 - Duplicate of a previously
      overlapping dates of                                               payment already made for same- processed claim-line.
      service inst.                                                      similar procedure within set time
                                                                         frame.

471   Part B charges included in 97 - The benefit for this service is    M80 - Not covered when             454 - Procedure code for services
      per diem.                  included in the payment-allowance for   performed during the same          rendered.
                                 another service-procedure that has      session-date as a previously
                                 already been adjudicated.               processed service for the patient.

472   Suspect duplicate,            18 - Duplicate claim-service.        M86 - Service denied because      54 - Duplicate of a previously
      overlapping dates of                                               payment already made for same- processed claim-line.
      service inst.                                                      similar procedure within set time
                                                                         frame.

473   Nursing home days denied B15 - This service-procedure requires     M2 - Not paid separately when      258 - Days-units for procedure-
      or recouped to pay       that a qualifying service-procedure be    the patient is an inpatient.       revenue code.
      inpatient hospital days. received and covered. The qualifying
                               other service-procedure has not been                              M86 -
                               received-adjudicated.                     Service denied because payment
                                                                         already made for same-similar
                                                                         procedure within set time frame.

474   Suspect dupe-overlap         18 - Duplicate claim-service.         M86 - Service denied because      54 - Duplicate of a previously
      service date, prof sys plug.                                       payment already made for same- processed claim-line.
                                                                         similar procedure within set time
                                                                         frame.

475   Suspect dupe-exact           18 - Duplicate claim-service.         M86 - Service denied because      54 - Duplicate of a previously
      service date, prof sys plug.                                       payment already made for same- processed claim-line.
                                                                         similar procedure within set time
                                                                         frame.



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                                                   EOB Code Crosswalk to HIPAA Standard Codes

476   Suspect dupe prof sys       18 - Duplicate claim-service.        M86 - Service denied because      54 - Duplicate of a previously
      plug.                                                            payment already made for same- processed claim-line.
                                                                       similar procedure within set time
                                                                       frame.

477   Suspect dupe prof sys       18 - Duplicate claim-service.        M86 - Service denied because      54 - Duplicate of a previously
      plug.                                                            payment already made for same- processed claim-line.
                                                                       similar procedure within set time
                                                                       frame.

478   Suspect dupe-dental sys     18 - Duplicate claim-service.        M86 - Service denied because      54 - Duplicate of a previously
      plug.                                                            payment already made for same- processed claim-line.
                                                                       similar procedure within set time
                                                                       frame.

479   Suspect dupe prof sys       18 - Duplicate claim-service.        M86 - Service denied because      54 - Duplicate of a previously
      plug.                                                            payment already made for same- processed claim-line.
                                                                       similar procedure within set time
                                                                       frame.

480   Less severe dupe prof sys 18 - Duplicate claim-service.          M86 - Service denied because      54 - Duplicate of a previously
      plug.                                                            payment already made for same- processed claim-line.
                                                                       similar procedure within set time
                                                                       frame.

481   Less severe dupe-           18 - Duplicate claim-service.        M86 - Service denied because      54 - Duplicate of a previously
      outpatient hour. system                                          payment already made for same- processed claim-line.
      plug.                                                            similar procedure within set time
                                                                       frame.

482   Less severe dupe inst sys   18 - Duplicate claim-service.        M86 - Service denied because      54 - Duplicate of a previously
      plug.                                                            payment already made for same- processed claim-line.
                                                                       similar procedure within set time
                                                                       frame.

483   Less severe dupe inst sys   18 - Duplicate claim-service.        M86 - Service denied because      54 - Duplicate of a previously
      plug.                                                            payment already made for same- processed claim-line.
                                                                       similar procedure within set time
                                                                       frame.


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484   Less severe dupe inst sys   18 - Duplicate claim-service.        M86 - Service denied because      54 - Duplicate of a previously
      plug.                                                            payment already made for same- processed claim-line.
                                                                       similar procedure within set time
                                                                       frame.

485   Less severe dupe inst sys   18 - Duplicate claim-service.        M86 - Service denied because      54 - Duplicate of a previously
      plug.                                                            payment already made for same- processed claim-line.
                                                                       similar procedure within set time
                                                                       frame.

486   Less severe dupe inst sys   18 - Duplicate claim-service.        M86 - Service denied because      54 - Duplicate of a previously
      plug.                                                            payment already made for same- processed claim-line.
                                                                       similar procedure within set time
                                                                       frame.

487   Less severe dupe-3 digit    18 - Duplicate claim-service.        M86 - Service denied because      54 - Duplicate of a previously
      procedure, prof sys plug.                                        payment already made for same- processed claim-line.
                                                                       similar procedure within set time
                                                                       frame.

488   Less severe dupe-dental     18 - Duplicate claim-service.        M86 - Service denied because      54 - Duplicate of a previously
      sys plug.                                                        payment already made for same- processed claim-line.
                                                                       similar procedure within set time
                                                                       frame.

489   Less severe dupe prof sys 18 - Duplicate claim-service.          M86 - Service denied because      54 - Duplicate of a previously
      plug.                                                            payment already made for same- processed claim-line.
                                                                       similar procedure within set time
                                                                       frame.

490   Duplicate denied.           18 - Duplicate claim-service.        M86 - Service denied because      54 - Duplicate of a previously
                                                                       payment already made for same- processed claim-line.
                                                                       similar procedure within set time
                                                                       frame.

491   Exact dupe-same provider- 18 - Duplicate claim-service.          M86 - Service denied because      54 - Duplicate of a previously
      DOS-prescription number.                                         payment already made for same- processed claim-line.
                                                                       similar procedure within set time
                                                                       frame.


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                                                     EOB Code Crosswalk to HIPAA Standard Codes



492   Exact dupe-overlap           18 - Duplicate claim-service.          M86 - Service denied because      54 - Duplicate of a previously
      service date, inst sys plug.                                        payment already made for same- processed claim-line.
                                                                          similar procedure within set time
                                                                          frame.

493   Exact dupe inst sys plug.     18 - Duplicate claim-service.         M86 - Service denied because      54 - Duplicate of a previously
                                                                          payment already made for same- processed claim-line.
                                                                          similar procedure within set time
                                                                          frame.

494   Exact dupe prof sys plug.     18 - Duplicate claim-service.         M86 - Service denied because      54 - Duplicate of a previously
                                                                          payment already made for same- processed claim-line.
                                                                          similar procedure within set time
                                                                          frame.

495   Each additional cyst only 107 - The related or qualifying claim-     N19 - Procedure code incidental   454 - Procedure code for services
      allowed when billed on the service was not identified on this claim. to primary procedure.             rendered.
      same day as puncture                                                          N161 - This drug-
      aspiration of cyst of breast.                                        service-supply is covered only
                                                                           when the associated service is
                                                                           covered.

496   Exact dupe x-over prof sys 18 - Duplicate claim-service.            M86 - Service denied because      54 - Duplicate of a previously
      plug.                                                               payment already made for same- processed claim-line.
                                                                          similar procedure within set time
                                                                          frame.

497   Exact dupe-3digit             18 - Duplicate claim-service.         M86 - Service denied because      54 - Duplicate of a previously
      procedure, prof sys plug.                                           payment already made for same- processed claim-line.
                                                                          similar procedure within set time
                                                                          frame.

498   Exact dupe dental sys         18 - Duplicate claim-service.         M86 - Service denied because      54 - Duplicate of a previously
      plug.                                                               payment already made for same- processed claim-line.
                                                                          similar procedure within set time
                                                                          frame.




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                                                    EOB Code Crosswalk to HIPAA Standard Codes



499   Exact dupe prof sys plug.    18 - Duplicate claim-service.           M86 - Service denied because      54 - Duplicate of a previously
                                                                           payment already made for same- processed claim-line.
                                                                           similar procedure within set time
                                                                           frame.

500   Routine follow up care       97 - The benefit for this service is    M80 - Not covered when             454 - Procedure code for services
      included in surgical fee.    included in the payment-allowance for   performed during the same          rendered.
                                   another service-procedure that has      session-date as a previously
                                   already been adjudicated.               processed service for the patient.

501   Admission history and       18 - Duplicate claim-service.            M86 - Service denied because      54 - Duplicate of a previously
      physical or pre-operative                                            payment already made for same- processed claim-line.
      care paid prior to surgery,                                          similar procedure within set time
      resubmit as an adjustment.                                           frame.


502   CAP limitation has been      B5 - Coverage-program guidelines       N362 - The number of Days or          259 - Frequency of service.
      exceeded.                    were not met or were exceeded.         Units of Service exceeds our           483 - Maximum coverage
                                                                          acceptable maximum.                   amount met or exceeded for
                                                                                     N381 - Consult our         benefit period.
                                                                          contractual agreement for
                                                                          restrictions-billing-payment
                                                                          information related to these
                                                                          charges
503   Allow 1 australian antigen   119 - Benefit maximum for this time    M86 - Service denied because          259 - Frequency of service.
      lab-mo for crd recipients.   period or occurrence has been reached. payment already made for same-
                                                                          similar procedure within set time
                                                                          frame.                       N357 -
                                                                           Time frame requirements
                                                                          between this service-procedure-
                                                                          supply and a related service-
                                                                          procedure-supply have not been
                                                                          met

504   Allow 1 bone survey-year     119 - Benefit maximum for this time    M90 - Not covered more than           259 - Frequency of service.
      for crd recipients.          period or occurrence has been reached. once in a 12 month period.




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                                                     EOB Code Crosswalk to HIPAA Standard Codes


505   Unacceptable consent         16 - Claim-service lacks information       N3 - Missing consent form.         123 - Additional information
      form copy. Resubmit          which is needed for adjudication.                                             requested from entity.
      consent form copy with all
      field showing.
506   Surgery fee includes         97 - The benefit for this service is       M80 - Not covered when             454 - Procedure code for services
      admission hist- physical     included in the payment-allowance for      performed during the same          rendered.
      and pre-op care.             another service-procedure that has         session-date as a previously
                                   already been adjudicated.                  processed service for the patient.

507   Procedure code 95957      107 - The related or qualifying claim-        N19 - Procedure code incidental 454 - Procedure code for services
      allowed only in           service was not identified on this claim.     to primary procedure.              rendered.
      conjunction with codes                                                           N161 - This drug-service-
      95816,95819,or 95954. EEG                                               supply is covered only when the
      must be billed prior to                                                 associated service is covered.
      payment for code 95957.

508   Bitewing x-rays allowed      119 - Benefit maximum for this time    M90 - Not covered more than            259 - Frequency of service.
      once within 12 calendar      period or occurrence has been reached. once in a 12 month period.             483 - Maximum coverage amount
      months.                                                             N59 - Alert- Please refer to           met or exceeded for benefit period.
                                                                          your provider manual for
                                                                          additional program and
                                                                          provider information

509   Allow 2 psychiatric          197 - Precertification-authorization-  N54 - Claim information is        48 - Referral-authorization.
      outpatient visits without    notification absent.                   inconsistent with pre-certified-                            259 -
      prior approval.                                                     authorized services.              Frequency of service.
510   Allow 1 visit-day for        119 - Benefit maximum for this time    M86 - Service denied because      259 - Frequency of service.
      migrant-rural-free-          period or occurrence has been reached. payment already made for same-
      standing clinics.                                                   similar procedure within set time
                                                                          frame.

511   Services covered by          22 - This care may be covered by           MA04 - Secondary payment           116 - Claim submitted to incorrect
      Medicare, bill Medicare      another payer per coordination of          cannot be considered without the payer.
      carrier.                     benefits.                                  identity of or payment information
                                                                              from the primary payer. The
                                                                              information was either not
                                                                              reported or was illegible.



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                                                    EOB Code Crosswalk to HIPAA Standard Codes



512   CAP limitation has been      B5 - Coverage-program guidelines         N362 - The number of Days or         259 - Frequency of service.
      exceeded.                    were not met or were exceeded.           Units of Service exceeds our         483 - Maximum coverage amount
                                                                            acceptable maximum.                  met or exceeded for benefit period.
                                                                                       N381 - Consult our
                                                                            contractual agreement for
                                                                            restrictions-billing-payment
                                                                            information related to these
                                                                            charges
513   Inpatient respite care,      B15 - This service-procedure requires    M53 -Missing-incomplete-invalid      258 - Days-units for procedure-
      RC655 not allowed more       that a qualifying service-procedure be   days or units of service.            revenue code.
      than 5 consecutive days.     received and covered. The qualifying                   N61 - Rebill
      Split and rebill all         other service-procedure has not been     services on separate claims.
      subsequent days of           received-adjudicated.
      hospital stay as RC651
      routine home care.                                                      N63 - Rebill services on
                                                                            separate claim lines.

514   CAP limitation has been      B5 - Coverage-program guidelines         N362 - The number of Days or         259 - Frequency of service.
      exceeded.                    were not met or were exceeded.           Units of Service exceeds our                   483 - Maximum
                                                                            acceptable maximum.                  coverage amount met or
                                                                                       N381 - Consult our        exceeded for benefit period.
                                                                            contractual agreement for
                                                                            restrictions-billing-payment
                                                                            information related to these
                                                                            charges
515   Service included in Health   97 - The benefit for this service is     M80 - Not covered when               454 - Procedure code for services
      Check package.               included in the payment-allowance for    performed during the same            rendered.
                                   another service-procedure that has       session-date as a previously
                                   already been adjudicated.                processed service for the patient.

516   Not in accordance with       B5 - Coverage-program guidelines         No Mapping Required                  21 - Missing or invalid information.
      rehab guidelines.            were not met or were exceeded.
517   Duplicate charge…DOS         18 - Duplicate claim-service.            M86 - Service denied because      54 - Duplicate of a previously
      billed by CAP provider.                                               payment already made for same- processed claim-line.
                                                                            similar procedure within set time
                                                                            frame.




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                                                    EOB Code Crosswalk to HIPAA Standard Codes

518   Allow one bone mineral        119 - Benefit maximum for this time    M86 - Service denied because      259 - Frequency of service.
      density every six months      period or occurrence has been reached. payment already made for same-
      for crd.                                                             similar procedure within set time
                                                                           frame.                       N357
                                                                           - Time frame requirements
                                                                           between this service-procedure-
                                                                           supply and a related service-
                                                                           procedure-supply have not been
                                                                           met

519   Hepatitis B surface or core   119 - Benefit maximum for this time    M90 - Not covered more than          259 - Frequency of service.
      antibody allowed once per     period or occurrence has been reached. once in a 12 month period.
      year.
520   Lab test allowed once         119 - Benefit maximum for this time    M86 - Service denied because      259 - Frequency of service.
      every 3 months for crd.       period or occurrence has been reached. payment already made for same-
                                                                           similar procedure within set time
                                                                           frame.                       N357
                                                                           - Time frame requirements
                                                                           between this service-procedure-
                                                                           supply and a related service-
                                                                           procedure-supply have not been
                                                                           met

521   Supply code denied.      96 - Non-covered charge(s).                  N56 - Procedure code billed is        258 - Days-units for procedure-
      Additional payment not                                                not correct-valid for the services revenue code.
      allowed unless facility-                                              billed or the date of service billed.
      based procedure has been
      performed in physician
      office.                                                               M77 - Incomplete-invalid place of
                                                                            service(s).
522   Individual sealant included 97 - The benefit for this service is      M80 - Not covered when             454 - Procedure code for services
      in Quadrant previously      included in the payment-allowance for     performed during the same          rendered.
      billed.                     another service-procedure that has        session-date as a previously
                                  already been adjudicated.                 processed service for the patient.

523   Code multiple lab tests on    97 - The benefit for this service is    M80 - Not covered when             454 - Procedure code for services
      the same day to the           included in the payment-allowance for   performed during the same          rendered.
      equivalent panel code.        another service-procedure that has      session-date as a previously
                                    already been adjudicated.               processed service for the patient.


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                                                   EOB Code Crosswalk to HIPAA Standard Codes



524   Records previously          16 - Claim-service lacks information       M127 - Missing patient medical  123 - Additional information
      submitted are insufficient. which is needed for adjudication.          record for this service.        requested from entity.
      Resubmit as an                                                                              N163 -              295 - Attending physician
      adjustment with attending                                              Medical Record does not support report.
      physician records specific                                             code billed per the code
      to denied DOS & original                                               definition.
      RA copy

525   Exceeds legislative limits   119 - Benefit maximum for this time    No Mapping Required                  259 - Frequency of service.
      for provider visits for      period or occurrence has been reached.
      fiscal year.
526   Billed procedure only        107 - The related or qualifying claim-    N19 - Procedure code incidental 454 - Procedure code for services
      allowed on same day as       service was not identified on this claim. to primary procedure.            rendered.
      Y2038, Y2027,Y2039or                                                                   N161 - This
      Y2040.                                                                 drug-service-supply is covered
                                                                             only when the associated service
                                                                             is covered.

527   Laboratory services          97 - The benefit for this service is      M80 - Not covered when             454 - Procedure code for services
      included in hospital         included in the payment-allowance for     performed during the same          rendered.
      reimbursement.               another service-procedure that has        session-date as a previously
                                   already been adjudicated.                 processed service for the patient.

528   Combine charges and          A1 - Claim-Service denied. At least one   MA51 - Missing-incomplete-      258 - Days-units for procedure-
      rebill using major surgery   Remark Code must be provided (may         invalid procedure code(s). N203 revenue code.
      code. Indicate total time    be comprised of either the Remittance     - Missing-incomplete-invalid     454 - Procedure code for services
      units in column G. File      Advice Remark Code or NCPDP Reject        anesthesia time-units           rendered.
      adjustment of previously     Reason Code.) This change to be                                           523 - Anesthesia Unit Count
      paid claim if necessary.     effective 7-1-2010- Claim-Service
                                   denied. At least one Remark Code
                                   must be provided (may be comprised
                                   of either the NCPDP Reject Reason
                                   Code, or Remittance Advice Remark
                                   Code that is not an ALERT.)




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                                                    EOB Code Crosswalk to HIPAA Standard Codes

529   Rebill assistant surgeon     125 - Submission-billing error(s).      N93 - A separate claim must be 21 - Missing or invalid information.
      on separate claim form.                                              submitted for each place of
                                                                           service. Services furnished at
                                                                           multiple sites may not be billed in
                                                                           the same claim.


530   Services included in initial 97 - The benefit for this service is    M80 - Not covered when             454 - Procedure code for services
      dialysis training fee.       included in the payment-allowance for   performed during the same          rendered.
                                   another service-procedure that has      session-date as a previously
                                   already been adjudicated.               processed service for the patient.

531   Service included in          97 - The benefit for this service is    M80 - Not covered when             454 - Procedure code for services
      monthly professional         included in the payment-allowance for   performed during the same          rendered.
      dialysis fee.                another service-procedure that has      session-date as a previously
                                   already been adjudicated.               processed service for the patient.

532   Only one EKG allowed in 3 119 - Benefit maximum for this time    M86 - Service denied because      259 - Frequency of service.
      months for dialysis       period or occurrence has been reached. payment already made for same-
      patients.                                                        similar procedure within set time
                                                                       frame.                       N357
                                                                       - Time frame requirements
                                                                       between this service-procedure-
                                                                       supply and a related service-
                                                                       procedure-supply have not been
                                                                       met

533   Only one nerve velocity      119 - Benefit maximum for this time    M86 - Service denied because      259 - Frequency of service.
      test allowed in 3 mths for   period or occurrence has been reached. payment already made for same-
      dialysis.                                                           similar procedure within set time
                                                                          frame.                       N357
                                                                          - Time frame requirements
                                                                          between this service-procedure-
                                                                          supply and a related service-
                                                                          procedure-supply have not been
                                                                          met

534   Copay previously             3 - Co-payment Amount                   No Mapping Required               104 - Processed according to plan
      deducted for this date of                                                                              provisions.
      service.

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                                                  EOB Code Crosswalk to HIPAA Standard Codes


535   Maximum allowable          45 - Charge exceeds fee schedule-         N381 - Consult our contractual      483 - Maximum coverage amount
      facility fee has been      maximum allowable or contracted-          agreement for restrictions-billing- met or exceeded for benefit period.
      reached.                   legislated fee arrangement. (Use          payment information related to
                                 Group Codes PR or CO depending            these charges
                                 upon liability).
536   Total surgical time must   152 - Payment adjusted because the        M53 - Missing-incomplete-invalid 21 - Missing or invalid information.
      be indicated on claim.     payer deems the information submitted     days or units of service.
                                 does not support this length of service

537   Procedure Code or          96 - Non-covered charge(s).               N56 - Procedure code billed is        453 - Procedure Code Modifier(s)
      procedure -modifier code                                             not correct-valid for the service     for Service(s) Rendered.
      combination is not                                                   billed or the date of service billed.
      covered for the date of                                                                                                       457 - Non-
      service.                                                             N301 - Missing-incomplete-            Covered Day(s).
                                                                           invalid procedure date(s).
538   Procedure not allowed in   B15 - This service-procedure requires     N20 - Service not payable with        258 - Days-units for procedure-
      conjunction with general   that a qualifying service-procedure be    other service rendered on the         revenue code.
      anesthesia.                received and covered. The qualifying      same date.
                                 other service-procedure has not been
                                 received-adjudicated.

539   Exceeds limit for          119 - Benefit maximum for this time    M86 - Service denied because 259 - Frequency of service.
      screening mammogram:       period or occurrence has been reached. payment already made for
      Age 35-39 allow one; age                                          same-similar procedure within
      40 and over allow annual                                          set time frame.
      exam.                                                                 N130 - Alert- Consult plan
                                                                        benefit documents for
                                                                        information about restrictions
                                                                        for this service.
                                                                                          N357 - Time
                                                                        frame requirements between
                                                                        this service-procedure-supply
                                                                        and a related service-
                                                                        procedure-supply have not
                                                                        been met




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                                                  EOB Code Crosswalk to HIPAA Standard Codes




540   Initial dialysis training   97 - The benefit for this service is    M80 - Not covered when             454 - Procedure code for services
      includes fee for other      included in the payment-allowance for   performed during the same          rendered.
      services.                   another service-procedure that has      session-date as a previously
                                  already been adjudicated.               processed service for the patient.

541   Monthly professional        97 - The benefit for this service is    M80 - Not covered when             454 - Procedure code for services
      dialysis includes fee for   included in the payment-allowance for   performed during the same          rendered.
      other service.              another service-procedure that has      session-date as a previously
                                  already been adjudicated.               processed service for the patient.

542   Routine follow up is        97 - The benefit for this service is    M80 - Not covered when             454 - Procedure code for services
      included in surgical fee.   included in the payment-allowance for   performed during the same          rendered.
                                  another service-procedure that has      session-date as a previously
                                  already been adjudicated.               processed service for the patient.

543   Tympanometry and Health B15 - This service-procedure requires       N20 - Service not payable with    258 - Days-units for procedure-
      Check screening are not  that a qualifying service-procedure be     other service rendered on the     revenue code.
      allowed on the same day. received and covered. The qualifying       same date.
                               other service-procedure has not been
                               received-adjudicated.

544   Chemotherapy                97 - The benefit for this service is    M80 - Not covered when             454 - Procedure code for services
      administration denied, ov   included in the payment-allowance for   performed during the same          rendered.
      or consult included in      another service-procedure that has      session-date as a previously
      administration fee          already been adjudicated.               processed service for the patient.
      previously paid to the
      same provider for this
      date of service.
545   PDN services is non-        96 - Non-covered charge(s).             M2 - Not paid separately when     454 - Procedure code for services
      covered when recipient is                                           the patient is an inpatient.      rendered.
      receiving inpatient
      services.




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                                                     EOB Code Crosswalk to HIPAA Standard Codes


546   Chemo admin code              97 - The benefit for this service is    M80 - Not covered when             454 - Procedure code for services
      includes surgical             included in the payment-allowance for   performed during the same          rendered.
      procedure previously paid     another service-procedure that has      session-date as a previously
      to same provider for same     already been adjudicated.               processed service for the patient.
      DOS. Refund or request
      recoupment of paid
      surgery code for
      reconsideration of chemo
      admin code.

547   Only one initial consult    119 - Benefit maximum for this time    M86 - Service denied because          259 - Frequency of service.
      allowed in a 15 day period. period or occurrence has been reached. payment already made for same-
                                                                         similar procedure within set time
                                                                         frame
548   Proc code billed not        B15 - This service-procedure requires N30 - Patient ineligible for this      258 - Days-units for procedure-
      allowed in client's CAP     that a qualifying service-procedure be service.                              revenue code.
      PGM. Rebill using the       received and covered. The qualifying
      correct proc code or        other service-procedure has not been
      confirm client's CAP        received-adjudicated.                  N52 - Patient not enrolled in the
      status with CAP mgr. For                                           billing providers managed care
      further resolution call EDS                                        plan on the date of service.
      NPI Helpdesk.                                                      N56 - Procedure code billed is
                                                                         not correct-valid for the services
                                                                         billed or the date of service billed.

549   Service denied: exceeds       119 - Benefit maximum for this time    M86 - Service denied because      259 - Frequency of service.
      limit of 4 billings per 365   period or occurrence has been reached. payment already made for same-
      days.                                                                similar procedure within set time
                                                                           frame
550   Exceeds maximum of 12         119 - Benefit maximum for this time    N357 - Time frame requirements 259 - Frequency of service.
      units per calendar week.      period or occurrence has been reached. between this service-procedure-
                                                                           supply and a related service-
                                                                           procedure-supply have not been
                                                                           met.                       N362 -
                                                                           The number of Days or Units of
                                                                           Service exceeds our acceptable
                                                                           maximum



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                                                    EOB Code Crosswalk to HIPAA Standard Codes



551   ESRD related services        119 - Benefit maximum for this time    M86 - Service denied because      259 - Frequency of service.
      allowed once per month.      period or occurrence has been reached. payment already made for same-
                                                                          similar procedure within set time
                                                                          frame.

552   Therapeutic radiology port 119 - Benefit maximum for this time     M86 - Service denied because      259 - Frequency of service.
      films allowed once per day. period or occurrence has been reached. payment already made for same-
                                                                         similar procedure within set time                             612 -
                                                                         frame.                            Per Day Limit Amount

553   Resubmit as an               16 - Claim-service lacks information      N29 - Missing documentation-      263 - Length of time for services
      adjustment with              which is needed for adjudication.         orders-notes-summary-report-      rendered
      documentation of time                                                  chart.                               294 - Supporting documentation

554   Chronic disease              B15 - This service-procedure requires     N20 - Service not payable with    258 - Days-units for procedure-
      monitoring and               that a qualifying service-procedure be    other service rendered on the     revenue code.
      components( Y2006,           received and covered. The qualifying      same date.
      Y2007 and Y2024) not         other service-procedure has not been
      allowed on the same day      received-adjudicated.
      of service.
555   Daily and monthly ESRD       B15 - This service-procedure requires     M86 - Service denied because      258 - Days-units for procedure-
      related services not         that a qualifying service-procedure be    payment already made for same- revenue code.
      allowed within the same      received and covered. The qualifying      similar procedure within set time
      calendar month.              other service-procedure has not been      frame.
                                   received-adjudicated.

556   Primary diagnosis code       146 - Diagnosis was invalid for the       MA63 - Missing-incomplete-        21 - Missing or invalid information.
      must be further              date(s) of service reported.              invalid principal diagnosis.
      subdivided. The code
      must have four or five                                                                                      255 - Diagnosis code.
      digits.
557   Secondary diagnosis code     146 - Diagnosis was invalid for the       M64 - Missing-incomplete-invalid 21 - Missing or invalid information.
      must be further              date(s) of service reported.              other diagnosis.
      subdivided. (the code
      must have four or five                                                                                      255 - Diagnosis code.
      digits).



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                                                      EOB Code Crosswalk to HIPAA Standard Codes




558   Other diagnosis code 3         146 - Diagnosis was invalid for the      M64 - Missing-incomplete-invalid 21 - Missing or invalid information.
      must be further                date(s) of service reported.             other diagnosis.
      subdivided. ( the code
      must have four or five                                                                                       255 - Diagnosis code.
      digits).
559   Other diagnosis code 4         146 - Diagnosis was invalid for the      M64 - Missing-incomplete-invalid 21 - Missing or invalid information.
      must be further                date(s) of service reported.             other diagnosis.
      subdivided. ( the code
      must have four or five                                                                                       255 - Diagnosis code.
      digits).
560   Other diagnosis code 5         146 - Diagnosis was invalid for the      M64 - Missing-incomplete-invalid 21 - Missing or invalid information.
      must be further                date(s) of service reported.             other diagnosis.
      subdivided.
                                                                                                                  255 - Diagnosis code.
561   Acellular DTP vaccine          119 - Benefit maximum for this time    M86 - Service denied because        259 - Frequency of service.
      allowed once per date of       period or occurrence has been reached. payment already made for same-
      service.                                                              similar procedure within set time                                 612 -
                                                                            frame.                            Per Day Limit Amount

562   Service is included in the     97 - The benefit for this service is     M80 - Not covered when             454 - Procedure code for services
      chemotherapy                   included in the payment-allowance for    performed during the same          rendered.
      administration code            another service-procedure that has       session-date as a previously
      previously paid to the         already been adjudicated.                processed service for the patient.
      same provider for this
      DOS.
563   Audiology assessment           119 - Benefit maximum for this time    M86 - Service denied because      259 - Frequency of service.
      limited to 2 hours ( 8 units   period or occurrence has been reached. payment already made for same-
      ) per day.                                                            similar procedure within set time                             612 -
                                                                            frame.                       N362 Per Day Limit Amount
                                                                            - The number of Days or Units of
                                                                            Service exceeds our acceptable
                                                                            maximum




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                                                    EOB Code Crosswalk to HIPAA Standard Codes



564   Speech-language               119 - Benefit maximum for this time    M86 - Service denied because      259 - Frequency of service.
      assessment limited to 2       period or occurrence has been reached. payment already made for same-
      hours ( 8 units) per day.                                            similar procedure within set time                             612 -
                                                                           frame.                       N362 Per Day Limit Amount
                                                                           - The number of Days or Units of
                                                                           Service exceeds our acceptable
                                                                           maximum

565   Assessments limited to        119 - Benefit maximum for this time    M86 - Service denied because      259 - Frequency of service.
      two hours ( 8 units ) per     period or occurrence has been reached. payment already made for same-
      day.                                                                 similar procedure within set time                             612 -
                                                                           frame.                       N362 Per Day Limit Amount
                                                                           - The number of Days or Units of
                                                                           Service exceeds our acceptable
                                                                           maximum

566   Physical therapy              119 - Benefit maximum for this time    M86 - Service denied because      259 - Frequency of service.
      assessment limited to 2       period or occurrence has been reached. payment already made for same-
      hours ( 8 units) per day.                                            similar procedure within set time                             612 -
                                                                           frame.                       N362 Per Day Limit Amount
                                                                           - The number of Days or Units of
                                                                           Service exceeds our acceptable
                                                                           maximum

567   Psychology assessment        119 - Benefit maximum for this time    M86 - Service denied because      259 - Frequency of service.
      limited to 2 hours ( 8 units period or occurrence has been reached. payment already made for same-
      ) per day.                                                          similar procedure within set time                             612 -
                                                                          frame.                       N362 Per Day Limit Amount
                                                                          - The number of Days or Units of
                                                                          Service exceeds our acceptable
                                                                          maximum

568   Depo-Provera 150 mg. for      119 - Benefit maximum for this time    M86 - Service denied because      259 - Frequency of service.
      contraceptive use limited     period or occurrence has been reached. payment already made for same-
      to one per date of service.                                          similar procedure within set time                             612 -
                                                                           frame.                            Per Day Limit Amount




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                                                     EOB Code Crosswalk to HIPAA Standard Codes

569   Service denied; procedure 197 - Precertification-authorization-         N54 - Claim information is            453 - Procedure code modifier(s)
      code or procedure code-    notification absent.                         inconsistent with pre-certified-      for service(s) rendered.
      modifier combination                                                    authorized services.
      requiring PA does not                                                       N56 - Procedure code billed is
      match the code or code-                                                 not correct-valid for the services
      modifier billed by the                                                  billed or the date of service billed.
      primary physician for this
      date.                                                                            N188 - The
                                                                          approved level of care does not
                                                                          match the procedure code
                                                                          submitted.
570   Percutaneous                 119 - Benefit maximum for this time    M86 - Service denied because      259 - Frequency of service.
      transluminal angioplasty     period or occurrence has been reached. payment already made for same-
      limit to four per day.                                              similar procedure within set time                             612 -
                                                                          frame.                       N357 Per Day Limit Amount
                                                                          - Time frame requirements
                                                                          between this service-procedure-
                                                                          supply and a related service-
                                                                          procedure-supply have not been
                                                                          met

571   Limit percutaneous           119 - Benefit maximum for this time    M86 - Service denied because      259 - Frequency of service.
      transluminal atherectomy     period or occurrence has been reached. payment already made for same-
      to four per day.                                                    similar procedure within set time                             612 -
                                                                          frame.                       N357 Per Day Limit Amount
                                                                          - Time frame requirements
                                                                          between this service-procedure-
                                                                          supply and a related service-
                                                                          procedure-supply have not been
                                                                          met

572   Service denied; PA has       197 - Precertification-authorization-      N54 - Claim information is         48 - Referral-authorization.
      not been obtained by the     notification absent.                       inconsistent with pre-certified-                            84 -
      primary physician.                                                      authorized services.               Service not authorized.

573   Maternity care               119 - Benefit maximum for this time    M86 - Service denied because      259 - Frequency of service.
      coordination home visit      period or occurrence has been reached. payment already made for same-
      allowed once per date of                                            similar procedure within set time                             612 -
      service.                                                            frame.                            Per Day Limit Amount


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                                                   EOB Code Crosswalk to HIPAA Standard Codes




574   Procedure or procedure-     96 - Non-covered charge(s).              MA66 - Missing-incomplete-          453 - Procedure Code Modifier(s)
      modifier combination is                                              invalid principal procedure code.   for Service(s) Rendered.
      not covered for the date of
      processing.                                                            N301 - Missing-incomplete-                            457 - Non-
                                                                           invalid procedure date(s).          Covered Day(s).

575   Procedure or procedure-     96 - Non-covered charge(s).              MA66 - Missing-incomplete-          453 - Procedure Code Modifier(s)
      modifier combination is                                              invalid principal procedure code.   for Service(s) Rendered.
      not covered for the date of
      receipt.                                                                   N301 - Missing-incomplete-                        457 - Non-
                                                                           invalid procedure date(s).       Covered Day(s).

576   W9922 can only be billed     150 - Payment adjusted because the      MA66 - Missing-incomplete-          97 - Patient eligibility not found
      for Carolina access          payer deems the information submitted invalid principal procedure code.     with entity.
      recipients.                  does not support this level of service.

577   PCP's cannot bill w9922      150 - Payment adjusted because the      MA66 - Missing-incomplete-          97 - Patient eligibility not found
      for their enrolled           payer deems the information submitted invalid principal procedure code.     with entity.
      recipients.                  does not support this level of service.
                                                                           N188 - The approved level of
                                                                           care does not match the
                                                                           procedure code submitted
578   Non ER services billed for   125 - Submission-billing error(s).      N46 - Missing-incomplete-invalid    21 - Missing or invalid information.
      ca recipient with invalid                                            admission hour.                                  230 - Hospital
      admit hour. Rebill with                                                                                  admission hour.       471 - Were
      admit hour.                                                                                              services related to an emergency?




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                                                    EOB Code Crosswalk to HIPAA Standard Codes




579   Diag not true emergency. 125 - Submission-billing error(s).          MA63 - Missing-incomplete-         21 - Missing or invalid information.
      Svc rendered 8am-5pm,                                                invalid principal diagnosis.
      Monday - Friday. Resubmit
      new claim for med                                                                                         488 - Diagnosis code(s) for the
      screening exam fee                                                                                      services rendered
      (W9922) to EDS or submit
      claim to Carolina Access
      for retrospective review.
580   Diagnosis not true           125 - Submission-billing error(s).      MA63 - Missing-incomplete-         21 - Missing or invalid information.
      emergency. Service                                                   invalid principal diagnosis.
      rendered 5pm to 8am
      Monday thru Friday or 24                                                                                  488 - Diagnosis code(s) for the
      hrs sat-sun. Service may                                                                                services rendered
      be authorized by PCP or
      bill medical screening
      exam fee (W9922).
581   Invalid ER room auth for  197 - Precertification-authorization-      N54 - Claim information is         252 - Authorization-certification
      CA recipient. Rebill with notification absent.                       inconsistent with pre-certified-   number.
      correct authorization or                                             authorized services.
      for assessment fee W9922.


582   ER services paid in        16 - Claim-service lacks information      M86 - Service denied because     294 - Supporting documentation.
      history, medical screening which is needed for adjudication.         payment already made for similar
      exam fee denied. Refile                                              procedure within set time frame.
      claim as an adjustment
      and attach ER medical                                                                N29 - Missing
      records.                                                             documentation-orders-notes-
                                                                           summary-report-chart.




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583   Medical screening exam        16 - Claim-service lacks information      M15 - Separately billed services- 294 - Supporting documentation.
      fee paid in history – ER      which is needed for adjudication.         tests have been bundled as they
      services denied. Refile                                                 are considered components of
      claim as an adjustment                                                  the same procedure. Separate
      and attach ER medical                                                   payment is not allowed.
      records.                                                                                    N20 -
                                                                              Service not payable with other
                                                                              service rendered on the same
                                                                              date.

587   If sterilization charges are 125 - Submission-billing error(s).         M76 - Missing-incomplete-invalid 178 - Submitted charges.
      not covered, remove the                                                 diagnosis or condition.                     454 - Procedure code
         sterilization diagnosis                                                 N188 - The approved level of for services rendered.
      and procedure codes from                                                care does not match the               488 - Diagnosis code(s) for
      the claim and resubmit as                                               procedure code submitted.        the services rendered.
      a new claim.


588   Surgical procedure is not 125 - Submission-billing error(s).            MA66 - Missing-incomplete-           21 - Missing or invalid information.
      billed on this claim.                                                   invalid principal procedure code.
      Please remove the icd-9
      surgical procedure code
      and bill as a    new claim.


589   Other procedure code 4 is     125 - Submission-billing error(s).        N56 - Procedure code billed is        21 - Missing or invalid information.
      invalid.                                                                not correct-valid for the services                 490 - Other
                                                                              billed or the date of service billed. procedure code for service(s)
                                                                                                                    rendered
590   Other procedure code 5        125 - Submission-billing error(s).        N56 - Procedure code billed is        21 - Missing or invalid information.
      is invalid.                                                             not correct-valid for the services                         490 - Other
                                                                              billed or the date of service billed. procedure code for service(s)
                                                                                                                    rendered




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                                                     EOB Code Crosswalk to HIPAA Standard Codes

591   Claims history shows          16 - Claim-service lacks information      M29 - Missing operative report.      65 - Claim-line has been paid.
      Medicaid has previously       which is needed for adjudication.                                                        298 - Operative report.
      paid for tonsillectomies                                                                    M30 - Missing                     311 - Pathology
      for this recipient.                                                     pathology report.                    notes-report.
      Resubmit corrected claim
      or file as an adjustment
      with operative note and
      path report.

592   Claim history shows           16 - Claim-service lacks information      M29 - Missing operative report.      65 - Claim-line has been paid
      Medicaid has previously       which is needed for adjudication.                                                        298 - Operative report
      paid for adenoidectomies                                                                    M30 - Missing                     311 - Pathology
      for this recipient.                                                     pathology report.                    notes-report
      Resubmit corrected claim
      or file as an adjustment
      with operative note and
      path report.


593   Other procedure code 6 is     125 - Submission-billing error(s).        N56 - Procedure code billed is        21 - Missing or invalid information.
      invalid.                                                                not correct-valid for the services                       490 - Other
                                                                              billed or the date of service billed. procedure code for service(s)
                                                                                                                    rendered.
594   Service denied.               97 - The benefit for this service is      M80 - Not covered when                454 - Procedure code for services
      Components of this blood      included in the payment-allowance for     performed during the same             rendered.
      panel have already been       another service-procedure that has        session-date as a previously
      paid for the same date of     already been adjudicated.                 processed service for the patient.
      service.

595   Service denied. This test     97 - The benefit for this service is      M80 - Not covered when             454 - Procedure code for services
      is included in a related      included in the payment-allowance for     performed during the same          rendered.
      panel code already paid       another service-procedure that has        session-date as a previously
      for the same date of          already been adjudicated.                 processed service for the patient.
      service.
596   Billed procedure limited      119 - Benefit maximum for this time    M86 - Service denied because      259 - Frequency of service.
      to one per date of service.   period or occurrence has been reached. payment already made for same-
                                                                           similar procedure within set time                             612 -
                                                                           frame.                            Per Day Limit Amount



                                                                           Page 95
                                                    EOB Code Crosswalk to HIPAA Standard Codes

597   Postpartum- newborn          119 - Benefit maximum for this time    M86 - Service denied because      259 - Frequency of service.
      home visit limited to one    period or occurrence has been reached. payment already made for same-
      billing every 154 days.                                             similar procedure within set time
                                                                          frame.                       N357
                                                                          - Time frame requirements
                                                                          between this service-procedure-
                                                                          supply and a related service-
                                                                          procedure-supply have not been
                                                                          met

598   General anesthesia for       97 - The benefit for this service is       M80 - Not covered when             454 - Procedure code for services
      sterilization billed in      included in the payment-allowance for      performed during the same          rendered.
      conjunction with general     another service-procedure that has         session-date as a previously
      anesthesia for delivery is   already been adjudicated.                  processed service for the patient.
      being reimbursed to
      reflect time only.

599   Newborn Health Check         149 - Lifetime benefit maximum has         N117 - This service is paid only   259 - Frequency of service.
      screening limited to once    been reached for this service-benefit      once in a patients lifetime.
      per lifetime.                category

600   Allow one full mouth       119 - Benefit maximum for this time          M86 - Service denied because      259 - Frequency of service.
      debridement to enable      period or occurrence has been reached.       payment already made for same-
      comprehensive                                                           similar procedure within set time
      periodontal evaluation and                                              frame.                       N357
      diagnosis every 364 days.                                               - Time frame requirements
                                                                              between this service-procedure-
                                                                              supply and a related service-
                                                                              procedure-supply have not been
                                                                              met

601   Only four quadrants of       149 - Lifetime benefit maximum has         M86 - Service denied because      259 - Frequency of service.
      periodontal surgery          been reached for this service-benefit      payment already made for same-
      allowed per lifetime.        category                                   similar procedure within set time
                                                                              frame.
                                                                              N362 - The number of Days or
                                                                              Units of Service exceeds our
                                                                              acceptable maximum



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                                                    EOB Code Crosswalk to HIPAA Standard Codes

602   Sterilization epidural       125 - Submission-billing error(s).      M53 - Missing-incomplete-invalid 12 - One or more originally
      anesthesia cut back to                                               days or units of service.        submitted procedure codes have
      reflect time only when                                                                                been combined.
      billed in conjunction with
      delivery under epidural.

603   Allow one oral evaluation    119 - Benefit maximum for this time    N59 - Alert- Please refer to      259 - Frequency of service.
      within 6 calendar months.    period or occurrence has been reached. your provider manual for           483 - Maximum coverage amount
                                                                          additional program and            met or exceeded for benefit period.
                                                                          provider information

604   Maximum daily units        119 - Benefit maximum for this time       N357 - Time frame requirements 259 - Frequency of service.
      exceeded for service. CPT period or occurrence has been reached.     between this service-procedure-
      description limits code to                                           supply and a related service-                              612 -
      8 units per day                                                      procedure-supply have not been Per Day Limit Amount
      (1unit=1hour) . Correct                                              met.                       N362 -
      and resubmit as a new                                                The number of Days or Units of
      claim.                                                               Service exceeds our acceptable
                                                                           maximum

605   Allow one routine dental     119 - Benefit maximum for this time    N59 - Alert- Please refer to      259 - Frequency of service.
      prophylaxis within 6         period or occurrence has been reached. your provider manual for           483 - Maximum coverage amount
      calendar months.                                                    additional program and            met or exceeded for benefit period.
                                                                          provider information
606   Two periodontal              119 - Benefit maximum for this time    M86 - Service denied because      259 - Frequency of service.
      maintenance procedures       period or occurrence has been reached. payment already made for same-
      allowed per year .                                                  similar procedure within set time
                                                                          frame.
                                                                          N357 - Time frame requirements
                                                                          between this service-procedure-
                                                                          supply and a related service-
                                                                          procedure-supply have not been
                                                                          met

607   A valid date is required     125 - Submission-billing error(s).      N299 - Missing-incomplete-       21 - Missing or invalid information.
      with occurrence code.                                                invalid occurrence date(s).
      Correct and resubmit as a
      new claim.                                                                                              187 - Date(s) of service.
                                                                                                                    461 - NUBC occurrence
                                                                                                            code(s) and date(s).

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                                                     EOB Code Crosswalk to HIPAA Standard Codes



608   Recommended                119 - Benefit maximum for this time         M86 - Service denied because      259 - Frequency of service.
      immunization schedule      period or occurrence has been reached.      payment already made for same-
      exceeded for this vaccine.                                             similar procedure within set time
      Recipient has received                                                 frame.
      same immunization within
      300 days of claim date of
      service.


609   Payer identification is       125 - Submission-billing error(s).       M56 - Missing-incomplete-invalid 21 - Missing or invalid information.
      required on NC Medicaid                                                payer identifier.
      claims. See billing                                                                    MA48 - Missing-
      guidelines                                                             incomplete-invalid name or
                                                                             address of responsible party or
                                                                             primary payer.

610   Tooth number missing or       125 - Submission-billing error(s).       N37 - Missing-incomplete-invalid    21 - Missing or invalid information.
      invalid. Correct detail and                                            tooth number-letter.
      resubmit claim.
                                                                                                                   242 - Tooth numbers, surfaces,
                                                                                                                 and-or quadrants involved.

611   Submit claim for payment      109 - Claim not covered by this payer-   No Mapping Required                 116 - Claim submitted to incorrect
      to the Carolina               contractor. You must send the claim to                                       payer.
      alternatives agency           the correct payer-contractor.
      responsible for the
      recipient's county of
      residence.
612   Critical care, first hour     125 - Submission-billing error(s).       MA66 - Missing-incomplete-          54 - Duplicate of a previously
      already paid for this date.                                            invalid principal procedure code.   processed claim-line.
      Rebill additional time                                                                                           454 - Procedure code for
      using CPT 99292.                                                                                           services rendered.
613   OB echography allowed         119 - Benefit maximum for this time    M86 - Service denied because          259 - Frequency of service.
      once per day, same            period or occurrence has been reached. payment already made for same-
      provider.                                                            similar procedure within set time                                  612 -
                                                                           frame.                            Per Day Limit Amount




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614   Allow panorex film once       119 - Benefit maximum for this time    M86 - Service denied because      259 - Frequency of service.
      every five years per state    period or occurrence has been reached. payment already made for same-
      limit.                                                               similar procedure within set time
                                                                           frame.
                                                                           N357 - Time frame requirements
                                                                           between this service-procedure-
                                                                           supply and a related service-
                                                                           procedure-supply have not been
                                                                           met

615   Allow extraction and root 149 - Lifetime benefit maximum has           N117 - This service is paid only   259 - Frequency of service.
      recovery once per lifetime. been reached for this service-benefit      once in a patients lifetime.
                                  category
616   Only one 2 digit modifier   125 - Submission-billing error(s).         MA130 - Your claim contains       21 - Missing or invalid information.
      allowed per proc. code.                                                incomplete and-or invalid
      Refile claim and verify if                                             information, and no appeal rights
      free or purchased and                                                  are afforded because the claim is   453 - Procedure code
      dose number in series.                                                 unprocessable. Please submit a modifier(s) for service(s) rendered.
      Thank you for reporting                                                new claim with the complete-
      vaccine.                                                               correct information.

617   Insertion or reinsertion of   119 - Benefit maximum for this time    M86 - Service denied because      259 - Frequency of service.
      implantable contraceptive     period or occurrence has been reached. payment already made for same-
      capsules(norplant) is                                                similar procedure within set time                             612 -
      allowed once per date of                                             frame.                            Per Day Limit Amount
      service.

618   Removal of implantable     119 - Benefit maximum for this time         M86 - Service denied because      259 - Frequency of service.
      contraceptive capsule      period or occurrence has been reached.      payment already made for same-
      (norplant)allowed once per                                             similar procedure within set time                             612 -
      date of service.                                                       frame.                            Per Day Limit Amount




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619   Verify source of prior    125 - Submission-billing error(s).          MA130 - Your claim contains       21 - Missing or invalid information.
      payment. If filing for                                                incomplete and-or invalid
      additional payment from                                               information, and no appeal rights
      Medicaid, submit through                                              are afforded because the claim is   446 - Documentation from prior
      adjustment or replacement                                             unprocessable. Please submit a claim(s) related to service(s).
      claim                                                                 new claim with the complete-
                                                                            correct information.

620   Vaccine requires 2 digit      125 - Submission-billing error(s).      MA130 - Your claim contains       21 - Missing or invalid information.
      modifier in block 24d.                                                incomplete and-or invalid
      Refile claim and verify if                                            information, and no appeal rights
      vaccine is free or                                                    are afforded because the claim is   453 - Procedure code
      purchased, dose no. in                                                unprocessable. Please submit a modifier(s) for service(s) rendered.
      series, or if                                                         new claim with the complete-
      contraindicated. Thanks                                               correct information.
      for reporting vaccine.

621   Date of next Health Check 125 - Submission-billing error(s).          N29 - Missing documentation-       21 - Missing or invalid information.
      screening missing, invalid                                            orders- notes- summary- report-                  187 - Date(s) of
      or not in required mm-dd-                                             chart.                             service.
      yy format in block 15 of
      CMS 1500 claim Form.                                                              N78 - The necessary
                                                                            components of the child and teen
                                                                            checkup (EPSDT) were not
                                                                            completed.
622   Next screening date is       125 - Submission-billing error(s).       N59 - Alert- Please refer to     21 - Missing or invalid information.
      calculated too far in the                                             your provider manual for                           187 - Date(s) of
      future for the recipient's                                            additional program and           service.                        259 -
      age at this date of service.                                          provider information              Frequency of service.

623   Epidural code 62278-62279     97 - The benefit for this service is    M80 - Not covered when             454 - Procedure code for services
      has been paid on a            included in the payment-allowance for   performed during the same          rendered.
      separate claim. Payment       another service-procedure that has      session-date as a previously
      for w8208-00955 includes      already been adjudicated.               processed service for the patient.
      the epidural. 62278-62279
      must be recouped to pay
      w8208-00955. Please file
      adjustment.


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                                                     EOB Code Crosswalk to HIPAA Standard Codes


624   Duplicate procedure. Paid     18 - Duplicate claim-service.          M86 - Service denied because      259 - Frequency of service.
      to your office for a                                                 payment already made for same-
      different date of service.                                           similar procedure within set time
                                                                           frame.

625   Allow full mouth survey       119 - Benefit maximum for this time    M86 - Service denied because      259 - Frequency of service.
      once every five years per     period or occurrence has been reached. payment already made for same-
      state limit.                                                         similar procedure within set time
                                                                           frame.
                                                                           N357 - Time frame requirements
                                                                           between this service-procedure-
                                                                           supply and a related service-
                                                                           procedure-supply have not been
                                                                           met

626   Exceeds maximum              119 - Benefit maximum for this time    M86 - Service denied because      259 - Frequency of service.
      allowed for intraoral films. period or occurrence has been reached. payment already made for same-
                                                                          similar procedure within set time
                                                                          frame.
                                                                          N362 - The number of Days or
                                                                          Units of Service exceeds our
                                                                          acceptable maximum

627   One periapical single first   119 - Benefit maximum for this time    M86 - Service denied because      259 - Frequency of service.
      film per day.                 period or occurrence has been reached. payment already made for same-
                                                                           similar procedure within set time                             612 -
                                                                           frame.                            Per Day Limit Amount

628   Allow one hyperbaric          119 - Benefit maximum for this time    M86 - Service denied because      259 - Frequency of service.
      oxygen therapy per 30         period or occurrence has been reached. payment already made for same-
      days.                                                                similar procedure within set time                             612 -
                                                                           frame.                       N357 Per Day Limit Amount
                                                                           - Time frame requirements
                                                                           between this service-procedure-
                                                                           supply and a related service-
                                                                           procedure-supply have not been
                                                                           met



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629   Allow 1 service-day for div 119 - Benefit maximum for this time    M86 - Service denied because      259 - Frequency of service.
      of serv for blind.          period or occurrence has been reached. payment already made for same-
                                                                         similar procedure within set time                             612 -
                                                                         frame.                            Per Day Limit Amount

630   Only two visits allowed      119 - Benefit maximum for this time    M86 - Service denied because      259 - Frequency of service.
      per 365 days.                period or occurrence has been reached. payment already made for same-
                                                                          similar procedure within set time
                                                                          frame.                       N357
                                                                          - Time frame requirements
                                                                          between this service-procedure-
                                                                          supply and a related service-
                                                                          procedure-supply have not been
                                                                          met

631   Critical care previously     18 - Duplicate claim-service.          M86 - Service denied because      259 - Frequency of service.
      paid for this date of                                               payment already made for same-
      service.                                                            similar procedure within set time
                                                                          frame.

632   One visit allowed per 365    119 - Benefit maximum for this time    M90 - Not covered more than       259 - Frequency of service.
      days.                        period or occurrence has been reached. once in a 12 month period.

633   Only 2 prosthetic lens       119 - Benefit maximum for this time    N362 - The number of Days or      259 - Frequency of service.
      procedures allowed w-o       period or occurrence has been reached. Units of Service exceeds our
      prior approval.                                                     acceptable maximum


634   One visit allowed per 365    119 - Benefit maximum for this time    M90 - Not covered more than       259 - Frequency of service.
      days.                        period or occurrence has been reached. once in a 12 month period.

635   One venipuncture for         119 - Benefit maximum for this time    M86 - Service denied because      259 - Frequency of service.
      specimen collection          period or occurrence has been reached. payment already made for same-
      allowed per day.                                                    similar procedure within set time                        612 - Per
                                                                          frame.                            Day Limit Amount




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636   One catheterization for     119 - Benefit maximum for this time    M86 - Service denied because      259 - Frequency of service.
      collection allowed per day. period or occurrence has been reached. payment already made for same-
                                                                         similar procedure within set time                        612 - Per
                                                                         frame.                            Day Limit Amount

637   One cataract surgery       119 - Benefit maximum for this time    M86 - Service denied because      259 - Frequency of service.
      procedure allowed per day. period or occurrence has been reached. payment already made for same-
                                                                        similar procedure within set time                        612 - Per
                                                                        frame.                            Day Limit Amount

638   One cataract procedure       119 - Benefit maximum for this time    M86 - Service denied because      259 - Frequency of service.
      allowed per day.             period or occurrence has been reached. payment already made for same-
                                                                          similar procedure within set time                        612 - Per
                                                                          frame.                            Day Limit Amount

639   Follow-up allowed only      149 - Lifetime benefit maximum has         N362 - The number of Days or        259 - Frequency of service.
      twice in a life time.       been reached for this service-benefit      Units of Service exceeds our
                                  category                                   acceptable maximum
640   Procedure allowed once in 149 - Lifetime benefit maximum has           N117 - This service is paid only    259 - Frequency of service.
      a life time.                been reached for this service-benefit      once in a patients lifetime.
                                  category
641   Rebill using y5576 for both 125 - Submission-billing error(s).         MA66 - Missing-incomplete-          21 - Missing or invalid information.
      eyes.                                                                  invalid principal procedure code.

642   Rebill using single eye      125 - Submission-billing error(s).        MA66 - Missing-incomplete-          21 - Missing or invalid information.
      follow up code y5575.                                                  invalid principal procedure code.

643   Only one annual physical     119 - Benefit maximum for this time    M90 - Not covered more than            259 - Frequency of service.
      allowed per year.            period or occurrence has been reached. once in a 12 month period.

644   Physician attendance limit 119 - Benefit maximum for this time    M86 - Service denied because      259 - Frequency of service.
      one per day.               period or occurrence has been reached. payment already made for same-
                                                                        similar procedure within set time                        612 - Per
                                                                        frame.                            Day Limit Amount




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645   Only 5 hrs of Psych-CNS- 151 - Payment adjusted because the         M53 - Missing-incomplete-invalid 259 - Frequency of service.
      Neuro-Cognitive-Mental-    payer deems the information submitted    days or units of service.
      Speech Testing allowed     does not support this many services.                                                               263 -
      per day. One unit=1 hr. If                                                       N29 - Missing       Length of time for services
      billing more than 5 hrs                                             documentation-orders-notes-      rendered.
      submit adjustment request                                           summary-report-chart.
      with documentation of                                                                                612 - Per Day Limit Amount
      time.

646   Tympanostomy includes       97 - The benefit for this service is    M80 - Not covered when             454 - Procedure code for services
      myringotomy procedure       included in the payment-allowance for   performed during the same          rendered.
      paid previously. Resubmit   another service-procedure that has      session-date as a previously
      as an adjustment.           already been adjudicated.               processed service for the patient.

647   Myringotomy included in 97 - The benefit for this service is        M80 - Not covered when             454 - Procedure code for services
      tympanostomy code 69436 included in the payment-allowance for       performed during the same          rendered.
      previously paid.        another service-procedure that has          session-date as a previously
                              already been adjudicated.                   processed service for the patient.

648   Allow procedure once per    149 - Lifetime benefit maximum has      N362 - The number of Days or       259 - Frequency of service.
      lifetime without prior      been reached for this service-benefit   Units of Service exceeds our
      approval.                   category                                acceptable maximum
649   Ventilation assist          97 - The benefit for this service is    M80 - Not covered when             454 - Procedure code for services
      management includes         included in the payment-allowance for   performed during the same          rendered.
      cpap and-or cnp already     another service-procedure that has      session-date as a previously
      paid.                       already been adjudicated.               processed service for the patient.

650   Cpap-cnp included in     97 - The benefit for this service is       M80 - Not covered when             454 - Procedure code for services
      ventilation assist       included in the payment-allowance for      performed during the same          rendered.
      management already paid. another service-procedure that has         session-date as a previously
                               already been adjudicated.                  processed service for the patient.

651   Repair-replacement of       97 - The benefit for this service is    M80 - Not covered when             454 - Procedure code for services
      pacemaker previously        included in the payment-allowance for   performed during the same          rendered.
      paid for this date of       another service-procedure that has      session-date as a previously
      service.                    already been adjudicated.               processed service for the patient.




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652   Services included in         97 - The benefit for this service is     M80 - Not covered when             54 - Duplicate of a previously
      pacemaker insertion          included in the payment-allowance for    performed during the same          processed claim-line.
      previously paid on this      another service-procedure that has       session-date as a previously
      date of service.             already been adjudicated.                processed service for the patient.

653   Private duty nursing not     B15 - This service-procedure requires    N20 - Service not payable with     258 - Days-units for procedure-
      allowed same day as HIT      that a qualifying service-procedure be   other service rendered on the      revenue code.
      self-administered drugs.     received and covered. The qualifying     same date.
      HIT payments are being       other service-procedure has not been
      recouped.                    received-adjudicated.

654   Temporary closure of         97 - The benefit for this service is     M80 - Not covered when             454 - Procedure code for services
      eyelids by suture included   included in the payment-allowance for    performed during the same          rendered.
      in fee for eye surgery       another service-procedure that has       session-date as a previously
      same day.                    already been adjudicated.                processed service for the patient.

655   Only one Health Check        B15 - This service-procedure requires    M86 - Service denied because      258 - Days-units for procedure-
      screening or interperiodic   that a qualifying service-procedure be   payment already made for same- revenue code.
      screen allowed per date of   received and covered. The qualifying     similar procedure within set time                               612
      service, same or different   other service-procedure has not been     frame.                            - Per Day Limit Amount
      provider.                    received-adjudicated.

656   Only one                     B15 - This service-procedure requires    M86 - Service denied because      258 - Days-units for procedure-
      electroencephalog-ram        that a qualifying service-procedure be   payment already made for same- revenue code.
      allowed per day.             received and covered. The qualifying     similar procedure within set time                               612
                                   other service-procedure has not been     frame.                            - Per Day Limit Amount
                                   received-adjudicated.

657   HITself administered         B15 - This service-procedure requires    N20 - Service not payable with     258 - Days-units for procedure-
      drugs not allowed same       that a qualifying service-procedure be   other service rendered on the      revenue code.
      day as IV pole.              received and covered. The qualifying     same date.
                                   other service-procedure has not been
                                   received-adjudicated.

658   Initial supply of batteries 97 - The benefit for this service is      M80 - Not covered when             454 - Procedure code for services
      included in dispensing fee included in the payment-allowance for      performed during the same          rendered.
      for new hearing aid-aids.   another service-procedure that has        session-date as a previously
                                  already been adjudicated.                 processed service for the patient.



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659   HIT self-administered       B15 - This service-procedure requires    N20 - Service not payable with      258 - Days-units for procedure-
      drugs not allowed same      that a qualifying service-procedure be   other service rendered on the       revenue code.
      day as private duty         received and covered. The qualifying     same date.
      nursing.                    other service-procedure has not been
                                  received-adjudicated.

660   IV-pole not allowed same    B15 - This service-procedure requires    N20 - Service not payable with      258 - Days-units for procedure-
      day as HIT self             that a qualifying service-procedure be   other service rendered on the       revenue code.
      administered drugs.         received and covered. The qualifying     same date.
                                  other service-procedure has not been
                                  received-adjudicated.

661   Only allowable y code       125 - Submission-billing error(s).       MA66 - Missing-incomplete-          21 - Missing or invalid information.
      services with residential                                            invalid principal procedure code.
      treatment are Case
      Management and                                                       N188 - The approved level of
      outpatient treatments.                                               care does not match the
                                                                           procedure code submitted
662   Influenza or                96 - Non-covered charge(s).              N30 - Patient ineligible for this   21 - Missing or invalid information.
      pneumococcal vaccine not                                             service.
      covered for recipients 21
      years or older for date of                                                                                                  187 - Date(s) of
      service prior to 10-01-93 .                                                                              service.


663   Procedure code w8211 no 96 - Non-covered charge(s).                  N302 - Missing-incomplete-          21 - Missing or invalid information.
      longer valid on or after 06-                                         invalid other procedure date(s).                     187 - Date(s) of
      01-93.                                                                                                   service.                      454 -
                                                                                                               Procedure code for services
                                                                                                               rendered.
664   Newborn screening not       B15 - This service-procedure requires    N20 - Service not payable with      258 - Days-units for procedure-
      allowed same day as         that a qualifying service-procedure be   other service rendered on the       revenue code.
      Health Check screen or      received and covered. The qualifying     same date.
      office visit.               other service-procedure has not been
                                  received-adjudicated.




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                                                     EOB Code Crosswalk to HIPAA Standard Codes



665   Influenza and               125 - Submission-billing error(s).           M76 - Missing-incomplete-invalid 254 - Primary diagnosis code.
      pneumococcal vaccines                                                    diagnosis or condition.
      for recipients 21 years and                                                  N59 - Alert- Please refer to
      older must be billed with                                                your provider manual for
      the appropriate diagnosis.                                               additional program and
                                                                               provider information

666   Previously submitted      16 - Claim-service lacks information           MA31 - Missing-incomplete-         21 - Missing or invalid information.
      consent has been          which is needed for adjudication.              invalid beginning and ending                               187 -
      approved with a different                                                dates of the period billed.        Date(s) of service
      DOS. Submit corrected
      ECS claim or correct                                                     N225 - Incomplete-invalid
      consent and resubmit with                                                documentation-orders- notes-
      claim and records as an                                                  summary- report- chart.
      adjustment

667   Newborn assessment            149 - Lifetime benefit maximum has         N117 - This service is paid only   259 - Frequency of service.
      limited to once per lifetime. been reached for this service-benefit      once in a patients lifetime.
                                    category
668   Secondary diagnosis is        146 - Diagnosis was invalid for the        M64 - Missing-incomplete-invalid 477 - Diagnosis code pointer is
      invalid.                      date(s) of service reported.               other diagnosis.                 missing or invalid
669   Other diagnosis code 3 is 146 - Diagnosis was invalid for the            M64 - Missing-incomplete-invalid 255 - Diagnosis code.
      invalid.                      date(s) of service reported.               other diagnosis.
                                                                                                                                           477 -
                                                                                                                Diagnosis code pointer is missing
                                                                                                                or invalid.
670   Other diagnosis code 4 is     146 - Diagnosis was invalid for the        M64 - Missing-incomplete-invalid 255 - Diagnosis code.
      invalid.                      date(s) of service reported.               other diagnosis.
                                                                                                                                           477 -
                                                                                                                Diagnosis code pointer is missing
                                                                                                                or invalid.
671   Other diagnosis code 5 is     146 - Diagnosis was invalid for the        M64 - Missing-incomplete-invalid 255 - Diagnosis code.
      invalid.                      date(s) of service reported.               other diagnosis.
                                                                                                                                           477 -
                                                                                                                Diagnosis code pointer is missing
                                                                                                                or invalid.



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672   Codes Y2141 and Y2151        B7 - This provider was not certified-        N95 - This provider type -           88 - Entity not eligible for benefits
      not payable for health       eligible to be paid for this procedure-      provider specialty may not bill      for submitted dates of service.
      departments for services     service on this date of service.             this service.
      on or after 7-1-93. Rebill
      using code 90731.

673   Units for monthly rental     125 - Submission-billing error(s).           M53 - Missing-incomplete-invalid 258 - Days-units for procedure-
      should be billed one per                                                  days or units of service.         revenue code.
      month regardless of the                                                                                          259 - Frequency of service.
      dates of service.                                                                                                                 476 - Missing
                                                                                                                  or invalid units of service
674   Y2151 is payable for         125 - Submission-billing error(s).           MA66 - Missing-incomplete-        21 - Missing or invalid information.
      health departments for                                                    invalid principal procedure code.
      ages 11-99. Rebill using
      y2141.
675   Other procedure code 4       125 - Submission-billing error(s).           N56 - Procedure code billed is        21 - Missing or invalid information.
      must be further                                                           not correct-valid for the services                   490 - Other
      subdivided. (the code                                                     billed or the date of service billed. procedure code for service(s)
      must have 4 digits).                                                                                            rendered
676   Other procedure code 5       125 - Submission-billing error(s).           N56 - Procedure code billed is        21 - Missing or invalid information.
      must be further                                                           not correct-valid for the services                            490 - Other
      subdivided. (the code                                                     billed or the date of service billed. procedure code for service(s)
      must have 4 digits).                                                                                            rendered.
677   Other procedure code 6       125 - Submission-billing error(s).           N56 - Procedure code billed is        21 - Missing or invalid information.
      must be further                                                           not correct-valid for the services                             490 - Other
      subdivided. (the code                                                     billed or the date of service billed. procedure code for service(s)
      must have 4 digits).                                                                                            rendered
678   Medicaid does not            119 - Benefit maximum for this time          No Mapping Required                   259 - Frequency of service.
      reimburse for multiple       period or occurrence has been reached.
      repeat sterilizations.




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679   Verify diagnosis and         11 - The diagnosis is inconsistent with   M76 - Missing-incomplete-invalid 277 - Paper claim.
      procedure(s) and rebill on   the procedure.                            diagnosis or condition.            294 - Supporting documentation.
      paper w/federal statement                                                   N56 - Procedure code billed
      and records                                                            is not correct-valid for the
                                                                             services billed or the date of                                 488 -
                                                                             service billed. N59 - Alert-      Diagnosis code(s) for the services
                                                                             Please refer to your provider    rendered.
                                                                             manual for additional program
                                                                             and provider information


680   Therapeutic abortion       11 - The diagnosis is inconsistent with     M76 - Missing-incomplete-invalid 488 - Diagnosis code(s) for the
      diagnosis code billed with the procedure.                              diagnosis or condition.          services rendered
      non-therapeutic                                                         N34 - Incorrect claim form-
      procedure. Correct                                                     format for this service.
      diagnosis or procedure
      code and resubmit

681   Non-therapeutic abortion     11 - The diagnosis is inconsistent with   M76 - Missing-incomplete-invalid 488 - Diagnosis code(s) for the
      must be billed with          the procedure.                            diagnosis or condition.          services rendered
      appropriate diagnosis                                                     N59 - Alert- Please refer to
      code. Correct and                                                      your provider manual for
      resubmit.                                                              additional program and
                                                                             provider information

682   Induced abortion             11 - The diagnosis is inconsistent with   M76 - Missing-incomplete-invalid 21 - Missing or invalid information.
      procedure code must be       the procedure.                            diagnosis or condition.                              277 - Paper
      billed with appropriate                                                   N59 - Alert- Please refer to  claim.
      diagnosis code. Correct                                                your provider manual for            294 - Supporting documentation.
      and resubmit on pap with                                               additional program and
      records and federal                                                    provider information
      abortion statement

683   Resubmit with abortion       16 - Claim-service lacks information      N29 - Missing documentation-      21 - Missing or invalid information.
      statement and records        which is needed for adjudication.         orders- notes- summary- report-                          294 -
                                                                             chart.                            Supporting documentation.




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684   Only 30 Home Health           119 - Benefit maximum for this time    M86 - Service denied because      259 - Frequency of service.
      visits allowed per month.     period or occurrence has been reached. payment already made for same-
                                                                           similar procedure within set time
                                                                           frame.
                                                                           N357 - Time frame requirements
                                                                           between this service-procedure-
                                                                           supply and a related service-
                                                                           procedure-supply have not been
                                                                           met

685   Health check services are     6 - The procedure-revenue code is          No Mapping Required                475 - Procedure code not valid for
      for Medicaid recipients       inconsistent with the patients age                                            patient age.
      birth thru age 20 only.

686   Prior approval is required    197 - Precertification-authorization-      N54 - Claim information is         48 - Referral-authorization.
      for more than 15              notification absent.                       inconsistent with pre-certified-                           84 -
      consecutive therapeutic                                                  authorized services.               Service not authorized.
      leave days.

687   Health check screen or        B15 - This service-procedure requires      N20 - Service not payable with     258 - Days-units for procedure-
      office visits are not         that a qualifying service-procedure be     other service rendered on the      revenue code.
      allowed on the same day       received and covered. The qualifying       same date.
      as newborn screening.         other service-procedure has not been
                                    received-adjudicated.

688   Refile with Medicare: part    23 - The impact of prior payer(s)      No Mapping Required                    116 - Claim submitted to incorrect
      B buy-in is now effective     adjudication including payments and-or                                        payer.
      for these dates of service.   adjustments.

689   Claim previously              23 - The impact of prior payer(s)      No Mapping Required                    116 - Claim submitted to incorrect
      submitted to Medicare         adjudication including payments and-or                                        payer.
      with an incorrect hic         adjustments.
      number. Please correct
      the hic number and refile
      with Medicare.




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690   Please re-file with            22 - This care may be covered by       M86 - Service denied because      107 - Processed according to
      Medicare: Records              another payer per coordination of      payment already made for same- contract-plan provisions.
      indicate that someone          benefits.                              similar procedure within set time    116 - Claim submitted to
      other than Medicaid is                                                frame.                            incorrect payer.
      paying Medicare part B
      premiums for this
      recipient for these dates of
      service.
691   Medicare denied your           23 - The impact of prior payer(s)      No Mapping Required               116 - Claim submitted to incorrect
      claim for correction and-or    adjudication including payments and-or                                   payer.
      additional information.        adjustments.                                                                123 - Additional information
      Please refile to Medicare                                                                               requested from entity.
      with the eomb correction
      requested.

692   Refresher childbirth           119 - Benefit maximum for this time    M86 - Service denied because      259 - Frequency of service.
      classes limited to once -      period or occurrence has been reached. payment already made for same-
      180 dys.                                                              similar procedure within set time
                                                                            frame.
                                                                            N357 - Time frame requirements
                                                                            between this service-procedure-
                                                                            supply and a related service-
                                                                            procedure-supply have not been
                                                                            met

693   Only one inpatient respite     119 - Benefit maximum for this time    M86 - Service denied because      259 - Frequency of service.
      care allowed per day.          period or occurrence has been reached. payment already made for same-
                                                                            similar procedure within set time                           612 -
                                                                            frame.                            Per Day Limit Amount

694   Exceeds daily limit for        119 - Benefit maximum for this time    M86 - Service denied because      259 - Frequency of service.
      continuous home care.          period or occurrence has been reached. payment already made for same-
      Rebill using RC651.                                                   similar procedure within set time                           612 -
                                                                            frame.                            Per Day Limit Amount
                                                                            N357 - Time frame requirements
                                                                            between this service-procedure-
                                                                            supply and a related service-
                                                                            procedure-supply have not been
                                                                            met


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695   One colectomy allowed        119 - Benefit maximum for this time    M86 - Service denied because      259 - Frequency of service.
      per day.                     period or occurrence has been reached. payment already made for same-
                                                                          similar procedure within set time                           612 -
                                                                          frame.                            Per Day Limit Amount

696   One colonoscopy allowed      119 - Benefit maximum for this time    M86 - Service denied because      259 - Frequency of service.
      per day.                     period or occurrence has been reached. payment already made for same-
                                                                          similar procedure within set time                           612 -
                                                                          frame.                            Per Day Limit Amount

697   One Home Health visit        119 - Benefit maximum for this time    M86 - Service denied because      259 - Frequency of service.
      allowed per date of service. period or occurrence has been reached. payment already made for same-
                                                                          similar procedure within set time                           612 -
                                                                          frame.                            Per Day Limit Amount

698   One unit equals multiple     125 - Submission-billing error(s).        M53 - Missing-incomplete-invalid 259 - Frequency of service.
      determinations, resubmit                                               days or units of service.                               476 -
      billing only one unit.                                                                                  Missing or invalid units of service


699   Exceeds one per month        119 - Benefit maximum for this time    M86 - Service denied because      259 - Frequency of service.
      limitation for Case          period or occurrence has been reached. payment already made for same-
      Management.                                                         similar procedure within set time
                                                                          frame.
                                                                          N357 - Time frame requirements
                                                                          between this service-procedure-
                                                                          supply and a related service-
                                                                          procedure-supply have not been
                                                                          met

700   Use established office       125 - Submission-billing error(s).        M13 - Only one initial visit is   21 - Missing or invalid information.
      visit code.                                                            covered per specialty per
                                                                             medical group.
                                                                                                                    454 - Procedure code for
                                                                                                                 services rendered.
701   Second surgery reduced       59 - Charges are adjusted based on        N381 - Consult our contractual      259 - Frequency of service.
      50% if performed on the      multiple or concurrent procedure rules.   agreement for restrictions-billing- 453 - Procedure Code Modifier(s)
      same day.                    (For example multiple surgery or          payment information related to      for Service(s) Rendered
                                   diagnostic imaging, concurrent            these charges
                                   anesthesia.)

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702   Periodic orthodontic        119 - Benefit maximum for this time      M86 - Service denied because      259 - Frequency of service.
      treatment visit (as part of period or occurrence has been reached.   payment already made for same-
      contract) allowed once per                                           similar procedure within set time
      calendar month.                                                      frame.
                                                                           N357 - Time frame requirements
                                                                           between this service-procedure-
                                                                           supply and a related service-
                                                                           procedure-supply have not been
                                                                           met

703   Rhythm strip included in    97 - The benefit for this service is     M80 - Not covered when             454 - Procedure code for services
      12 lead EKG.                included in the payment-allowance for    performed during the same          rendered.
                                  another service-procedure that has       session-date as a previously
                                  already been adjudicated.                processed service for the patient.

704   Component of EKG            97 - The benefit for this service is     M86 - Service denied because       454 - Procedure code for services
      previously paid this DOS.   included in the payment-allowance for    payment already made for           rendered.
      Please file adjustment.     another service-procedure that has       similar procedure within set
                                  already been adjudicated.                time frame
                                                                                           N1 - Alert- You
                                                                           may appeal this decision in
                                                                           writing within the required
                                                                           time limits following receipt of
                                                                           this notice by following the
                                                                           instructions included in your
                                                                           contract or plan benefit
                                                                           documents


705   Exceeds limitation per      119 - Benefit maximum for this time    M86 - Service denied because      259 - Frequency of service.
      DME guidelines.             period or occurrence has been reached. payment already made for same-
                                                                         similar procedure within set time
                                                                         frame




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706   Myelodysplasia clinic           119 - Benefit maximum for this time    M86 - Service denied because      259 - Frequency of service.
      limited to once per 90          period or occurrence has been reached. payment already made for same-
      days.                                                                  similar procedure within set time
                                                                             frame.                       N357
                                                                             - Time frame requirements
                                                                             between this service-procedure-
                                                                             supply and a related service-
                                                                             procedure-supply have not been
                                                                             met

707   Initial critical care allowed   119 - Benefit maximum for this time    M86 - Service denied because      259 - Frequency of service.
      once per hospitalization.       period or occurrence has been reached. payment already made for same-
                                                                             similar procedure within set time
                                                                             frame.                       N357
                                                                             - Time frame requirements
                                                                             between this service-procedure-
                                                                             supply and a related service-
                                                                             procedure-supply have not been
                                                                             met

708   Admission H&P allowed       119 - Benefit maximum for this time        M86 - Service denied because      259 - Frequency of service.
      once per hospitalization.   period or occurrence has been reached.     payment already made for same-
      Transfers within the same                                              similar procedure within set time
      facility do not support the                                            frame.                       N357
      billing of a new admission.                                            - Time frame requirements
      Rebill appropriate level                                               between this service-procedure-
      CPT E-M code.                                                          supply and a related service-
                                                                             procedure-supply have not been
                                                                             met

709   Exceeds once per month          119 - Benefit maximum for this time    M86 - Service denied because      259 - Frequency of service.
      limitation for tens             period or occurrence has been reached. payment already made for same-
      procedure.                                                             similar procedure within set time
                                                                             frame
710   Only one corneal                119 - Benefit maximum for this time    M86 - Service denied because      259 - Frequency of service.
      transplant per day. If          period or occurrence has been reached. payment already made for same-
      surgery performed on                                                   similar procedure within set time                           612 -
      both eyes, document and                                                frame.                            Per Day Limit Amount
      submit as an adjustment.


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711   Only one epidural follow-   119 - Benefit maximum for this time    M86 - Service denied because      259 - Frequency of service.
      up allowed per day.         period or occurrence has been reached. payment already made for same-
                                                                         similar procedure within set time                           612 -
                                                                         frame.                            Per Day Limit Amount

712   Only one epidural           119 - Benefit maximum for this time    M86 - Service denied because        259 - Frequency of service.
      procedure allowed every     period or occurrence has been reached. payment already made for same-
      four days.                                                         similar procedure within set time
                                                                         frame
713   Lupron depot limited to     119 - Benefit maximum for this time    M86 - Service denied because        259 - Frequency of service.
      once every 28 days.         period or occurrence has been reached. payment already made for same-
                                                                         similar procedure within set time
                                                                         frame
714   Routine, annual or          96 - Non-covered charge(s).            M79 - Missing-incomplete-invalid    454 - Procedure code for services
      screening mammography                                              charge                              rendered.
      non-covered.

715   Original surgery fee        97 - The benefit for this service is    M80 - Not covered when             454 - Procedure code for services
      includes multiple stage     included in the payment-allowance for   performed during the same          rendered.
      retinal repair.             another service-procedure that has      session-date as a previously
                                  already been adjudicated.               processed service for the patient.

716   Exceeds one per day         119 - Benefit maximum for this time    M86 - Service denied because      259 - Frequency of service.
      limitation.                 period or occurrence has been reached. payment already made for same-
                                                                         similar procedure within set time                           612 -
                                                                         frame.                            Per Day Limit Amount

717   Cap waiver supplies limit   119 - Benefit maximum for this time    M86 - Service denied because      259 - Frequency of service.
      once per day.               period or occurrence has been reached. payment already made for same-
                                                                         similar procedure within set time                           612 -
                                                                         frame.                            Per Day Limit Amount

718   Exceeds one per day         119 - Benefit maximum for this time    M86 - Service denied because      259 - Frequency of service.
      limitation.                 period or occurrence has been reached. payment already made for same-
                                                                         similar procedure within set time                           612 -
                                                                         frame.                            Per Day Limit Amount




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                                                    EOB Code Crosswalk to HIPAA Standard Codes


719   Exceeds CAP limitation for B5 - Coverage-program guidelines           N362 - The number of Days or          259 - Frequency of service.
      Case Management.           were not met or were exceeded.             Units of Service exceeds our          483 - Maximum coverage amount
                                                                            acceptable maximum.                   met or exceeded for benefit period.
                                                                            N381 - Consult our contractual
                                                                            agreement for restrictions-billing-
                                                                            payment information related to
                                                                            these charges
720   Sterilization under both     B15 - This service-procedure requires    N1 - Alert- You may appeal this       258 - Days-units for procedure-
      general anesthesia and       that a qualifying service-procedure be   decision in writing within the        revenue code.
      epidural anesthesia not      received and covered. The qualifying     required time limits following
      allowed on the same day.     other service-procedure has not been     receipt of this notice by
      Please file an adjustment    received-adjudicated.                    following the instructions
      request with                                                          included in your contract or
      documentation for                                                     plan benefit documents.
      exceptions.                                                                               N20 -
                                                                            Service not payable with other
                                                                            service rendered on the same
                                                                            date.

                                                                            N29 - Missing documentation-
                                                                            orders- notes- summary-
                                                                            report- chart.



721   Each additional lesion       107 - The related or qualifying claim-    N19 - Procedure code incidental      465 - Principal Procedure Code for
      only allowed when billed     service was not identified on this claim. to primary procedure.                Service(s) Rendered.
      on the same day as                                                          N161 - This drug-service-
      excision of breast lesion.                                             supply is covered only when the
                                                                             associated service is covered.

722   Each additional lesion       107 - The related or qualifying claim-    N19 - Procedure code incidental      465 - Principal Procedure Code for
      only allowed when billed     service was not identified on this claim. to primary procedure.                Service(s) Rendered.
      on the same day as                                                            N161 - This drug-service-
      preoperative placement                                                 supply is covered only when the
      needle localization wire;                                              associated service is covered.
      breast.



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723   Exceeds one per day           119 - Benefit maximum for this time    M86 - Service denied because      259 - Frequency of service.
      limitation.                   period or occurrence has been reached. payment already made for same-
                                                                           similar procedure within set time                           612 -
                                                                           frame.                            Per Day Limit Amount

724   Limit one CAP screening       119 - Benefit maximum for this time    M86 - Service denied because      259 - Frequency of service.
      per fiscal year.              period or occurrence has been reached. payment already made for same-
                                                                           similar procedure within set time
                                                                           frame.                       N357
                                                                           - Time frame requirements
                                                                           between this service-procedure-
                                                                           supply and a related service-
                                                                           procedure-supply have not been
                                                                           met

725   Capsulodesis for m-p joint    B15 - This service-procedure requires    N20 - Service not payable with        258 - Days-units for procedure-
      stabilization; single digit   that a qualifying service-procedure be   other service rendered on the         revenue code.
      and 2-4 digits not allowed    received and covered. The qualifying     same date.
      on the same date of           other service-procedure has not been
      service.                      received-adjudicated.

726   CAP home mobility dollar      45 - Charge exceeds fee schedule-        N381 - Consult our contractual      483 - Maximum coverage amount
      limitation has been met.      maximum allowable or contracted-         agreement for restrictions-billing- met or exceeded for benefit period.
                                    legislated fee arrangement. (Use         payment information related to
                                    Group Codes PR or CO depending           these charges
                                    upon liability).
727   CAP limitation has been       B5 - Coverage-program guidelines         N362 - The number of Days or          259 - Frequency of service.
      exceeded.                     were not met or were exceeded.           Units of Service exceeds our          483 - Maximum coverage amount
                                                                             acceptable maximum.                   met or exceeded for benefit period.
                                                                             N381 Consult our contractual
                                                                             agreement for restrictions-billing-
                                                                             payment information related to
                                                                             these charges
728   CAP limitation has been       B5 - Coverage-program guidelines         N362 - The number of Days or          259 - Frequency of service.
      exceeded.                     were not met or were exceeded.           Units of Service exceeds our          483 - Maximum coverage amount
                                                                             acceptable maximum.                   met or exceeded for benefit period.
                                                                             N381 - Consult our contractual
                                                                             agreement for restrictions-billing-
                                                                             payment information related to
                                                                             these charges

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                                                      EOB Code Crosswalk to HIPAA Standard Codes


729   CAP limitation has been        B5 -Coverage-program guidelines were N362 - The number of Days or            259 - Frequency of service.
      exceeded.                      not met or were exceeded.              Units of Service exceeds our          483 - Maximum coverage amount
                                                                            acceptable maximum.                   met or exceeded for benefit period.
                                                                            N381 - Consult our contractual
                                                                            agreement for restrictions-billing-
                                                                            payment information related to
                                                                            these charges
730   Dental exam not allowed        B15 - This service-procedure requires N20 - Service not payable with         258 - Days-units for procedure-
      on the same date of            that a qualifying service-procedure be other service rendered on the         revenue code.
      service as limited oral        received and covered. The qualifying   same date.
      evaluation problem             other service-procedure has not been
      focused.                       received-adjudicated.

731   CAP limitation has been        B5 - Coverage-program guidelines       N362 - The number of Days or          259 - Frequency of service.
      exceeded.                      were not met or were exceeded.         Units of Service exceeds our          483 - Maximum coverage amount
                                                                            acceptable maximum.                   met or exceeded for benefit period.
                                                                            N381 - Consult our contractual
                                                                            agreement for restrictions-billing-
                                                                            payment information related to
                                                                            these charges
732   Gamma globulin may be          119 - Benefit maximum for this time    M86 - Service denied because          259 - Frequency of service.
      billed only one time per       period or occurrence has been reached. payment already made for same-
      date of service. If billing                                           similar procedure within set time                               612 -
      multiple units, rebill using                                          frame.                                Per Day Limit Amount
      the appropriate dose
      specific HCPC code.


733   Depo-Provera                   119 - Benefit maximum for this time    M86 - Service denied because      259 - Frequency of service.
      contraceptive injection        period or occurrence has been reached. payment already made for same-
      allowed once every 75                                                 similar procedure within set time
      days .                                                                frame.                       N357
                                                                            - Time frame requirements
                                                                            between this service-procedure-
                                                                            supply and a related service-
                                                                            procedure-supply have not been
                                                                            met



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                                                     EOB Code Crosswalk to HIPAA Standard Codes

734   V20.2 must be primary         11 - The diagnosis is inconsistent with    M76 - Missing-incomplete-invalid 254 - Primary diagnosis code.
      diagnosis for Health          the procedure.                             diagnosis or condition.
      Check screening visit.
735   Diagnosis modifier            4 - The procedure code is inconsistent     No Mapping Required               488 - Diagnosis code(s) for the
      missing or invalid for        with the modifier or a required modifier                                     services rendered
      diagnosis code (s).           is missing.
      Health check visit requires
      each listed diagnosis to
      have a corresponding
      modifier in block 24D.
      V202 must be primary DX.


736   CAP limitation has been       B5 - Coverage-program guidelines       N362 - The number of Days or          259 - Frequency of service.
      exceeded.                     were not met or were exceeded.         Units of Service exceeds our          483 - Maximum coverage amount
                                                                           acceptable maximum.                   met or exceeded for benefit period.
                                                                           N381 - Consult our contractual
                                                                           agreement for restrictions-billing-
                                                                           payment information related to
                                                                           these charges
737   CAP limitation has been       B5 - Coverage-program guidelines       N362 - The number of Days or          259 - Frequency of service.
      exceeded.                     were not met or were exceeded.         Units of Service exceeds our          483 - Maximum coverage amount
                                                                           acceptable maximum.                   met or exceeded for benefit period.
                                                                           N381 - Consult our contractual
                                                                           agreement for restrictions-billing-
                                                                           payment information related to
                                                                           these charges
738   One supply item allowed       119 - Benefit maximum for this time    M86 - Service denied because          259 - Frequency of service.
      per day.                      period or occurrence has been reached. payment already made for same-
                                                                           similar procedure within set time                               612 -
                                                                           frame.                                Per Day Limit Amount

739   HIV Case Management           119 - Benefit maximum for this time    M86 - Service denied because      259 - Frequency of service.
      daily limit has exceeded      period or occurrence has been reached. payment already made for same-
      the maximum of 96 units                                              similar procedure within set time                           612 -
      allowed per day.                                                     frame.                       N362 Per Day Limit Amount
                                                                           - The number of Days or Units of
                                                                           Service exceeds our acceptable
                                                                           maximum


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                                                   EOB Code Crosswalk to HIPAA Standard Codes




740   CAP limitation has been      B5 - Coverage-program guidelines        N362 - The number of Days or          259 - Frequency of service.
      exceeded.                    were not met or were exceeded.          Units of Service exceeds our          483 - Maximum coverage amount
                                                                           acceptable maximum.                   met or exceeded for benefit period.
                                                                           N381 - Consult our contractual
                                                                           agreement for restrictions-billing-
                                                                           payment information related to
                                                                           these charges
741   Multiple surgery for       59 - Charges are adjusted based on        N381 - Consult our contractual        259 - Frequency of service.
      ambulatory surgical center multiple or concurrent procedure rules.   agreement for restrictions-billing-   453 - Procedure Code Modifier(s)
      cutback.                   (For example multiple surgery or          payment information related to        for Service(s) Rendered
                                 diagnostic imaging, concurrent            these charges
                                 anesthesia.)
742   Use established ER         125 - Submission-billing error(s).        MA66 - Missing-incomplete-            465 - Principal Procedure Code for
      procedure code.                                                      invalid principal procedure code.     Service(s) Rendered.

743   Allow eye surgery once-      119 - Benefit maximum for this time    M90 - Not covered more than            259 - Frequency of service.
      year-eye.                    period or occurrence has been reached. once in a 12 month period.

744   Allow one tens (w5001)       119 - Benefit maximum for this time    M86 - Service denied because      259 - Frequency of service.
      monthly.                     period or occurrence has been reached. payment already made for same-
                                                                          similar procedure within set time
                                                                          frame.
                                                                          N357 - Time frame requirements
                                                                          between this service-procedure-
                                                                          supply and a related service-
                                                                          procedure-supply have not been
                                                                          met

745   Exceeds monthly allowed      119 - Benefit maximum for this time    N381 - Consult our contractual      259 - Frequency of service.
      for tens rental.             period or occurrence has been reached. agreement for restrictions-billing- 483 - Procedure Code Modifier(s)
                                                                          payment information related to      for Service(s) Rendered
                                                                          these charges




                                                                      Page 120
                                                    EOB Code Crosswalk to HIPAA Standard Codes




746   Allow one tens (w5000)       119 - Benefit maximum for this time    M86 - Service denied because      259 - Frequency of service.
      weekly.                      period or occurrence has been reached. payment already made for same-
                                                                          similar procedure within set time
                                                                          frame.
                                                                          N357 - Time frame requirements
                                                                          between this service-procedure-
                                                                          supply and a related service-
                                                                          procedure-supply have not been
                                                                          met

747   Exceeds monthly              119 - Benefit maximum for this time    M86 - Service denied because      259 - Frequency of service.
      allowable for tens rental.   period or occurrence has been reached. payment already made for same-
                                                                          similar procedure within set time
                                                                          frame.
                                                                          N357 - Time frame requirements
                                                                          between this service-procedure-
                                                                          supply and a related service-
                                                                          procedure-supply have not been
                                                                          met

748   CAP limitation has been      B5 - Coverage-program guidelines       N362 - The number of Days or          259 - Frequency of service.
      exceeded.                    were not met or were exceeded.         Units of Service exceeds our          483 - Maximum coverage amount
                                                                          acceptable maximum.                   met or exceeded for benefit period.
                                                                          N381 - Consult our contractual
                                                                          agreement for restrictions-billing-
                                                                          payment information related to
                                                                          these charges
749   Prior claim for Case         18 - Duplicate claim-service.          M86 - Service denied because          259 - Frequency of service.
      Management has been                                                 payment already made for same-
      paid for this month.                                                similar procedure within set time
                                                                          frame.




                                                                      Page 121
                                                   EOB Code Crosswalk to HIPAA Standard Codes


750   Therapeutic leave days      119 - Benefit maximum for this time    M86 - Service denied because      259 - Frequency of service.
      have exceeded the           period or occurrence has been reached. payment already made for same-
      maximum of 60 allowed                                              similar procedure within set time
      for the calendar year.                                             frame.
                                                                         N357 - Time frame requirements
                                                                         between this service-procedure-
                                                                         supply and a related service-
                                                                         procedure-supply have not been
                                                                         met

751   Adult health assessment     119 - Benefit maximum for this time    M90 - Not covered more than       259 - Frequency of service.
      limited to once per 365     period or occurrence has been reached. once in a 12 month period.
      days.
752   Allow 2 eye exams a year.   119 - Benefit maximum for this time    M86 - Service denied because      259 - Frequency of service.
                                  period or occurrence has been reached. payment already made for same-
                                                                         similar procedure within set time
                                                                         frame.
                                                                         N357 - Time frame requirements
                                                                         between this service-procedure-
                                                                         supply and a related service-
                                                                         procedure-supply have not been
                                                                         met

753   Second billing of the same 18 - Duplicate claim-service.           M86 - Service denied because      259 - Frequency of service.
      quadrant for periodontal                                           payment already made for same-
      scaling root planning.                                             similar procedure within set time
                                                                         frame.

754   Only 4 quadrants of         119 - Benefit maximum for this time    M86 - Service denied because      259 - Frequency of service.
      periodontal scaling and     period or occurrence has been reached. payment already made for same-
      root planning allowed                                              similar procedure within set time
      every 364 days.                                                    frame.
                                                                         N357 - Time frame requirements
                                                                         between this service-procedure-
                                                                         supply and a related service-
                                                                         procedure-supply have not been
                                                                         met



                                                                     Page 122
                                                   EOB Code Crosswalk to HIPAA Standard Codes




755   ESRD related services for   125 - Submission-billing error(s).      M53 - Missing-incomplete-invalid   258 - Days-units for procedure-
      full month must be billed                                           days or units of service.          revenue code.
      using the last day of the                                                                 MA31 -         259 - Frequency of service.
      month and one unit of                                               Missing-incomplete-invalid                                     476 -
      service.                                                            beginning and ending dates of      Missing or invalid units of service.
                                                                          the period billed.
756   Allow circumcision once     149 - Lifetime benefit maximum has      N117 - This service is paid only 259 - Frequency of service.
      per lifetime.               been reached for this service-benefit   once in a patients lifetime.
                                  category
757   Allow therapeutic           119 - Benefit maximum for this time    M86 - Service denied because      259 - Frequency of service.
      apheresis once per day.     period or occurrence has been reached. payment already made for same-
                                                                         similar procedure within set time                           612 -
                                                                         frame.                            Per Day Limit Amount

758   Allow 1 dental sealant      119 - Benefit maximum for this time    No Mapping Required                 259 - Frequency of service.
      (01351) per tooth.          period or occurrence has been reached.

759   Colposcopy allowed once     119 - Benefit maximum for this time    M86 - Service denied because      259 - Frequency of service.
      per day.                    period or occurrence has been reached. payment already made for same-
                                                                         similar procedure within set time                           612 -
                                                                         frame.                            Per Day Limit Amount

760   Only one diagnosis          125 - Submission-billing error(s).      MA130 - Your claim contains       258 - Days-units for procedure-
      modifier allowed in block                                           incomplete and-or invalid         revenue code.
      24d per diagnosis code.                                             information, and no appeal rights
      1N not allowed in                                                   are afforded because the claim is
      conjunction with another                                            unprocessable. Please submit a
      diagnosis modifier such                                             new claim with the complete-
      as 2E, etc.                                                         correct information.




                                                                       Page 123
                                                    EOB Code Crosswalk to HIPAA Standard Codes


761   Ophthalmoscopy            119 - Benefit maximum for this time    M86 - Service denied because      259 - Frequency of service.
      angiographies allowed six period or occurrence has been reached. payment already made for same-
      times per 365 days.                                              similar procedure within set time
                                                                       frame.
                                                                       N357 - Time frame requirements
                                                                       between this service-procedure-
                                                                       supply and a related service-
                                                                       procedure-supply have not been
                                                                       met

762   Medical necessity for        50 - These are non-covered services        N180 - This item or service does 411 - Medical necessity for non-
      multiple ultrasounds not     because this is not deemed a `medical      not meet the criteria for the      routine service(s).
      apparent resubmit as         necessity by the payer.                    category under which it was billed
      adjustment with records

763   Cephalometric x-ray and- 149 - Lifetime benefit maximum has             N117 - This service is paid only   259 - Frequency of service.
      or diagnostic models are    been reached for this service-benefit       once in a patients lifetime.
      allowed once in a lifetime category
      in conjunction with an
      initial orthodontic workup.


764   Comprehensive                149 - Lifetime benefit maximum has         N117 - This service is paid only   259 - Frequency of service.
      orthodontic treatment of     been reached for this service-benefit      once in a patients lifetime.
      the adolescent dentition     category
      (banding) allowed once
      per lifetime.

765   Only one FP initial-         119 - Benefit maximum for this time    M86 - Service denied because      259 - Frequency of service.
      complete physical per 335    period or occurrence has been reached. payment already made for same-
      days.                                                               similar procedure within set time
                                                                          frame.
                                                                          N357 - Time frame requirements
                                                                          between this service-procedure-
                                                                          supply and a related service-
                                                                          procedure-supply have not been
                                                                          met



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                                                   EOB Code Crosswalk to HIPAA Standard Codes




766   Medical necessity for        50 - These are non-covered services     N180 - This item or service does 411 - Medical necessity for non-
      multiple non stress test     because this is not deemed a `medical   not meet the criteria for the      routine service(s).
      not apparent.                necessity by the payer.                 category under which it was billed

767   One adult health             119 - Benefit maximum for this time    M90 - Not covered more than        259 - Frequency of service.
      screening per 365 days.      period or occurrence has been reached. once in a 12 month period.

768   H-A batteries allowed six    119 - Benefit maximum for this time    M86 - Service denied because      259 - Frequency of service.
      times per 365 days.          period or occurrence has been reached. payment already made for same-
                                                                          similar procedure within set time
                                                                          frame.

769   Loaner hearing aid        119 - Benefit maximum for this time    M86 - Service denied because      259 - Frequency of service.
      payment limit per 10 week period or occurrence has been reached. payment already made for same-
      period has been exceeded.                                        similar procedure within set time
                                                                       frame.
                                                                       N357 - Time frame requirements
                                                                       between this service-procedure-
                                                                       supply and a related service-
                                                                       procedure-supply have not been
                                                                       met

770   Exceeds limit for periodic   119 - Benefit maximum for this time    N362 - The number of Days or       259 - Frequency of service.
      orthodontic treatment        period or occurrence has been reached. Units of Service exceeds our
      visits.                                                             acceptable maximum
771   Procedure allowed once in    149 - Lifetime benefit maximum has     N117 - This service is paid only   259 - Frequency of service.
      a lifetime.                  been reached for this service-benefit  once in a patients lifetime.
                                   category
772   Allow one refraction per     119 - Benefit maximum for this time    M90 - Not covered more than        259 - Frequency of service.
      year on recipients under     period or occurrence has been reached. once in a 12 month period.
      age twenty five.




                                                                      Page 125
                                                    EOB Code Crosswalk to HIPAA Standard Codes

773   Exceeds limit per 365 days. 119 - Benefit maximum for this time    M86 - Service denied because      259 - Frequency of service.
                                  period or occurrence has been reached. payment already made for same-
                                                                         similar procedure within set time
                                                                         frame.
                                                                         N357 - Time frame requirements
                                                                         between this service-procedure-
                                                                         supply and a related service-
                                                                         procedure-supply have not been
                                                                         met

774   Allow one refraction per     119 - Benefit maximum for this time    M86 - Service denied because      259 - Frequency of service.
      two years on recipients      period or occurrence has been reached. payment already made for same-
      age 25 years and older.                                             similar procedure within set time
                                                                          frame.
                                                                          N357 - Time frame requirements
                                                                          between this service-procedure-
                                                                          supply and a related service-
                                                                          procedure-supply have not been
                                                                          met

775   RC 590 allowed once per      119 - Benefit maximum for this time    M86 - Service denied because      259 - Frequency of service.
      day. If submitting           period or occurrence has been reached. payment already made for same-
      adjustment, attach time                                             similar procedure within set time                           612 -
      documentation.                                                      frame.                            Per Day Limit Amount

776   Allow two eye exams a        119 - Benefit maximum for this time    M86 - Service denied because      259 - Frequency of service.
      year.                        period or occurrence has been reached. payment already made for same-
                                                                          similar procedure within set time
                                                                          frame.
                                                                          N357 - Time frame requirements
                                                                          between this service-procedure-
                                                                          supply and a related service-
                                                                          procedure-supply have not been
                                                                          met

777   Rebill established visit     125 - Submission-billing error(s).      M13 - Only one initial visit is   21 - Missing or invalid information.
      code 92012 or 92014 for                                              covered per specialty per
      dates of service 11-01-90                                            medical group.
      and there after.


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                                                      EOB Code Crosswalk to HIPAA Standard Codes



778   Zoladex allowed once in        119 - Benefit maximum for this time    N118 - This service is not paid if   259 - Frequency of service.
      28 days.                       period or occurrence has been reached. billed more than once every 28
                                                                            days
779   Refractive code denied         125 - Submission-billing error(s).     M13 - Only one initial visit is      21 - Missing or invalid information.
      due to a medical                                                      covered per specialty per
      diagnosis-medical office                                              medical group.
      visit paid in history with                                                                                   454 - Procedure code for
      the same date of service.                                                                                  services rendered.
      If necessary file an adj. To
      correct the diagnosis-
      procedure

780   Only one wais bender test      119 - Benefit maximum for this time    M86 - Service denied because      259 - Frequency of service.
      allowed per six months.        period or occurrence has been reached. payment already made for same-
                                                                            similar procedure within set time
                                                                            frame.
                                                                            N357 - Time frame requirements
                                                                            between this service-procedure-
                                                                            supply and a related service-
                                                                            procedure-supply have not been
                                                                            met

781   Only on psychiatric            119 - Benefit maximum for this time    M86 - Service denied because      259 - Frequency of service.
      interview allowed per six      period or occurrence has been reached. payment already made for same-
      months.                                                               similar procedure within set time
                                                                            frame.
                                                                            N357 - Time frame requirements
                                                                            between this service-procedure-
                                                                            supply and a related service-
                                                                            procedure-supply have not been
                                                                            met

782   Only one psychiatric visit     119 - Benefit maximum for this time    M86 - Service denied because      259 - Frequency of service.
      allowed per day.               period or occurrence has been reached. payment already made for same-
                                                                            similar procedure within set time                           612 -
                                                                            frame.                            Per Day Limit Amount




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                                                  EOB Code Crosswalk to HIPAA Standard Codes




783   Pap test only allowed once 119 - Benefit maximum for this time    M90 - Not covered more than          259 - Frequency of service.
      per year for the same      period or occurrence has been reached. once in a 12 month period.
      provider unless diagnosis
      or symptoms warrant
      additional test.

784   Facility retraining fees    149 - Lifetime benefit maximum has       N362 - The number of Days or       259 - Frequency of service.
      limited to 15 per           been reached for this service-benefit    Units of Service exceeds our
      recipient's lifetime.       category                                 acceptable maximum
785   Professional retraining     149 - Lifetime benefit maximum has       N362 - The number of Days or       259 - Frequency of service.
      fees limited to eighteen.   been reached for this service-benefit    Units of Service exceeds our
                                  category                                 acceptable maximum
786   Only three visual field     119 - Benefit maximum for this time      M86 - Service denied because       259 - Frequency of service.
      exams allowed per year.     period or occurrence has been reached.   payment already made for same-
                                                                           similar procedure within set time
                                                                           frame.                      N357 -
                                                                            Time frame requirements
                                                                           between this service-procedure-
                                                                           supply and a related service-
                                                                           procedure-supply have not been
                                                                           met

787   Lupron depot allowed 16     119 - Benefit maximum for this time    N357 - Time frame requirements 259 - Frequency of service.
      units per 365 days.         period or occurrence has been reached. between this service-procedure-
                                                                         supply and a related service-
                                                                         procedure-supply have not been
                                                                         met.                       N362 -
                                                                         The number of Days or Units of
                                                                         Service exceeds our acceptable
                                                                         maximum




                                                                    Page 128
                                                  EOB Code Crosswalk to HIPAA Standard Codes

788   Only one therapeutic        119 - Benefit maximum for this time    M86 - Service denied because       259 - Frequency of service.
      abortion allowed per        period or occurrence has been reached. payment already made for same-
      month.                                                             similar procedure within set time
                                                                         frame.                      N357 -
                                                                          Time frame requirements
                                                                         between this service-procedure-
                                                                         supply and a related service-
                                                                         procedure-supply have not been
                                                                         met

789   Spinal orthotics allowed    119 - Benefit maximum for this time    M86 - Service denied because       259 - Frequency of service.
      once in 18 months.          period or occurrence has been reached. payment already made for same-
                                                                         similar procedure within set time
                                                                         frame.                      N357 -
                                                                          Time frame requirements
                                                                         between this service-procedure-
                                                                         supply and a related service-
                                                                         procedure-supply have not been
                                                                         met

790   Only three inhalers with    119 - Benefit maximum for this time    M86 - Service denied because       259 - Frequency of service.
      spacers allowed per year.   period or occurrence has been reached. payment already made for same-
                                                                         similar procedure within set time
                                                                         frame.                      N357 -
                                                                          Time frame requirements
                                                                         between this service-procedure-
                                                                         supply and a related service-
                                                                         procedure-supply have not been
                                                                         met

791   Exceeds CAP in-home         119 - Benefit maximum for this time    M86 - Service denied because       259 - Frequency of service.
      aide daily limit.           period or occurrence has been reached. payment already made for same- 612 - Per Day Limit Amount
                                                                         similar procedure within set time
                                                                         frame.                      N357 -
                                                                          Time frame requirements
                                                                         between this service-procedure-
                                                                         supply and a related service-
                                                                         procedure-supply have not been
                                                                         met


                                                                     Page 129
                                                  EOB Code Crosswalk to HIPAA Standard Codes




792   Epogen units exceeded.    119 - Benefit maximum for this time       N358 - Alert- This decision   259 - Frequency of service.
      Please resubmit as an     period or occurrence has been reached.    may be reviewed if additional
      adjustment with lab                                                 documentation as described in
      results and documentation                                           the contract or plan benefit
      to support payment for                                              documents is submitted.
      additional units.                                                        N362 - The number of
                                                                          Days or Units of Service
                                                                          exceeds our acceptable
                                                                          maximum


793   Reimbursement for          97 - The benefit for this service is     M80 - Not covered when             454 - Procedure code for services
      epidural is included in    included in the payment-allowance for    performed during the same          rendered.
      payment of code w8208-     another service-procedure that has       session-date as a previously
      00955.                     already been adjudicated.                processed service for the patient.

794   Delivery under both        B15 - This service-procedure requires    N20 - Service not payable with    258 - Days-units for procedure-
      general anesthesia and     that a qualifying service-procedure be   other service rendered on the     revenue code.
      epidural anesthesia not    received and covered. The qualifying     same date.
      allowed on the same day.   other service-procedure has not been
      Please file adjustment     received-adjudicated.
      request with
      documentation for
      exceptions.

795   Services recouped.         125 - Submission-billing error(s).       MA67 - Correction to a prior      101 - Claim was processed as
      Documentation shows a                                               claim.                            adjustment to previous claim.
      different provider as                                                                                                454 - Procedure
      admitting-attending                                                                                   code for services rendered.
      physician. Rebill as a
      consult.




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                                                   EOB Code Crosswalk to HIPAA Standard Codes

796   Pentamidine aerosol          119 - Benefit maximum for this time    M86 - Service denied because      259 - Frequency of service.
      therapy limited to once      period or occurrence has been reached. payment already made for same-
      every 4 weeks.                                                      similar procedure within set time
                                                                          frame.
                                                                          N357 - Time frame requirements
                                                                          between this service-procedure-
                                                                          supply and a related service-
                                                                          procedure-supply have not been
                                                                          met

797   Thanks for reporting         45 - Charge exceeds fee schedule-      M41 - We do not pay for this as   21 - Missing or invalid information.
      vaccine. Contraindication    maximum allowable or contracted-       the patient has no legal                        187 - Date(s) of
      modifier indicates vaccine   legislated fee arrangement. (Use       obligation to pay for this.       service.
      not given on date of         Group Codes PR or CO depending
      service. Please report if    upon liability).
      vaccine given at future
      date.


798   Exceeds CAP-MR-DD-in-        119 - Benefit maximum for this time    M86 - Service denied because      259 - Frequency of service.
      home aide level I daily      period or occurrence has been reached. payment already made for same- 612 - Per Day Limit Amount
      limit.                                                              similar procedure within set time
                                                                          frame.
                                                                          N357 - Time frame requirements
                                                                          between this service-procedure-
                                                                          supply and a related service-
                                                                          procedure-supply have not been
                                                                          met

799   Spinal supports allowed      119 - Benefit maximum for this time    M86 - Service denied because      259 - Frequency of service.
      once in 18 months.           period or occurrence has been reached. payment already made for same-
                                                                          similar procedure within set time
                                                                          frame.
                                                                          N357 - Time frame requirements
                                                                          between this service-procedure-
                                                                          supply and a related service-
                                                                          procedure-supply have not been
                                                                          met



                                                                       Page 131
                                                   EOB Code Crosswalk to HIPAA Standard Codes


800   CAP medical supplies limit 119 - Benefit maximum for this time    M86 - Service denied because      259 - Frequency of service.
      once per day.              period or occurrence has been reached. payment already made for same-
                                                                        similar procedure within set time                           612 -
                                                                        frame.                            Per Day Limit Amount

801   Medical necessity for       50 - These are non-covered services     N157 - Transportation to-from       428 - Reason for transport by
      ambulance transportation    because this is not deemed a `medical   this destination is not covered.    ambulance
      is not apparent.            necessity by the payer.

802   Allow 1 CAP phone Alert-    119 - Benefit maximum for this time    M86 - Service denied because      259 - Frequency of service.
      month.                      period or occurrence has been reached. payment already made for same-
                                                                         similar procedure within set time
                                                                         frame.
                                                                         N357 - Time frame requirements
                                                                         between this service-procedure-
                                                                         supply and a related service-
                                                                         procedure-supply have not been
                                                                         met

803   Maximum 320 units per       119 - Benefit maximum for this time    N357 - Time frame requirements 259 - Frequency of service.
      month limit has been        period or occurrence has been reached. between this service-procedure-
      reached.                                                           supply and a related service-
                                                                         procedure-supply have not been
                                                                         met.                       N362 -
                                                                         The number of Days or Units of
                                                                         Service exceeds our acceptable
                                                                         maximum

804   Resubmit with anesthesia    152 - Payment adjusted because the      N29 - Missing documentation-        21 - Missing or invalid information.
      time noted on the claim.    payer deems the information submitted orders- notes- summary- report-
                                  does not support this length of service chart.
                                                                                                                251 - Total anesthesia minutes.
                                                                          N203 - Missing-imcomplete-
                                                                          invalid anesthesia time-units.
805   REBILL USING PERIODIC       125 - Submission-billing error(s).      MA66 - Missing-incomplete-          21 - Missing or invalid information.
      ORAL EXAMINATION                                                    invalid principal procedure code.
      CODE.
                                                                                                                239 - Dental information.


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                                                   EOB Code Crosswalk to HIPAA Standard Codes

806   Units were changed to     119 - Benefit maximum for this time    N362 - The number of Days or           258 - Days-units for procedure-
      allow a maximum of 320    period or occurrence has been reached. Units of Service exceeds our           revenue code.
      units per month.                                                 acceptable maximum.                                           259 -
                                                                       N381 - Consult our contractual         Frequency of service.
                                                                       agreement for restrictions-billing-
                                                                       payment information related to
                                                                       these charges
807   Medical necessity for     50 - These are non-covered services    N180 - This item or service does       411 - Medical necessity for non-
      multiple fetal            because this is not deemed a `medical not meet the criteria for the           routine service(s).
      cardiovascular ultrasound necessity by the payer.                category under which it was billed
      not apparent.

808   Exceeds CAP-c daily          119 - Benefit maximum for this time    M86 - Service denied because      259 - Frequency of service.
      service limit for nursing.   period or occurrence has been reached. payment already made for same- 612 - Per Day Limit Amount
                                                                          similar procedure within set time
                                                                          frame.

809   Only one fetal             119 - Benefit maximum for this time    M86 - Service denied because      259 - Frequency of service.
      cardiovascular ultra sound period or occurrence has been reached. payment already made for same-
      allowed per day.                                                  similar procedure within set time                           612 -
                                                                        frame.                            Per Day Limit Amount

810   Adjustment denied;         125 - Submission-billing error(s).       N3 - Missing consent form.          21 - Missing or invalid information.
      adjustment can not be
      processed without
      corrected information.                                                                                    294 - Supporting documentation.
      Refile adjustment with a
      complete, legible,
      corrected claim copy.
811   Adjustment denied, attach 177 - Patient has not met the required    N30 - Patient ineligible for this   123 - Additional information
      copy of recipient Medicaid eligibility requirements.                service.                            requested from entity.
      card for these dates and
      forward to Division of
      Medical Assistance, 1985
      Umstead Dr. Box 29529
      Raleigh NC 27626-0529.




                                                                      Page 133
                                                      EOB Code Crosswalk to HIPAA Standard Codes

812   Adjustment denied, please 16 - Claim-service lacks information         N29 - Missing documentation-      294 - Supporting documentation.
      refile with all related R-A‟s which is needed for adjudication.        orders- notes- summary- report-
      including original                                                     chart.
      processing.

813   This Home Health claim         97 - The benefit for this service is    N144 - The rate changed during 65 - Claim-line has been paid.
      has been adjusted to           included in the payment-allowance for   the dates of service billed.        101 - Claim was processed as
      reflect the rate increase      another service-procedure that has      N381 - Consult our contractual      adjustment to previous claim
      effective 07-01-92.            already been adjudicated.               agreement for restrictions-billing-
                                                                             payment information related to
                                                                             these charges

814   Office visit included in fee   97 - The benefit for this service is    M80 - Not covered when             454 - Procedure code for services
      for iud.                       included in the payment-allowance for   performed during the same          rendered.
                                     another service-procedure that has      session-date as a previously
                                     already been adjudicated.               processed service for the patient.

815   Claim adjusted to reflect    97 - The benefit for this service is      N144 - The rate changed during 65 - Claim-line has been paid.
      4.2% increase effective 1-1- included in the payment-allowance for     the dates of service billed.
      90.                          another service-procedure that has        N381 - Consult our contractual      101 - Claim was processed as
                                   already been adjudicated.                 agreement for restrictions-billing- adjustment to previous claim
                                                                             payment information related to
                                                                             these charges

816   Exceeds maximum                119 - Benefit maximum for this time    M86 - Service denied because      259 - Frequency of service.
      number of physical             period or occurrence has been reached. payment already made for same-
      therapy modalities (3)                                                similar procedure within set time
      allowed per day.                                                      frame.                            442 - Modalities of service.
                                                                            N357 - Time frame requirements
                                                                            between this service-procedure-                             612 - Per
                                                                            supply and a related service-     Day Limit Amount
                                                                            procedure-supply have not been
                                                                            met

817   Services are not to be         125 - Submission-billing error(s).      M53 - Missing-incomplete-invalid 21 - Missing or invalid information.
      billed spanning multiple                                               days or units of service.
      calendar months. Rebill                                                                     MA31 -
      with dates of service                                                  Missing-incomplete-invalid         187 - Date(s) of service.
      within one month only.                                                 beginning and ending dates of
                                                                             the period billed.

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                                                     EOB Code Crosswalk to HIPAA Standard Codes

819   Both the 'from' and 'to'      125 - Submission-billing error(s).        M53 - Missing-incomplete-invalid 21 - Missing or invalid information.
      date of service must be                                                 days or units of service.
      the date of delivery when                                                                    MA31 -
      billing total ob package or                                             Missing-incomplete-invalid         188 - Statement from-through
      delivery codes.                                                         beginning and ending dates of    dates.
                                                                              the period billed.
820   Submit as adjustment with     16 - Claim-service lacks information      N29 - Missing documentation-     21 - Missing or invalid information.
      legible                       which is needed for adjudication.         orders-notes-summary-report-
      documentation/attachment                                                chart.
      s
821   Full recoupment, all          97 - The benefit for this service is      M80 - Not covered when             454 - Procedure code for services
      outpatient charges are        included in the payment-allowance for     performed during the same          rendered.
      included in per diem          another service-procedure that has        session-date as a previously
      payment.                      already been adjudicated.                 processed service for the patient.

822   The consent form has an       16 - Claim-service lacks information      N3 - Missing consent form..       123 - Additional information
      incomplete address.           which is needed for adjudication.                                           requested from entity.
      Please complete the
      address by adding street,
      city, state, and zip

823   The consent/statement is      16 - Claim-service lacks information      N3 - Missing consent form.        21 - Missing or invalid information.
      incomplete. Complete all      which is needed for adjudication.                                                                   421 -
      blank spaces with                                                                                         Medical review attachment-
      appropriate information                                                                                   information for service(s).


824   The sterilization consent   16 - Claim-service lacks information        N3 - Missing consent form.        465 - Principal Procedure Code for
      form is completed           which is needed for adjudication.                                             Service(s) Rendered.
      incorrectly. Please correct
      by completing or
      correcting the procedure
      code spaces.


825   IUD included fee for office   97 - The benefit for this service is      M80 - Not covered when             454 - Procedure code for services
      visit.                        included in the payment-allowance for     performed during the same          rendered.
                                    another service-procedure that has        session-date as a previously
                                    already been adjudicated.                 processed service for the patient.


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                                                     EOB Code Crosswalk to HIPAA Standard Codes

826   Only two 12 hour              119 - Benefit maximum for this time    M86 - Service denied because      259 - Frequency of service.
      pneumograms allowed in        period or occurrence has been reached. payment already made for same-
      6 months.                                                            similar procedure within set time
                                                                           frame.
                                                                           N357 - Time frame requirements
                                                                           between this service-procedure-
                                                                           supply and a related service-
                                                                           procedure-supply have not been
                                                                           met

827   Only one waveform             119 - Benefit maximum for this time    M86 - Service denied because      259 - Frequency of service.
      monitor allowed per           period or occurrence has been reached. payment already made for same-
      month.                                                               similar procedure within set time
                                                                           frame.
                                                                           N357 - Time frame requirements
                                                                           between this service-procedure-
                                                                           supply and a related service-
                                                                           procedure-supply have not been
                                                                           met

828   Disproportionate share     76 - Disproportionate Share Adjustment. No Mapping Required                    104 - Processed according to plan
      hospital payment increase                                                                                 provisions.
      of 5% for children under
      age 6 with charges greater
      than annual maximum or
      stays over 65 days.


829   All claims and R-A's          16 - Claim-service lacks information      N1 - Alert- You may appeal this 21 - Missing or invalid information.
      related to interim billings   which is needed for adjudication.         decision in writing within the
      must be attached to                                                     required time limits following
      adjustment request.                                                     receipt of this notice by
                                                                              following the instructions
                                                                              included in your contract or
                                                                              plan benefit documents.

                                                                                 N3 - Missing consent form.



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                                                 EOB Code Crosswalk to HIPAA Standard Codes



830   Non-disproportionate        76 - Disproportionate Share Adjustment. No Mapping Required             104 - Processed according to plan
      share hospital payment                                                                              provisions.
      increase of 5% for children
      under age 1 with charges
      greater than annual
      maximum or stays over 65
      days.

831   DME procedure allowed      119 - Benefit maximum for this time    M86 - Service denied because      259 - Frequency of service.
      once in two years.         period or occurrence has been reached. payment already made for same-
                                                                        similar procedure within set time
                                                                        frame.
                                                                        N357 - Time frame requirements
                                                                        between this service-procedure-
                                                                        supply and a related service-
                                                                        procedure-supply have not been
                                                                        met

832   DME allowed once in three 119 - Benefit maximum for this time     No Mapping Required               187 - Date(s) of service.
      years. If prior approval   period or occurrence has been reached.
      was obtained for this
      piece of equipment for                                                                                    259 - Frequency of service.
      dates of service prior to
      November 1, 1996, please
      resubmit as an adjustment.


833   DME procedure allowed      119 - Benefit maximum for this time    M86 - Service denied because      259 - Frequency of service.
      once in five years.        period or occurrence has been reached. payment already made for same-
                                                                        similar procedure within set time
                                                                        frame.
                                                                        N357 - Time frame requirements
                                                                        between this service-procedure-
                                                                        supply and a related service-
                                                                        procedure-supply have not been
                                                                        met




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                                                  EOB Code Crosswalk to HIPAA Standard Codes



834   This previously paid claim 76 - Disproportionate Share Adjustment. No Mapping Required                  104 - Processed according to plan
      has been recouped and                                                                                   provisions.
      repaid in this check write
      to include the additional
      disproportionate share 5%.


835   Subsequent billing of       59 - Charges are adjusted based on        N381 - Consult our contractual      259 - Frequency of service.
      repair code has been paid   multiple or concurrent procedure rules.   agreement for restrictions-billing-
      at the secondary            (For example multiple surgery or          payment information related to      453 - Procedure Code Modifier(s)
      maximum allowed rate.       diagnostic imaging, concurrent            these charges                       for Service(s) Rendered
                                  anesthesia.)
836   Fludara (fludarabine        119 - Benefit maximum for this time       M86 - Service denied because      259 - Frequency of service.
      phosphate) limited to 2     period or occurrence has been reached.    payment already made for same-
      dosages per day (50 mg                                                similar procedure within set time                          612 - Per
      each).                                                                frame.                            Day Limit Amount
                                                                            N357 - Time frame requirements
                                                                            between this service-procedure-
                                                                            supply and a related service-
                                                                            procedure-supply have not been
                                                                            met

837   Heel wedge limited to two   119 - Benefit maximum for this time    M86 - Service denied because      259 - Frequency of service.
      per date of service.        period or occurrence has been reached. payment already made for same-
                                                                         similar procedure within set time                          612 - Per
                                                                         frame.                            Day Limit Amount

838   BLS and ALS limited to 3    119 - Benefit maximum for this time    M86 - Service denied because      259 - Frequency of service.
      trips in 365 days.          period or occurrence has been reached. payment already made for same-
                                                                         similar procedure within set time
                                                                         frame.
                                                                         N357 - Time frame requirements
                                                                         between this service-procedure-
                                                                         supply and a related service-
                                                                         procedure-supply have not been
                                                                         met




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                                                    EOB Code Crosswalk to HIPAA Standard Codes




839   Newborn screening test        119 - Benefit maximum for this time    M86 - Service denied because      259 - Frequency of service.
      allowed once per day.         period or occurrence has been reached. payment already made for same-
                                                                           similar procedure within set time                          612 - Per
                                                                           frame.                            Day Limit Amount

840   Exceeds daily limit for At-   119 - Benefit maximum for this time    M86 - Service denied because      259 - Frequency of service.
      Risk Case Management          period or occurrence has been reached. payment already made for same- 612 - Per Day Limit Amount
      (adult).                                                             similar procedure within set time
                                                                           frame.
                                                                           N357 - Time frame requirements
                                                                           between this service-procedure-
                                                                           supply and a related service-
                                                                           procedure-supply have not been
                                                                           met

841   Exceeds daily limit for At-   119 - Benefit maximum for this time    M86 - Service denied because      259 - Frequency of service.
      Risk Case Management          period or occurrence has been reached. payment already made for same- 612 - Per Day Limit Amount
      (child).                                                             similar procedure within set time
                                                                           frame.
                                                                           N357 - Time frame requirements
                                                                           between this service-procedure-
                                                                           supply and a related service-
                                                                           procedure-supply have not been
                                                                           met

842   DME equipment allowed         119 - Benefit maximum for this time    M86 - Service denied because      259 - Frequency of service.
      once in three years.          period or occurrence has been reached. payment already made for same-
                                                                           similar procedure within set time
                                                                           frame.
                                                                           N357 - Time frame requirements
                                                                           between this service-procedure-
                                                                           supply and a related service-
                                                                           procedure-supply have not been
                                                                           met




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                                               EOB Code Crosswalk to HIPAA Standard Codes




843   DME equipment allowed   119 - Benefit maximum for this time    M86 - Service denied because      259 - Frequency of service.
      once in three years.    period or occurrence has been reached. payment already made for same-
                                                                     similar procedure within set time
                                                                     frame.
                                                                     N357 - Time frame requirements
                                                                     between this service-procedure-
                                                                     supply and a related service-
                                                                     procedure-supply have not been
                                                                     met

844   DME equipment allowed   18 - Duplicate claim-service.          M86 - Service denied because      259 - Frequency of service.
      once in three years.                                           payment already made for same-
                                                                     similar procedure within set time
                                                                     frame.

845   DME equipment allowed   119 - Benefit maximum for this time    M86 - Service denied because      259 - Frequency of service.
      once in five years.     period or occurrence has been reached. payment already made for same-
                                                                     similar procedure within set time
                                                                     frame.
                                                                     N357 - Time frame requirements
                                                                     between this service-procedure-
                                                                     supply and a related service-
                                                                     procedure-supply have not been
                                                                     met

846   DME equipment allowed   119 - Benefit maximum for this time    M86 - Service denied because      259 - Frequency of service.
      once in two years.      period or occurrence has been reached. payment already made for same-
                                                                     similar procedure within set time
                                                                     frame.
                                                                     N357 - Time frame requirements
                                                                     between this service-procedure-
                                                                     supply and a related service-
                                                                     procedure-supply have not been
                                                                     met




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                                                 EOB Code Crosswalk to HIPAA Standard Codes


847   DME equipment allowed      119 - Benefit maximum for this time    M86 - Service denied because      259 - Frequency of service.
      once in three years.       period or occurrence has been reached. payment already made for same-
                                                                        similar procedure within set time
                                                                        frame.
                                                                        N357 - Time frame requirements
                                                                        between this service-procedure-
                                                                        supply and a related service-
                                                                        procedure-supply have not been
                                                                        met

848   DME equipment allowed      119 - Benefit maximum for this time    M86 - Service denied because      259 - Frequency of service.
      once in three years.       period or occurrence has been reached. payment already made for same-
                                                                        similar procedure within set time
                                                                        frame.
                                                                        N357 - Time frame requirements
                                                                        between this service-procedure-
                                                                        supply and a related service-
                                                                        procedure-supply have not been
                                                                        met

849   Payment reduced to equal   108 - Rent-purchase guidelines were    M7 - No rental payments after         186 - Purchase and rental price of
      new purchase price.        not met.                               the item is purchased, or after       durable medical equipment.
      Medicaid has previously                                           the total of issued rental
      paid for this equipment                                           payments equals the purchase
      code.                                                             price.
                                                                        N381 - Consult our contractual
                                                                        agreement for restrictions-billing-
                                                                        payment information related to
                                                                        these charges
850   Medicaid has paid          108 - Rent-purchase guidelines were    M7 - No rental payments after         186 - Purchase and rental price of
      maximum allowable for      not met.                               the item is purchased, or after       durable medical equipment
      this equipment code.                                              the total of issued rental
                                                                        payments equals the purchase
                                                                        price.
                                                                        N381 - Consult our contractual
                                                                        agreement for restrictions-billing-
                                                                        payment information related to
                                                                        these charges


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                                                 EOB Code Crosswalk to HIPAA Standard Codes

851   DME equipment allowed      119 - Benefit maximum for this time    M86 - Service denied because      259 - Frequency of service.
      once in three years.       period or occurrence has been reached. payment already made for same-
                                                                        similar procedure within set time
                                                                        frame.

852   DME equipment allowed      119 - Benefit maximum for this time    M86 - Service denied because        259 - Frequency of service.
      once in three years.       period or occurrence has been reached. payment already made for same-
                                                                        similar procedure within set time
                                                                        frame
853   DME equipment allowed      119 - Benefit maximum for this time    M86 - Service denied because        259 - Frequency of service.
      once in three years.       period or occurrence has been reached. payment already made for same-
                                                                        similar procedure within set time
                                                                        frame
854   DME equipment allowed      119 - Benefit maximum for this time    M86 - Service denied because        259 - Frequency of service.
      once in three years.       period or occurrence has been reached. payment already made for same-
                                                                        similar procedure within set time
                                                                        frame
855   DME equipment allowed      119 - Benefit maximum for this time    M86 - Service denied because        259 - Frequency of service.
      once in three years.       period or occurrence has been reached. payment already made for same-
                                                                        similar procedure within set time
                                                                        frame
856   DME equipment allowed      119 - Benefit maximum for this time    M86 - Service denied because        259 - Frequency of service.
      once in three years.       period or occurrence has been reached. payment already made for same-
                                                                        similar procedure within set time
                                                                        frame
857   DME equipment allowed      119 - Benefit maximum for this time    M86 - Service denied because        259 - Frequency of service.
      once in three years.       period or occurrence has been reached. payment already made for same-
                                                                        similar procedure within set time
                                                                        frame
858   DME equipment allowed      119 - Benefit maximum for this time    M86 - Service denied because        259 - Frequency of service.
      once per day.              period or occurrence has been reached. payment already made for same-
                                                                        similar procedure within set time
                                                                        frame                               612 - Per Day Limit Amount
859   DME equipment allowed      119 - Benefit maximum for this time    M86 - Service denied because        259 - Frequency of service.
      once per day.              period or occurrence has been reached. payment already made for same-
                                                                        similar procedure within set time
                                                                        frame                               612 - Per Day Limit Amount
860   This code is non-covered   96 - Non-covered charge(s).            M79 - Missing-incomplete-invalid    454 - Procedure code for services
      for paternity testing.                                            charge                              rendered.


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                                                   EOB Code Crosswalk to HIPAA Standard Codes




861   DME equipment allowed      119 - Benefit maximum for this time    M86 - Service denied because            259 - Frequency of service.
      once per day.              period or occurrence has been reached. payment already made for same-
                                                                        similar procedure within set time
                                                                        frame                                   612 - Per Day Limit Amount
862   DME equipment allowed      119 - Benefit maximum for this time    M86 - Service denied because            259 - Frequency of service.
      once per day.              period or occurrence has been reached. payment already made for same-
                                                                        similar procedure within set time
                                                                        frame                                   612 - Per Day Limit Amount
863   Hysterectomy statement     16 - Claim-service lacks information   N3 - Missing consent form.              21 - Missing or invalid information.
      does not meet federal      which is needed for adjudication.                            N59 - Alert-                             421 -
      guidelines, resubmit newly                                         Please refer to your provider          Medical review attachment-
      obtained statement                                                manual for additional program           information for service(s).
                                                                        and provider information.

864   Hysterectomy statement      16 - Claim-service lacks information      N3 - Missing consent form.          21 - Missing or invalid information.
      received illegible.         which is needed for adjudication.                            N205 -                                  421 -
      Resubmit a legible                                                    Information provider was illegible. Medical review attachment-
      statement                                                                                                 information for service(s).

865   Wrong hysterectomy          16 - Claim-service lacks information      N3 - Missing consent form.        21 - Missing or invalid information.
      statement sent. Resubmit    which is needed for adjudication.                              N59 - Alert-                         421 -
      the 'prior to' statement.                                              Please refer to your provider    Medical review attachment-
                                                                            manual for additional program information for service(s).
                                                                            and provider information.

866   DOS is incorrect or       16 - Claim-service lacks information        N3 - Missing consent form.          21 - Missing or invalid information.
      missing on the            which is needed for adjudication.                                                                      187 -
      hysterectomy statement                                                                                    Date(s) of service
      correct DOS on statement,                                                                                  298 - Operative report
      initial date correction &
      resubmit as adjustment
      with claim, statement &
      operative record




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                                                   EOB Code Crosswalk to HIPAA Standard Codes



867   Verify hysterectomy        16 - Claim-service lacks information       N29 - Missing documentation-        21 - Missing or invalid information.
      procedure, correct your    which is needed for adjudication.          orders-notes-summary-report-                            298 -
      claim and resubmit as an                                              chart.                              Operative report
      adjustment with operative                                                                                   454 - Procedure code for
      records for                                                                                               services rendered.
      documentation, i.e. one
      says abdominal hyster, the
      other says vaginal


868   Verify date of service,    16 - Claim-service lacks information       N29 - Missing-incomplete-invalid    187 - Date(s) of service.
      correct your claim &       which is needed for adjudication.          documentation-orders-notes-                298 - Operative report.
      resubmit as an adjustment                                             summary-report-chart
      with operative records for
      documentation, i.e., Date
      on claim differs from date
      on statement

869   Illegible witness and/or    16 - Claim-service lacks information      N3 - Missing consent form.          21 - Missing or invalid information.
      patient signature on        which is needed for adjudication.                            N205 -                                  421 -
      hysterectomy statement.                                               Information provided was illegible. Medical review attachment-
      Please identify signature                                                                                 information for service(s).
      and resubmit


870   Personal Care Services      B15 - This service-procedure requires     N20 - Service not payable with      258 - Days-units for procedure-
      not allowed the same day    that a qualifying service-procedure be    other service rendered on the       revenue code.
      as CAP In-Home Level II     received and covered. The qualifying      same date.
      and In-Home Level III.      other service-procedure has not been
                                  received-adjudicated.

871   CAP In-Home Level II and    B15 - This service-procedure requires     N20 - Service not payable with      258 - Days-units for procedure-
      In-Home Level III not       that a qualifying service-procedure be    other service rendered on the       revenue code.
      allowed same day as         received and covered. The qualifying      same date.
      Personal Care Services.     other service-procedure has not been
                                  received-adjudicated.




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                                                     EOB Code Crosswalk to HIPAA Standard Codes




872   I&D included in previously 97 - The benefit for this service is        M80 - Not covered when             454 - Procedure code for services
      paid appendectomy.         included in the payment-allowance for       performed during the same          rendered.
                                 another service-procedure that has          session-date as a previously
                                 already been adjudicated.                   processed service for the patient.

873   Catherization included in     97 - The benefit for this service is     M80 - Not covered when             454 - Procedure code for services
      dilation.                     included in the payment-allowance for    performed during the same          rendered.
                                    another service-procedure that has       session-date as a previously
                                    already been adjudicated.                processed service for the patient.

874   Multiple ER visits not        B15 - This service-procedure requires    M86 - Service denied because      258 - Days-units for procedure-
      allowed same DOS, same        that a qualifying service-procedure be   payment already made for same- revenue code.
      provider specialty. File      received and covered. The qualifying     similar procedure within set time
      adjustment if visits were     other service-procedure has not been     frame.
      separate occasions.           received-adjudicated.


875   Full recoup, rebill using    125 - Submission-billing error(s).        MA67 - Correction to a prior       250 - Type of service.
      the correct type of service.                                           claim.

876   Facility fee For labor care   97 - The benefit for this service is     M80 - Not covered when             54 - Duplicate of a previously
      previously paid.              included in the payment-allowance for    performed during the same          processed claim-line.
                                    another service-procedure that has       session-date as a previously
                                    already been adjudicated.                processed service for the patient.

877   Labor care included in        97 - The benefit for this service is     M80 - Not covered when             454 - Procedure code for services
      previously paid delivery.     included in the payment-allowance for    performed during the same          rendered.
                                    another service-procedure that has       session-date as a previously
                                    already been adjudicated.                processed service for the patient.

878   Episiotomy included in        97 - The benefit for this service is     M80 - Not covered when             454 - Procedure code for services
      vaginal delivery.             included in the payment-allowance for    performed during the same          rendered.
                                    another service-procedure that has       session-date as a previously
                                    already been adjudicated.                processed service for the patient.




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879   Physician charge denied   B15 - This service-procedure requires    N20 - Service not payable with    258 - Days-units for procedure-
      same DOS as facility      that a qualifying service-procedure be   other service rendered on the     revenue code.
      billing.                  received and covered. The qualifying     same date.
                                other service-procedure has not been
                                received-adjudicated.

880   Facility charge denied    B15 - This service-procedure requires    M86 - Service denied because      258 - Days-units for procedure-
      same DOS as physician     that a qualifying service-procedure be   payment already made for same- revenue code.
      billing.                  received and covered. The qualifying     similar procedure within set time
                                other service-procedure has not been     frame.
                                received-adjudicated.

881   EMG one extremity         119 - Benefit maximum for this time    M86 - Service denied because      259 - Frequency of service.
      allowed per day.          period or occurrence has been reached. payment already made for same-
                                                                       similar procedure within set time
                                                                       frame.                            612 - Per Day Limit Amount

882   One EMG two extremities   119 - Benefit maximum for this time    M86 - Service denied because      259 - Frequency of service.
      allowed per day.          period or occurrence has been reached. payment already made for same-
                                                                       similar procedure within set time
                                                                       frame.                            612 - Per Day Limit Amount

883   EMG three extremities     119 - Benefit maximum for this time    M86 - Service denied because      259 - Frequency of service.
      allowed once per day.     period or occurrence has been reached. payment already made for same-
                                                                       similar procedure within set time
                                                                       frame.                            612 - Per Day Limit Amount

884   Rebill adjustment with    151 - Payment adjusted because the    M53 - Missing-incomplete-        21 - Missing or invalid information.
      records documenting       payer deems the information submitted invalid days or units of
      units.                    does not support this many services.  service.
                                                                              N1 - Alert- You may
                                                                      appeal this decision in writing
                                                                      within the required time limits
                                                                      following receipt of this notice
                                                                      by following the instructions
                                                                      included in your contract or
                                                                      plan benefit documents.



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885   Rebill adjustment with       151 - Payment adjusted because the    M53 - Missing-incomplete-        21 - Missing or invalid information.
      records documenting          payer deems the information submitted invalid days or units of
      units.                       does not support this many services.  service.
                                                                                 N1 - Alert- You may
                                                                         appeal this decision in writing
                                                                         within the required time limits
                                                                         following receipt of this notice
                                                                         by following the instructions
                                                                         included in your contract or
                                                                         plan benefit documents.


886   Exceeds the limit of six     119 - Benefit maximum for this time    M86 - Service denied because        259 - Frequency of service.
      units per day for reflex     period or occurrence has been reached. payment already made for same-
      study.                                                              similar procedure within set time
                                                                          frame                               612 - Per Day Limit Amount
887   DME equipment allowed        119 - Benefit maximum for this time    M86 - Service denied because        259 - Frequency of service.
      once per day.                period or occurrence has been reached. payment already made for same-
                                                                          similar procedure within set time
                                                                          frame.                              612 - Per Day Limit Amount

888   Coverage for these new        96 - Non-covered charge(s).           MA66 - Missing-incomplete-          454 - Procedure code for services
      CPT codes are still under                                           invalid principal procedure code.   rendered.
      evaluation. Please do not
      rebill until notified through
      your bulletin.

889   Medicare covered days are 148 - Information from another provider N4 - Missing-incomplete-invalid       21 - Missing or invalid information.
      missing or invalid. Refile was not provided or was insufficient-  prior insurance carrier EOB.                          285 - Vouchers-
      paper claim with Medicare incomplete.                                                                   explanation of benefits (EOB).
      EOB.                                                                                                                             456 -
                                                                                                              Covered Day(s)
890   Paid at Medicaid per diem    45 - Charge exceeds fee schedule-      N381 - Consult our contractual      65 - Claim-line has been paid.
      rate; paid maximum           maximum allowable or contracted-       agreement for restrictions-billing- 483 - Maximum coverage amount
      allowable.                   legislated fee arrangement. (Use       payment information related to      met or exceeded for benefit period
                                   Group Codes PR or CO depending         these charges
                                   upon liability).



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891   Self-administered drugs     119 - Benefit maximum for this time    M86 - Service denied because      259 - Frequency of service.
      limited to once per day.    period or occurrence has been reached. payment already made for same-
                                                                         similar procedure within set time
                                                                         frame.                            612 - Per Day Limit Amount

892   Units cut back. Lab        151 - Payment adjusted because the        N362 - The number of Days or          258 - Days-units for procedure-
      results do not support     payer deems the information submitted     Units of Service exceeds our          revenue code.
      necessity for more than 14 does not support this many services.      acceptable maximum.                     259 - Frequency of service.
      units EPO per day.                                                   N381 - Consult our contractual
                                                                           agreement for restrictions-billing-               612 - Per Day Limit
                                                                           payment information related to        Amount
                                                                           these charges
893   Medical necessity not       50 - These are non-covered services      N180 - This item or service does       258 - Days-units for procedure-
      apparent for critical care- because this is not deemed a `medical    not meet the criteria for the         revenue code.
      prolonged services and      necessity by the payer.                  category under which it was billed               411 - Medical necessity
      consults on the same day.                                                                                  for non-routine service(s).

894   Prolonged services and      B15 - This service-procedure requires    N20 - Service not payable with        258 - Days-units for procedure-
      critical care not allowed   that a qualifying service-procedure be   other service rendered on the         revenue code.
      same date of service.       received and covered. The qualifying     same date.
                                  other service-procedure has not been
                                  received-adjudicated.

895   Exceeds daily limit for     45 - Charge exceeds fee schedule-        N381 - Consult our contractual      259 - Frequency of service.
      termination allowance.      maximum allowable or contracted-         agreement for restrictions-billing- 612 - Per Day Limit Amount
                                  legislated fee arrangement. (Use         payment information related to
                                  Group Codes PR or CO depending           these charges
                                  upon liability).
896   Additional procedure        59 - Charges are adjusted based on       N381 - Consult our contractual      259 - Frequency of service.
      same date of service paid multiple or concurrent procedure rules.    agreement for restrictions-billing- 453 - Procedure Code Modifier(s)
      at 50 percent of allowable. (For example multiple surgery or         payment information related to      for Service(s) Rendered
                                  diagnostic imaging, concurrent           these charges
                                  anesthesia.)
897   TCD included in fee for     97 - The benefit for this service is     M80 - Not covered when             454 - Procedure code for services
      surgery.                    included in the payment-allowance for    performed during the same          rendered.
                                  another service-procedure that has       session-date as a previously
                                  already been adjudicated.                processed service for the patient.



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898   Newborn resuscitation        150 - Payment adjusted because the      M13 - Only one initial visit is          21 - Missing or invalid information.
      only payable on date of      payer deems the information submitted covered per specialty per
      delivery. Rebill using       does not support this level of service. medical group.
      appropriate level hospital
      visit or critical care code.

899   Units cutback. maximum        119 - Benefit maximum for this time    N362 - The number of Days or             258 - Days-units for procedure-
      number of units per day       period or occurrence has been reached. Units of Service exceeds our             revenue code.
      exceeded.                                                            acceptable maximum.                                            259 -
                                                                           N381 - Consult our contractual           Frequency of service.
                                                                           agreement for restrictions-billing-
                                                                           payment information related to                                    612 - Per
                                                                           these charges                            Day Limit Amount
900   Claim denied for lack of      125 - Submission-billing error(s).     N29 - Missing documentation-             21 - Missing or invalid information.
      requested information.                                               orders- notes- summary- report-          95 - Requested additional
                                                                           chart.                                   information not received.

901   No adjustment due.            45 - Charge exceeds fee schedule-         No Mapping Required                   104 - Processed according to plan
                                    maximum allowable or contracted-                                                provisions.
                                    legislated fee arrangement. (Use
                                    Group Codes PR or CO depending
                                    upon liability).
902   Claim paid - EAC price        45 - Charge exceeds fee schedule-         N45 - Payment based on                65 - Claim-line has been paid.
      adjusted.                     maximum allowable or contracted-          authorized amount.
                                    legislated fee arrangement. (Use                                  N381 -         107 - Processed according to
                                    Group Codes PR or CO depending            Consult our contractual               contract-plan provisions.
                                    upon liability).                          agreement for restrictions-billing-
                                                                              payment information related to
                                                                              these charges
903   Claim paid - MAC price        45 - Charge exceeds fee schedule-         N45 - Payment based on                65 - Claim-line has been paid.
      adjusted.                     maximum allowable or contracted-          authorized amount.
                                    legislated fee arrangement. (Use                                  N381 -        107 - Processed according to
                                    Group Codes PR or CO depending            Consult our contractual               contract-plan provisions.
                                    upon liability).                          agreement for restrictions-billing-
                                                                              payment information related to
                                                                              these charges



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904   Claim paid - AWP price         45 - Charge exceeds fee schedule-            N45 - Payment based on                65 - Claim-line has been paid.
      adjusted.                      maximum allowable or contracted-             authorized amount.
                                     legislated fee arrangement. (Use                                     N381 -        107 - Processed according to
                                     Group Codes PR or CO depending               Consult our contractual               contract-plan provisions.
                                     upon liability).                             agreement for restrictions-billing-
                                                                                  payment information related to
                                                                                  these charges
905   Drug not covered under         96 - Non-covered charge(s).                  M79 - Missing-incomplete-invalid      454 - Procedure code for services
      rebate agreement.                                                           charge                                rendered.

906   Cervical braces allowed        119 - Benefit maximum for this time     M86 - Service denied because               259 - Frequency of service.
      once in 18 months.             period or occurrence has been reached. payment already made for same-
                                                                             similar procedure within set time
                                                                             frame
907   Full recoupment per            45 - Charge exceeds fee schedule-       MA67 - Correction to a prior               101 - Claim was processed as
      pharmacy of record review.     maximum allowable or contracted-        claim.                                     adjustment to previous claim.
                                     legislated fee arrangement. (Use
                                     Group Codes PR or CO depending
                                     upon liability).
908   Refer to your 1992 CPT         125 - Submission-billing error(s).      N59 - Alert- Please refer to               21 - Missing or invalid information.
      book and rebill.                                                       your provider manual for
                                                                             additional program and
                                                                             provider information
909   Please resubmit claim with     150 - Payment adjusted because the      M22 - Missing-incomplete-invalid           21 - Missing or invalid information.
      both mileage and base fee      payer deems the information submitted number of miles traveled.
      coded to the same level of     does not support this level of service.
      service, (ie: ALS or BLS).

910   Rebill with form 5016          125 - Submission-billing error(s).           N34 - Incorrect claim form-format 21 - Missing or invalid information.
      indicating patient liability                                                for this service.
      amount.                                                                                     N58 - Missing-
                                                                                  incomplete-invalid patient liability
                                                                                  amount.
911   Denied CMS termination.        B7 - This provider was not certified-        No Mapping Required                  104 - Processed according to plan
                                     eligible to be paid for this procedure-                                           provisions.
                                     service on this date of service.




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912   Provider must enroll with 133 - The disposition of this claim-          MA07 - Alert- The claim             16 - Claim-encounter has been
      the Division of Medical    service is pending further review.           information has also been           forwarded to entity.
      Assistance. Visit our                                                   forwarded to Medicaid for
      website for an enrollment                                               review
      packet or contact Provider
      Services at 1 800 688 6696
      Option 3.

913   Rebill your claim using the 125 - Submission-billing error(s).          MA66 - Missing-incomplete-          21 - Missing or invalid information.
      correct consultation                                                    invalid principal procedure code.                 454 - Procedure
      code(s).                                                                                                    code for services rendered.

914   Dispensing fees for           97 - The benefit for this service is      M80 - Not covered when             454 - Procedure code for services
      accessories are included      included in the payment-allowance for     performed during the same          rendered.
      in the dispensing fee for a   another service-procedure that has        session-date as a previously
      new aid-aids.                 already been adjudicated.                 processed service for the patient.

915   A component of the EKG        B15 - This service-procedure requires     N20 - Service not payable with      454 - Procedure code for services
      has paid on a previous        that a qualifying service-procedure be    other service rendered on the       rendered.
      claim. File adjustment of     received and covered. The qualifying      same date.
      that claim, combine           other service-procedure has not been
      charges and code to all       received-adjudicated.
      inclusive EKG code.

916   Resubmit claim with the    16 - Claim-service lacks information         N29 - Missing documentation-        21 - Missing or invalid information.
      post-evaluation report and which is needed for adjudication.            orders- notes- summary- report-              294 - Supporting
      applicable invoices.                                                    chart.                              documentation.

917   The consent form is           16 - Claim-service lacks information      N3 - Missing consent form.          21 - Missing or invalid information.
      completed incorrectly.        which is needed for adjudication.
      Please correct by                                                         N252 - Missing-incomplete-
      eliminating abbreviations                                               invalid attending provider name.
      in the clinic-doctor name
      spaces.




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918   The consent form is           16 - Claim-service lacks information      MA36 - Missing-incomplete-         21 - Missing or invalid information.
      completed incorrectly.        which is needed for adjudication.         invalid patient name.                                       124 -
      Please correct by placing                                                                  N3 - Missing    Entitys name, address, phone and
      the recipients full name in                                             consent form.                      id number
      the “name of individual”
      space.
919   The recipient date of birth   16 - Claim-service lacks information      N3 - Missing consent form.         21 - Missing or invalid information.
      on record is different from   which is needed for adjudication.                                                                   158 - Entitys
      consent form. Please                                                                 N329 - Missing-       date of birth
      correct the DOB field on                                                incomplete-invalid patient birth
      the consent form and                                                    date.
      resubmit.

920   CLIA certification number 125 - Submission-billing error(s).            MA120 - Missing-incomplete-        21 - Missing or invalid information.
      is unknown to NC                                                        invalid CLIA certification number.
      Medicaid. Contact your
      state CLIA authority. NC                                                                                     142 - Entitys license-certification
      providers contact NC DFS,                                                                                  number.
      CLIA, PO Box 29530                                                                                                                         630 -
      Raleigh, NC 27626-0530.                                                                                    Referring CLIA Number


921   Service denied: the           97 - The benefit for this service is      M80 - Not covered when             454 - Procedure code for services
      dispensing fee for            included in the payment-allowance for     performed during the same          rendered.
      accessories that is           another service-procedure that has        session-date as a previously
      included in disp. fee for     already been adjudicated.                 processed service for the patient.
      new hearing aid(s) has
      been paid for this date of
      service.
922   Claim suspended due to        133 - The disposition of this claim-      No Mapping Required                40 - Waiting for final approval.
      court order.                  service is pending further review.
923   Consultation and              B15 - This service-procedure requires     N20 - Service not payable with     258 - Days-units for procedure-
      emergency room visit not      that a qualifying service-procedure be    other service rendered on the      revenue code.
      allowed on same DOS,          received and covered. The qualifying      same date.
      same provider specialty.      other service-procedure has not been
                                    received-adjudicated.




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924   Emergency room visit and     B15 - This service-procedure requires    N20 - Service not payable with   258 - Days-units for procedure-
      consultation not allowed     that a qualifying service-procedure be   other service rendered on the    revenue code.
      on same DOS, same            received and covered. The qualifying     same date.
      provider specialty.          other service-procedure has not been
                                   received-adjudicated.

925   Admit date and 'from' date 125 - Submission-billing error(s).         MA30 - Missing-incomplete-       21 - Missing or invalid information.
      of service not consistent                                             invalid type of bill.
      with 3rd digit-frequency                                                                     MA31 -
      code of bill type. Enter                                              Missing-incomplete-invalid         189 - Facility admission date
      correct bill type, admit                                              beginning and ending dates of
      date or 'from' DOS and                                                the period billed.
      submit as a new claim.


926   Services billed under      96 - Non-covered charge(s).                N115 - This decision was based 488 - Diagnosis code(s) for the
      routine diagnosis are non-                                            on a local medical review policy services rendered
      covered.                                                              (LMRP) or Local Coverage
                                                                            Determination (LCD). An LMRP-
                                                                            LCD provides a guide to assist in
                                                                            determining whether a particular
                                                                            item or service is covered. A
                                                                            copy of this policy is available at
                                                                            http---www.cms.hhs.gov-mcd, or
                                                                            if you do not have web access,
                                                                            you may contact the contractor to
                                                                            request a copy of the LMRP-LCD



927   Code is to cover 24 hours, 119 - Benefit maximum for this time    M86 - Service denied because      259 - Frequency of service.
      therefore only one unit    period or occurrence has been reached. payment already made for same-
      allowed per day.                                                  similar procedure within set time                           612 -
                                                                        frame.                            Per Day Limit Amount




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928   Injection of antigen is       97 - The benefit for this service is     M86 - Service denied because      454 - Procedure code for services
      included in the fee for       included in the payment-allowance for    payment already made for same- rendered.
      allergenic immunotherapy      another service-procedure that has       similar procedure within set time
      with provision of             already been adjudicated.                frame.
      allergenic extract already
      paid for this date of
      service.
929   Injection of antigen has      97 - The benefit for this service is     M86 - Service denied because      54 - Duplicate of a previously
      already been paid for this    included in the payment-allowance for    payment already made for same- processed claim-line.
      date of service. Rebill       another service-procedure that has       similar procedure within set time
      using code for provision      already been adjudicated.                frame.
      of allergenic extract only.

930   Any combination of            B15 - This service-procedure requires    N20 - Service not payable with      258 - Days-units for procedure-
      periodontal and prophy        that a qualifying service-procedure be   other service rendered on the       revenue code.
      allowed on same date of       received and covered. The qualifying     same date.
      service.                      other service-procedure has not been
                                    received-adjudicated.

931   Patient must be eligible on 177 - Patient has not met the required     N30 - Patient ineligible for this   90 - Entity not eligible for medical
      banding date and banding eligibility requirements.                     service.                            benefits for submitted dates of
      claim.                                                                                                     service.

932   CLIA cert info could not be 125 - Submission-billing error(s).         MA120 - Missing-incomplete-        21 - Missing or invalid information.
      verified. Verify CLIA                                                  invalid CLIA certification number.
      number on summary page.
      Contact your state CLIA                                                                                      142 - Entitys license-certification
      authority-NC providers                                                                                     number.
      contact NC DFS CLIA PO
      BOX 29530 Raleigh NC                                                                                       630 - Referring CLIA Number
      27626.


933   W5141 or J1055 not            B15 - This service-procedure requires    N20 - Service not payable with      258 - Days-units for procedure-
      allowed on the same DOS       that a qualifying service-procedure be   other service rendered on the       revenue code.
      as J1050 or J1051..           received and covered. The qualifying     same date.
                                    other service-procedure has not been
                                    received-adjudicated.



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934   J1050 or J1051 is not         B15 - This service-procedure requires        N20 - Service not payable with     258 - Days-units for procedure-
      allowed on the same date      that a qualifying service-procedure be       other service rendered on the      revenue code.
      of service as W5141 or        received and covered. The qualifying         same date.
      J1055.                        other service-procedure has not been
                                    received-adjudicated.

935   Skilled nurse home visit      B15 - This service-procedure requires        N20 - Service not payable with     258 - Days-units for procedure-
      not allowed same DOS as       that a qualifying service-procedure be       other service rendered on the      revenue code.
      related procedure.            received and covered. The qualifying         same date.
                                    other service-procedure has not been
                                    received-adjudicated.

936   CLIA cert not valid for       B7 - This provider was not certified-        MA120 - Missing-incomplete-        21 - Missing or invalid information.
      DOS-level. If you have        eligible to be paid for this procedure-      invalid CLIA certification number.
      only 1 CLIA #, contact        service on this date of service.
      agency that issued cert. If                                                                                     142 - Entitys license-certification
      multi CLIA#, send copy of                                                                                     number.
      cert-claim & inquiry form
      to EDS Provider Services.                                                                                     630 - Referring CLIA Number


937   Maternity care not allowed B15 - This service-procedure requires           N20 - Service not payable with     258 - Days-units for procedure-
      same date of service as    that a qualifying service-procedure be          other service rendered on the      revenue code.
      related procedure.         received and covered. The qualifying            same date.
                                 other service-procedure has not been
                                 received-adjudicated.

938   Postpartum-newborn            B15 - This service-procedure requires        N20 - Service not payable with     258 - Days-units for procedure-
      home visit not allowed        that a qualifying service-procedure be       other service rendered on the      revenue code.
      with related procedure,       received and covered. The qualifying         same date.
      same date of service.         other service-procedure has not been
                                    received-adjudicated.

939   Maternity care-newborn        B15 - This service-procedure requires        N20 - Service not payable with     258 - Days-units for procedure-
      visit not allowed same        that a qualifying service-procedure be       other service rendered on the      revenue code.
      DOS as skilled nurse          received and covered. The qualifying         same date.
      maternal care home visit.     other service-procedure has not been
                                    received-adjudicated.



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940   The recipient first initial   125 - Submission-billing error(s).      MA36 - Missing-incomplete-          21 - Missing or invalid information.
      and last name required.                                               invalid patient name

                                                                                                                             125 - Entitys name.

941   Prescription number           125 - Submission-billing error(s).      M119 - Missing-incomplete-          219 - Prescription number.
      required.                                                             invalid-deactivated-withdrawn
                                                                            National Drug Code (NDC).
942   Prescriber name or DEA        125 - Submission-billing error(s).      N31 - Missing-incomplete-invalid    21 - Missing or invalid information.
      number is required .                                                  prescribing provider identifier.

                                                                                                                  150 - Entitys drug enforcement
                                                                                                                agency (DEA) number.

943   Date of claim is prior to     110 - Billing date predates service date No Mapping Required                88 - Entity not eligible for benefits
      date of service.                                                                                          for submitted dates of service.

944   Quantity dispensed(if IV-  154 - Payment adjusted because the         M119 - Missing-incomplete-          21 - Missing or invalid information.
      give bags) and days        payer deems the information submitted      invalid-deactivated-withdrawn
      supply(not dosage) req.;   does not support this days supply.         National Drug Code (NDC).
      or total quantity mismatch                                                                                  221 - Drug days supply and
      on detail line 0-9 vs.                                                                                    dosage.
      compound items                                                        M123 - Missing-incomplete-
      (excludes tabs-cap-pwds.).                                            invalid name, strength, or dosage
                                                                            of the drug furnished.

945   Total amount billed (drug 125 - Submission-billing error(s).          M54 - Missing-incomplete-invalid 21 - Missing or invalid information.
      cost + disp. fee) is                                                  total charges.
      required in the dollars-
      cents field & must be
      greater than TPL-Medicare
      payment in other covered
      field. Do not bill co-pay-
      ded.




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946   Compound info req. give    125 - Submission-billing error(s).           M119 - Missing-incomplete-          21 - Missing or invalid information.
      drug name, strength, NDC,                                               invalid-deactivated-withdrawn
      Mfg,quantity and cost of                                                National Drug Code (NDC).
      all ingredients at bottom                                                                                     216 - Drug information.
      of form. On detail 0-9 put
      compd. drug name, if IV-                                                M123 - Missing-incomplete-
      give formula per bag.                                                   invalid name, strength, or dosage
                                                                              of the drug furnished.

947   The date of service is        125 - Submission-billing error(s).        MA06 - Missing-incomplete-          21 - Missing or invalid information.
      required on claim form.                                                 invalid beginning and-or ending
                                                                              date(s).
                                                                                                                               187 - Date(s) of
                                                                                                                  service.
948   Legible drug name,            125 - Submission-billing error(s).        M119 - Missing-incomplete-          216 - Drug information.
      NDC,MFG. Must be                                                        invalid-deactivated-withdrawn         217 - Drug name, strength and
      indicated on a legible                                                  National Drug Code (NDC).           dosage form.
      claim form and-or drug                                                                                               218 - NDC number.
      name-strength-NDC
      mismatch.                                                               M123 - Missing-incomplete-
                                                                              invalid name, strength, or dosage
                                                                              of the drug furnished.
949   Prescriptions on form         125 - Submission-billing error(s).        MA06 - Missing-incomplete-        21 - Missing or invalid information.
      must be for same month.                                                 invalid beginning and-or ending
                                                                              date(s).
950   Claim denied: EDS will        133 - The disposition of this claim-      N10 - Claim-service adjusted      42 - Awaiting related charges.
      refile-upon receipt of info   service is pending further review.        based on the findings of a
      from mfg.                                                               review organization-
                                                                              professional consult-manual
                                                                              adjudication-medical or dental
                                                                              advisor.
                                                                                         N185 - Alert- Do not
                                                                              resubmit this claim-service



951   Adjustment due to a         B5 - Coverage-program guidelines            No Mapping Required                 107 - Processed according to
      payment error discovered were not met or were exceeded.                                                     contract-plan provisions.
      from a drug rebate inquiry.


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952   Fixation of femur fracture   97 - The benefit for this service is     M80 - Not covered when             454 - Procedure code for services
      included in                  included in the payment-allowance for    performed during the same          rendered.
      hemiarthroplasty, hip        another service-procedure that has       session-date as a previously
      partial.                     already been adjudicated.                processed service for the patient.

953   Individual has restricted    109 - Claim not covered by this payer-   No Mapping Required               84 - Service not authorized
      coverage - Medicaid only     contractor. You must send the claim to
      pays the part B premium.     the correct payer-contractor.

954   Level of Service billed is   150 - Payment adjusted because the      N1 - Alert- You may appeal this 21 - Missing or invalid information.
      not documented. Please       payer deems the information submitted decision in writing within the                 294 - Supporting
      refile as an adjustment      does not support this level of service. required time limits following  documentation
      with further                                                         receipt of this notice by
      documentation or using                                               following the instructions
      the non-emergent codes.                                              included in your contract or
                                                                           plan benefit documents.
                                                                                                     N29 -
                                                                           Missing documentation-orders-
                                                                            notes- summary- report- chart.



956   Comprehensive evaluation     B15 - This service-procedure requires    N20 - Service not payable with    258 - Days-units for procedure-
      and related components       that a qualifying service-procedure be   other service rendered on the     revenue code.
      not allowed on the same      received and covered. The qualifying     same date.
      DOS, same or different       other service-procedure has not been
      provider.                    received-adjudicated.

957   Dialysis treatment allowed 119 - Benefit maximum for this time        M86 - Service denied because      259 - Frequency of service.
      once per day. If more than period or occurrence has been reached.     payment already made for same-
      one treatment is provided                                             similar procedure within set time
      submit an adjustment with                                             frame.                              612 - Per Day Limit Amount
      documentation showing
      medical necessity.




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958   Units cut back;only one      119 - Benefit maximum for this time    M86 - Service denied because      259 - Frequency of service.
      unit allowed per day. If     period or occurrence has been reached. payment already made for same-
      multiple unrelated tests                                            similar procedure within set time
      were performed, file as an                                          frame.                              612 - Per Day Limit Amount
      adjustment.

959   Maximum number of units 119 - Benefit maximum for this time        N20 - Service not payable with        259 - Frequency of service.
      per day previously paid for period or occurrence has been reached. other service rendered on the
      this date of service.                                              same date.
                                                                                                                 612 - Per Day Limit Amount
960   Please specify the name of 125 - Submission-billing error(s).         M123 - Missing-incomplete-        21 - Missing or invalid information.
      the medication given in                                               invalid name, strength, or dosage
      this injection.                                                       of the drug furnished.
                                                                                                                 409 - Medication logs-records
                                                                                                              (including medication therapy).

961   Newborn Health Check         B15 - This service-procedure requires    N20 - Service not payable with     258 - Days-units for procedure-
      screen and Newborn           that a qualifying service-procedure be   other service rendered on the      revenue code.
      Assessment not allowed       received and covered. The qualifying     same date.
      on the same day.             other service-procedure has not been
                                   received-adjudicated.

962   Writing prescriptions for    97 - The benefit for this service is     M80 - Not covered when             454 - Procedure code for services
      medication is included in    included in the payment-allowance for    performed during the same          rendered.
      your fee for services.       another service-procedure that has       session-date as a previously
                                   already been adjudicated.                processed service for the patient.

963   Childbirth classes and       B15 - This service-procedure requires    N20 - Service not payable with     258 - Days-units for procedure-
      refresher classes not        that a qualifying service-procedure be   other service rendered on the      revenue code.
      allowed on the same day.     received and covered. The qualifying     same date.
                                   other service-procedure has not been
                                   received-adjudicated.

964   1993 Adult health            B15 - This service-procedure requires    N20 - Service not payable with     258 - Days-units for procedure-
      assessment code not          that a qualifying service-procedure be   other service rendered on the      revenue code.
      allowed with related         received and covered. The qualifying     same date.
      codes(Y2000;Y2133;W8001      other service-procedure has not been
      ).                           received-adjudicated.



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965   Related procedure not        B15 - This service-procedure requires     N20 - Service not payable with    258 - Days-units for procedure-
      allowed same day as          that a qualifying service-procedure be    other service rendered on the     revenue code.
      Y2039.                       received and covered. The qualifying      same date.
                                   other service-procedure has not been
                                   received-adjudicated.

966   Only one Fetal non-stress 119 - Benefit maximum for this time          M86 - Service denied because      259 - Frequency of service.
      test allowed-day. Detail   period or occurrence has been reached.      payment already made for same-
      has been cut back to allow                                             similar procedure within set time
      one unit.                                                              frame.

967   DHS immunizations            150 - Payment adjusted because the      N180 - This item or service does 454 - Procedure code for services
      cannot be assigned a         payer deems the information submitted not meet the criteria for the        rendered.
      family planning category     does not support this level of service. category under which it was billed
      of service; no family
      planning cos exists for
      required financial
      treatment.
968   Records indicate claim       11 - The diagnosis is inconsistent with   M76 - Missing-incomplete-invalid 488 - Diagnosis code(s) for the
      should be processed as a     the procedure.                            diagnosis or condition.          services rendered
      therapeutic abortion.
      Resubmit w/appropriate 5
      digit diagnosis code from
      the 635-635.9 range of
      codes & federal abortion
      statement.


969   Records indicate this is    11 - The diagnosis is inconsistent with    M76 - Missing-incomplete-invalid 488 - Diagnosis code(s) for the
      not a therapeutic abortion. the procedure.                             diagnosis or condition.          services rendered
       Please remove the                                                                                      454 - Procedure code for services
      therapeutic abortion code                                                                               rendered
      and resubmit with a
      corrected diagnosis code.




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970   A therapeutic abortion        11 - The diagnosis is inconsistent with   M76 - Missing-incomplete-invalid 488 - Diagnosis code(s) for the
      procedure is not billed on    the procedure.                            diagnosis or condition.          services rendered
      this claim. Please remove
      the therapeutic diagnosis
      code from your claim and
      resubmit.

971   Periodontal maintenance       97 - The benefit for this service is      M80 - Not covered when             454 - Procedure code for services
      procedures are allowed        included in the payment-allowance for     performed during the same          rendered.
      only as follow-up to          another service-procedure that has        session-date as a previously
      periodontal surgery.          already been adjudicated.                 processed service for the patient.

                                                                               N188 - The approved level of
                                                                              care does not match the
                                                                              procedure code submitted
972   Over 3 hours of physician     16 - Claim-service lacks information      N29 - Missing documentation-      263 - Length of time for services
      unusual travel must be        which is needed for adjudication.         orders- notes- summary- report-   rendered.
      documented. Resubmit                                                    chart.                                   294 - Supporting
      claim with records.                                                                                       documentation


973   Non-emergent                  B15 - This service-procedure requires     N20 - Service not payable with    258 - Days-units for procedure-
      ambulance:one-way             that a qualifying service-procedure be    other service rendered on the     revenue code.
      transportation and round      received and covered. The qualifying      same date.
      trip transportation are not   other service-procedure has not been
      allowed on the same day.      received-adjudicated.


974   Code invalid for this DOS.    125 - Submission-billing error(s).        MA31 - Missing-incomplete-        21 - Missing or invalid information.
                                                                              invalid beginning and ending
                                                                              dates of the period billed.
                                                                                                                  187 - Date(s) of service.




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                                                     EOB Code Crosswalk to HIPAA Standard Codes



975   Documentation does not        16 - Claim-service lacks information      M22 - Missing-incomplete-invalid 428 - Reason for transport by
      support the necessity for     which is needed for adjudication.         number of miles traveled.        ambulance
      air ambulance. Change
      miles to reflect ground                                                   N206 - The supporting
      transport. Do not change                                                documentation does not match
      your codes. Resubmit as                                                 the claim
      an adjustment.


976   Air ambulance services        150 - Payment adjusted because the      N381 - Consult our contractual       454 - Procedure code for services
      cut back to ground            payer deems the information submitted agreement for restrictions-billing-    rendered.
      reimbursement.                does not support this level of service. payment information related to
                                                                            these charges
977   Service denied. No            115 - Procedure postponed-canceled- No Mapping Required                      104 - Processed according to plan
      transport of patient.         or delayed.                                                                  provisions.
978   ALS not documented,           16 - Claim-service lacks information    N29 - Missing documentation-         123 - Additional information
      please refile as an           which is needed for adjudication.       orders- notes- summary- report-      requested from entity.
      adjustment with further                                               chart.                                       294 - Supporting
      documentation, or refile as                                                                                documentation.
      a BLS service.

979   ALS not documented,           150 - Payment adjusted because the     N381 - Consult our contractual        454 - Procedure code for services
      code changed to reflect       payer deems the information submitted agreement for restrictions-billing-    rendered
      BLS service.                  does not support this level of service payment information related to
                                                                           these charges
980   Miles cut back to the         117 - Payment adjusted because         N381 - Consult our contractual        267 - Number of miles patient was
      nearest appropriate facility. transportation is only covered to the  agreement for restrictions-billing-   transported.
                                    closest facility that can provide the  payment information related to           430 - Nearest appropriate
                                    necessary care.                        these charges                         facility
981   Non-emergent transport        16 - Claim-service lacks information   N29 - Missing documentation-          428 - Reason for transport by
      paid for “specialized         which is needed for adjudication.      orders- notes- summary- report-       ambulance
      services” only. Please                                               chart.
      document service
      rendered requiring
      transport and resubmit as
      an adjustment.



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                                                     EOB Code Crosswalk to HIPAA Standard Codes


982   Payment for outpatient        45 - Charge exceeds fee schedule-       N381 - Consult our contractual      249 - Place of service.
      place of service reduced      maximum allowable or contracted-        agreement for restrictions-billing-
      to 80% of fee schedule.       legislated fee arrangement. (Use        payment information related to
                                    Group Codes PR or CO depending          these charges
                                    upon liability).
983   Repeat medication             18 - Duplicate claim-service.           M86 - Service denied because      259 - Frequency of service.
      professional fee denied.                                              payment already made for same-
                                                                            similar procedure within set time
                                                                            frame.

984   Non-emergent transport        97 - The benefit for this service is    M77 - Missing-incomplete-invalid 249 - Place of service.
      paid only for specialized     included in the payment-allowance for   place of service.                                        454 -
      services that cannot be       another service-procedure that has                                       Procedure code for services
      provided in the place of      already been adjudicated.                                                rendered.
      residence.

985   Exceeds monthly           119 - Benefit maximum for this time    M86 - Service denied because          259 - Frequency of service.
      legislative limit for     period or occurrence has been reached. payment already made for same-
      prescriptions.                                                   similar procedure within set time
                                                                       frame
986   Primary procedure code is 125 - Submission-billing error(s).     N56 - Procedure code billed is        21 - Missing or invalid information.
      invalid.                                                         not correct-valid for the service
                                                                       billed or the date of service billed.
                                                                                                                465 - Principal Procedure Code
                                                                                                             for Service(s) Rendered
987   Other procedure code 2 is 125 - Submission-billing error(s).     N56 - Procedure code billed is        21 - Missing or invalid information.
      invalid.                                                         not correct-valid for the service                 490 - Other procedure
                                                                       billed or the date of service billed. code for service(s) rendered

988   Other procedure code 3 is     125 - Submission-billing error(s).      N56 - Procedure code billed is        21 - Missing or invalid information.
      invalid.                                                              not correct-valid for the service                490 - Other procedure
                                                                            billed or the date of service billed. code for service(s) rendered

989   Primary procedure code        125 - Submission-billing error(s).      MA66 - Missing-incomplete-           21 - Missing or invalid information.
      must be further                                                       invalid principal procedure code.
      subdivided. (The code
      must have four digits).                                                                                       465 - Principal Procedure Code
                                                                                                                 for Service(s) Rendered


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                                                    EOB Code Crosswalk to HIPAA Standard Codes

990   Other procedure code 2       125 - Submission-billing error(s).       N56 - Procedure code billed is        21 - Missing or invalid information.
      must be further                                                       not correct-valid for the services               490 - Other procedure
      subdivided. (The code                                                 billed or the date of service billed. code for service(s) rendered
      must have 4 digits).

991   Other procedure code 3      125 - Submission-billing error(s).        N56 - Procedure code billed is        21 - Missing or invalid information.
      must be further                                                       not correct-valid for the services               490 - Other procedure
      subdivided (the code must                                             billed or the date of service billed. code for service(s) rendered
      have 4 digits).
992   CPT 90741 may not be        125 - Submission-billing error(s).        N56 - Procedure code billed is        21 - Missing or invalid information.
      billed for dates of service                                           not correct-valid for the service
      on or after 01-01-1994.                                               billed or the date of service billed.
      Please rebill using the                                                                                       187 - Date(s) of service.
      appropriate, dose specific
      HCPC code (J1460-J1561).

993   Exceeds limitations per      119 - Benefit maximum for this time    M86 - Service denied because           259 - Frequency of service.
      365 days, submit as an       period or occurrence has been reached. payment already made for same-          287 - Medical necessity for
      adjustment                                                          similar procedure within set time      service.
                                                                          frame.                                     294 - Supporting
                                                                          N435 - Exceeds number-                 documentation.
                                                                          frequency approved -allowed
                                                                          within time period without support
                                                                          documentation.

994   Up to 3 routes allowed for   151 - Payment adjusted because the    N29 - Missing documentation-            259 - Frequency of service.
      chemotherapy                 payer deems the information submitted orders-notes-summary-report-                  421 - Medical review
      administration. If more      does not support this many services.  chart.                                  attachment-information for
      than 3 routes required,                                             N163 - Medical Record does             service(s)
      submit as an adjustment                                            not support code billed per the
      with medical records                                               code definition
      documenting services.

995   Service rendered by      185 - The rendering provider is not          N95 - This provider type -           91 - Entity not eligible-not
      salaried FQHC physicians eligible to perform the service billed.      provider specialty may not bill      approved for dates of service.
      must be billed by the                                                 this service.
      FQHC; payment cannot be
      made directly to the
      attending provider.


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                                                     EOB Code Crosswalk to HIPAA Standard Codes



996    Payment has been             119 - Benefit maximum for this time    No Mapping Required                   186 - Purchase and rental price of
       adjusted to equal new        period or occurrence has been reached.                                       durable medical equipment.
       purchase price. Medicaid
       has previously paid for
       this equipment code.

997    Full recoupment; Inpatient 18 - Duplicate claim-service.              M86 - Service denied because      259 - Frequency of service.
       charges have been paid                                                payment already made for same-
       for some of these dates of                                            similar procedure within set time
       service. Rebill for covered                                           frame.
       days only. Correct and
       resubmit as a new claim.


998    Claim does not require       125 - Submission-billing error(s).       N59 - Alert- Please refer to        21 - Missing or invalid information.
       adjustment processing.                                                your provider manual for
       Resubmit claim with                                                   additional program and
       corrections as a new day                                              provider information
       claim. If POS, reverse and
       resubmit.

999    CPT chiropractic             B15 - This service-procedure requires    N20 - Service not payable with      258 - Days-units for procedure-
       manipulative treatment       that a qualifying service-procedure be   other service rendered on the       revenue code.
       codes not allowed on the     received and covered. The qualifying     same date.
       same date of service as      other service-procedure has not been
       HCPCS manual                 received-adjudicated.
       manipulation of the spine.


1001   Recipient is entitled to     177 - Patient has not met the required   N196 - Alert- Patient eligible to   197 - Effective coverage date(s).
       Medicare but failed to       eligibility requirements.                apply for other coverage
       apply. Service is not                                                 which may be primary
       covered. Bill recipient.
1002   Exceeds CAP-MR-DD            119 - Benefit maximum for this time    M86 - Service denied because      259 - Frequency of service.
       personal emergency           period or occurrence has been reached. payment already made for same-
       response monthly                                                    similar procedure within set time
       limitation.                                                         frame



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                                                     EOB Code Crosswalk to HIPAA Standard Codes


1003   Date of service is more      177 - Patient has not met the required   N30 - Patient ineligible for this   91 - Entity not eligible-not
       than 30 days prior to CAP    eligibility requirements.                service.                            approved for dates of service.
       effective date.

1004   Cap services recouped to 169 - Payment adjusted because an         M2 - Not paid separately when          258 - Days-units for procedure-
       pay inpatient stay charges. alternate benefit has been provided    the patient is an inpatient.           revenue code.
       Cap service are not                                                   N20 - Service not payable with
       allowed during inpatient                                           other service rendered on the
       stay.                                                              same date.
                                                                                    N30 - Patient ineligible
                                                                          for this service
1005   Cap services denied when 169 - Payment adjusted because an         M2 - Not paid separately when          258 - Days-units for procedure-
       recipient is receiving      alternate benefit has been provided    the patient is an inpatient.           revenue code.
       inpatient services.                                                   N20 - Service not payable with
                                                                          other service rendered on the
                                                                          same date.
                                                                          N30 - Patient ineligible for this
                                                                          service
1006   CAP limitation of 2016      119 - Benefit maximum for this time    M86 - Service denied because           259 - Frequency of service.
       hours per waiver year has   period or occurrence has been reached. payment already made for same-
       been exceeded for crisis                                           similar procedure within set time
       stabilization.                                                     frame
1007   Units have been changed 119 - Benefit maximum for this time        N362 - The number of Days or           258 - Days-units for procedure-
       to allow maximum on 31      period or occurrence has been reached. Units of Service exceeds our           revenue code.
       units per month.                                                   acceptable maximum.                                 259 - Frequency of
                                                                          N381 - Consult our contractual         service.               476 - Missing
                                                                          agreement for restrictions-billing-    or invalid units of service
                                                                          payment information related to
                                                                          these charges
1008   Sterilization guidelines    16 - Claim-service lacks information   N3 - Missing consent form.             21 - Missing or invalid information.
       not met. Invalid 'estimated which is needed for adjudication.                                                          492 - Other
       date of confinement' on                                                                                   Procedure Date.
       consent form.

1009   Procedure denied:          97 - The benefit for this service is       N20 - Service not payable with      454 - Procedure code for services
       Included in 52647 or 52648 included in the payment-allowance for      other service rendered on the       rendered.
       already billed.            another service-procedure that has         same date.
                                  already been adjudicated.


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                                                     EOB Code Crosswalk to HIPAA Standard Codes


1010   W5142 not allowed on         B15 - This service-procedure requires    N20 - Service not payable with      258 - Days-units for procedure-
       same day as J7300.           that a qualifying service-procedure be   other service rendered on the       revenue code.
                                    received and covered. The qualifying     same date.
                                    other service-procedure has not been
                                    received-adjudicated.

1011   J7300 not allowed same       B15 - This service-procedure requires    N20 - Service not payable with      454 - Procedure code for services
       day as w5142.                that a qualifying service-procedure be   other service rendered on the       rendered
                                    received and covered. The qualifying     same date.
                                    other service-procedure has not been
                                    received-adjudicated.

1012   Units have been reduced    119 - Benefit maximum for this time    N43 - Bed hold or leave days            498 - Maximum leave days
       to allow maximum of 60     period or occurrence has been reached. exceeded.                               exhausted
       therapeutic leave days for                                                         N381 - Consult our
       the calendar year.                                                contractual agreement for
                                                                         restrictions-billing-payment
                                                                         information related to these
                                                                         charges
1013   Adult care home personal B15 - This service-procedure requires N20 - Service not payable with             258 - Days-units for procedure-
       care service are not       that a qualifying service-procedure be other service rendered on the           revenue code.
       reimbursed when            received and covered. The qualifying   same date.
       therapeutic leave has been other service-procedure has not been
       paid for the same dates of received-adjudicated.
       service.

1014   Service denied or cut        119 - Benefit maximum for this time    N362 - The number of Days or          258 - Days-units for procedure-
       back. Exceeds 14             period or occurrence has been reached. Units of Service exceeds our          revenue code.
       consecutive day limit.                                              acceptable maximum.                                259 - Frequency of
                                                                           N381 - Consult our contractual        service.
                                                                           agreement for restrictions-billing-
                                                                           payment information related to
                                                                           these charges
1015   DTP-HIB immunization         18 - Duplicate claim-service.          M86 - Service denied because          259 - Frequency of service.
       previously paid for this                                            payment already made for same-
       date of service under                                               similar procedure within set time
       codes 90720-90721.                                                  frame.



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1016   DTAP immunization          18 - Duplicate claim-service.               M86 - Service denied because      259 - Frequency of service.
       previously paid for this                                               payment already made for same-
       date of service under code                                             similar procedure within set time
       90700.                                                                 frame.

1017   Initial observation has       18 - Duplicate claim-service.            M86 - Service denied because      259 - Frequency of service.
       already been paid for this                                             payment already made for same-
       date of service.                                                       similar procedure within set time
                                                                              frame.

1018   Observation discharge         18 - Duplicate claim-service.            M86 - Service denied because      259 - Frequency of service.
       has already been paid for                                              payment already made for same-
       this date of service.                                                  similar procedure within set time
                                                                              frame.

1019   Evaluation and                B15 - This service-procedure requires    M86 - Service denied because      258 - Days-units for procedure-
       Management not allowed        that a qualifying service-procedure be   payment already made for same- revenue code.
       same day as NICU. NICU        received and covered. The qualifying     similar procedure within set time
       has already been paid for     other service-procedure has not been     frame.
       this date of service.         received-adjudicated.

1020   Initial hour of prolonged     119 - Benefit maximum for this time    M86 - Service denied because      259 - Frequency of service.
       services allowed once per     period or occurrence has been reached. payment already made for same-
       date of service. Service                                             similar procedure within set time                             612 -
       has already been paid for                                            frame.                            Per Day Limit Amount
       this date.

1021   Critical care not allowed     B15 - This service-procedure requires    M86 - Service denied because      258 - Days-units for procedure-
       on same date of service as    that a qualifying service-procedure be   payment already made for same- revenue code.
       prolonged service.            received and covered. The qualifying     similar procedure within set time
       Prolonged service already     other service-procedure has not been     frame.
       paid for this date.           received-adjudicated.


1022   Carolina access              9 - The diagnosis is inconsistent with    M76 - Missing-incomplete-invalid 21 - Missing or invalid information.
       recipient‟s age is not valid the patients age.                         diagnosis or condition.
       for the approved
       emergency diagnosis.                                                                                            255 - Diagnosis code.


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                                                      EOB Code Crosswalk to HIPAA Standard Codes

1023   Carolina access               10 - The diagnosis is inconsistent with   M76 - Missing-incomplete-invalid 21 - Missing or invalid information.
       recipient‟s gender is not     the patients gender.                      diagnosis or condition.
       valid for the approved                                                                                                 157 - Entitys
       Emergency diagnosis.                                                                                     Gender.                255 -
                                                                                                                Diagnosis code.
1024   Prolonged service already     B15 - This service-procedure requires     N20 - Service not payable with   258 - Days-units for procedure-
       paid for this date of         that a qualifying service-procedure be    other service rendered on the    revenue code.
       service. No additional        received and covered. The qualifying      same date.
       payment allowed for stand-    other service-procedure has not been
       by on same DOS.               received-adjudicated.

1025   Cap-mr-dd prevocational       B15 - This service-procedure requires     N20 - Service not payable with    258 - Days-units for procedure-
       services not allowed same     that a qualifying service-procedure be    other service rendered on the     revenue code.
       day as supported              received and covered. The qualifying      same date.
       employment services or        other service-procedure has not been
       institutional respite care.   received-adjudicated.




1026   Reimbursement for related     97 - The benefit for this service is      N20 - Service not payable with    454 - Procedure code for services
       procedure is being            included in the payment-allowance for     other service rendered on the     rendered.
       recouped to pay primary       another service-procedure that has        same date.
       procedure (52647 or           already been adjudicated.
       52648).

1027   Reimbursement for             B15 - This service-procedure requires     N20 - Service not payable with    258 - Days-units for procedure-
       therapeutic leave denied.     that a qualifying service-procedure be    other service rendered on the     revenue code.
       Adult care home PCS has       received and covered. The qualifying      same date.
       been paid for the same        other service-procedure has not been
       date (s) of service.          received-adjudicated.

1028   CAP MR-DD supported           B15 - This service-procedure requires     N20 - Service not payable with    258 - Days-units for procedure-
       employment service not        that a qualifying service-procedure be    other service rendered on the     revenue code.
       allowed same day as           received and covered. The qualifying      same date.
       prevocational services or     other service-procedure has not been
       institutional respite care.   received-adjudicated.




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                                                      EOB Code Crosswalk to HIPAA Standard Codes



1029   CAP MR-DD institutional       B15 - This service-procedure requires    N20 - Service not payable with   258 - Days-units for procedure-
       respite not allowed on        that a qualifying service-procedure be   other service rendered on the    revenue code.
       same day as related CAP       received and covered. The qualifying     same date.
       services.                     other service-procedure has not been
                                     received-adjudicated.

1030   Personal care not allowed     B15 - This service-procedure requires    N20 - Service not payable with   258 - Days-units for procedure-
       on same day as CAP MR-        that a qualifying service-procedure be   other service rendered on the    revenue code.
       DD supported living           received and covered. The qualifying     same date.
       service.                      other service-procedure has not been
                                     received-adjudicated.

1031   CAP MR-DD supported           B15 - This service-procedure requires    N20 - Service not payable with   258 - Days-units for procedure-
       living services not allowed   that a qualifying service-procedure be   other service rendered on the    revenue code.
       on same day as personal       received and covered. The qualifying     same date.
       care.                         other service-procedure has not been
                                     received-adjudicated.

1032   CAP MR-DD supported           B15 - This service-procedure requires    N20 - Service not payable with   258 - Days-units for procedure-
       Living not allowed same       that a qualifying service-procedure be   other service rendered on the    revenue code.
       day as related CAP            received and covered. The qualifying     same date.
       services.                     other service-procedure has not been
                                     received-adjudicated.

1033   Related CAP MR-DD             B15 - This service-procedure requires    N20 - Service not payable with   258 - Days-units for procedure-
       services not on same day      that a qualifying service-procedure be   other service rendered on the    revenue code.
       as supported living           received and covered. The qualifying     same date.
       services.                     other service-procedure has not been
                                     received-adjudicated.

1034   CAP MR-DD crisis              B15 - This service-procedure requires    N20 - Service not payable with   258 - Days-units for procedure-
       stabilization not allowed     that a qualifying service-procedure be   other service rendered on the    revenue code.
       on same date of service as    received and covered. The qualifying     same date.
       institutional respite care.   other service-procedure has not been
                                     received-adjudicated.




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                                                      EOB Code Crosswalk to HIPAA Standard Codes

1035   This EOB is for internal      45 - Charge exceeds fee schedule-        No Mapping Required               19 - Entity acknowledges receipt
       tracking of Health Check      maximum allowable or contracted-                                           of claim-encounter.
       visits. To determine if       legislated fee arrangement. (Use                                               585 - Denied Charge or Non-
       claim paid or denied look     Group Codes PR or CO depending                                             covered Charge.
       in the screening section of   upon liability).
       your RA.

1036   Thank you for reporting       89 - Professional fees removed from      M41 - We do not pay for this as   19 - Entity acknowledges receipt
       vaccines. This vaccine is     charges.                                 the patient has no legal          of claim-encounter.
       provided at no charge                                                  obligation to pay for this.       598 - Non-payable Professional
       through the Vaccines For                                                                                 Component Billed Amount.
       Children program. No
       payment allowed.

1037   Thanks for reporting          45 - Charge exceeds fee schedule-        M41 - We do not pay for this as   15 - One or more originally
       vaccine to our database.      maximum allowable or contracted-         the patient has no legal          submitted procedure code have
       Free modifier (F) is on       legislated fee arrangement. (Use         obligation to pay for this.       been modified.
       claim; however vaccine is     Group Codes PR or CO depending                                                      19 - Entity acknowledges
       not available through         upon liability).                                                           receipt of claim-encounter.
       VFC. Refile with 'P'                                                                                                598 - Non-payable
       modifier if you purchased                                                                                Professional Component Billed
       vaccine.                                                                                                 Amount.


1038   Claim denied. Refile with     125 - Submission-billing error(s).       MA43 - Missing-incomplete-        21 - Missing or invalid information.
       the appropriate patient                                                invalid patient status.
       status.
1039   Regularly scheduled           B15 - This service-procedure requires    N20 - Service not payable with    258 - Days-units for procedure-
       Health Check screening        that a qualifying service-procedure be   other service rendered on the     revenue code.
       and interperiodic Health      received and covered. The qualifying     same date.
       Check exam are not            other service-procedure has not been
       allowed on the same day.      received-adjudicated.


1040   Personal care services not    B15 - This service-procedure requires    N20 - Service not payable with    258 - Days-units for procedure-
       allowed on the same date      that a qualifying service-procedure be   other service rendered on the     revenue code.
       of service as Adult Care      received and covered. The qualifying     same date.
       Home personal care            other service-procedure has not been
       service.                      received-adjudicated.


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                                                    EOB Code Crosswalk to HIPAA Standard Codes


1041   Only one high risk          119 - Benefit maximum for this time    M86 - Service denied because      259 - Frequency of service.
       intervention allowed per    period or occurrence has been reached. payment already made for same-
       day.                                                               similar procedure within set time
                                                                          frame.

1042   Only one Case               18 - Duplicate claim-service.             M86 - Service denied because      259 - Frequency of service.
       Management allowed per                                                payment already made for same-
       day. Case management                                                  similar procedure within set time
       billed through another                                                frame.
       program has already been
       paid for this date of
       service.

1043   Units of service are not    151 - Payment adjusted because the    M53 - Missing-incomplete-invalid 258 - Days-units for procedure-
       consistent with dates of    payer deems the information submitted days or units of service.        revenue code.
       service. One calendar day   does not support this many services.
       equals one unit for this                                                                                                476 - Missing or
       HCPC code.                                                                                         invalid units of service.

1044   Multiple billings of same   B15 - This service-procedure requires     N20 - Service not payable with    258 - Days-units for procedure-
       or similar dme supply-      that a qualifying service-procedure be    other service rendered on the     revenue code.
       equipment not allowed on    received and covered. The qualifying      same date.
       the same date of service.   other service-procedure has not been
                                   received-adjudicated.

1045   Please complete the         16 - Claim-service lacks information      MA37 - Missing-incomplete-        21 - Missing or invalid information.
       hysterectomy statement      which is needed for adjudication.         invalid patients address
       by adding the recipient‟s                                                                                               126 - Entitys
       complete address.                                                                          N225 -       address.                      421 -
                                                                             Incomplete-invalid                Medical review attachment-
                                                                             documentation-orders- notes-      information for service(s).
                                                                             summary- report- chart.
1046   Please complete the         16 - Claim-service lacks information      N225 - Incomplete-invalid         21 - Missing or invalid information.
       hysterectomy 'prior to my   which is needed for adjudication.         documentation-orders- notes-                             187 -
       surgery' statement by                                                 summary- report- chart.           Date(s) of service.
       adding the complete date                                                                                421 - Medical review attachment-
       of surgery.                                                                                             information for service(s).



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                                                     EOB Code Crosswalk to HIPAA Standard Codes


1047   The witness and/or           16 - Claim-service lacks information      MA75 - Missing-incomplete-          21 - Missing or invalid information.
       recipient signature has      which is needed for adjudication.         invalid patient or authorized                            421 - Medical
       been omitted on the                                                    representative signature.           review attachment-information for
       hysterectomy statement.                                                                                    service(s).
       Resubmit a new
       completed "prior to my                                                     N225 - Incomplete-invalid
       surgery" statement.                                                    documentation-orders- notes-
                                                                              summary- report- chart.
1048   The signature/witness        16 - Claim-service lacks information      MA75 - Missing-incomplete-          21 - Missing or invalid information.
       date has been omitted        which is needed for adjudication.         invalid patient or authorized                               421 -
       from the hysterectomy                                                  representative signature            Medical review attachment-
       statement. Submit                                                                                          information for service(s).
       completed statement and                                                                                         492 - Other Procedure Date
       initial the date.
1049   The DOS on the               16 - Claim-service lacks information      M52 - Missing-incomplete-invalid 187 - Date(s) of service.
       hysterectomy statement is    which is needed for adjudication. At      from date(s) of service.           21 - Missing or invalid
       different than the claim.    least one Remark Code must be                                              information. Note- At least one
       Correct and resubmit as      provided (may be comprised of either                           N29 -       other status code is required to
       adjustment with claim and    the Remittance Advice Remark Code         Missing documentation-orders-    identify the missing or invalid
       statement attached.          or NCPDP Reject Reason Code.)             notes-summary-report-chart.      information.
                                                                                                               421 - Medical review attachment-
                                                                                                               information for service(s

1050   Electronic provider         16 - Claim-service lacks information       N51 - Electronic interchange        21 - Missing or invalid information.
       agreement not on file. Call which is needed for adjudication.          agreement not on file for provider-              24 - Entity not
       ECS unit to obtain copy of                                             submitter.                          approved as an electronic
       agreement. No payment                                                                                      submitter.
       made to this prov # for
       electronic claims until
       agreement has been
       approved by DMA.

1051   At-Risk Case Management      B15 - This service-procedure requires     N20 - Service not payable with      258 - Days-units for procedure-
       not allowed on same day      that a qualifying service-procedure be    other service rendered on the       revenue code.
       as related Case              received and covered. The qualifying      same date.
       Management services.         other service-procedure has not been
                                    received-adjudicated.



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1052   Related Case Management     B15 - This service-procedure requires    N20 - Service not payable with       258 - Days-units for procedure-
       service not allowed on      that a qualifying service-procedure be   other service rendered on the        revenue code.
       same day as At-Risk Case    received and covered. The qualifying     same date.
       Management.                 other service-procedure has not been
                                   received-adjudicated.

1053   At-risk Case Management 169 - Payment adjusted because an            M2 - Not paid separately when        258 - Days-units for procedure-
       services are noncovered     alternate benefit has been provided      the patient is an inpatient.         revenue code.
       when recipient is receiving                                             N20 - Service not payable with
       inpatient service.                                                   other service rendered on the
                                                                            same date.
                                                                                      N30 - Patient ineligible
                                                                            for this service
1054   At-risk Case Management     169 - Payment adjusted because an        M2 - Not paid separately when        258 - Days-units for procedure-
       service recouped. This      alternate benefit has been provided      the patient is an inpatient.         revenue code.
       service not allowed when                                                N20 - Service not payable with
       recipient is receiving                                               other service rendered on the
       inpatient services.                                                  same date.
                                                                            N30 - Patient ineligible for this
                                                                            service
1055   ER and hospital adm not     B15 - This service-procedure requires    M2 - Not paid separately when        258 - Days-units for procedure-
       allowed same DOS-same       that a qualifying service-procedure be   the patient is an inpatient.         revenue code.
       provider.                   received and covered. The qualifying        N20 - Service not payable with
                                   other service-procedure has not been     other service rendered on the
                                   received-adjudicated.                    same date.
                                                                            N30 - Patient ineligible for this
                                                                            service
1056   ER services recouped. ER    B15 - This service-procedure requires    M2 - Not paid separately when        258 - Days-units for procedure-
       services and hospital adm   that a qualifying service-procedure be   the patient is an inpatient.         revenue code.
       not allowed same DOS-       received and covered. The qualifying        N20 - Service not payable with
       same provider.              other service-procedure has not been     other service rendered on the
                                   received-adjudicated.                    same date.
                                                                            N30 - Patient ineligible for this
                                                                            service




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                                                     EOB Code Crosswalk to HIPAA Standard Codes




1057   Valid revenue code must 125 - Submission-billing error(s).           M20 - Missing-incomplete-invalid 21 - Missing or invalid information.
       be billed with a valid                                               HCPCS.
       HCPC code. HCPC code is                                                       M50 - Missing-
       missing or invalid or                                                incomplete-invalid revenue                    455 - Revenue code
       HCPC code has been                                                   code(s).                         for services rendered.
       billed with missing or
       invalid revenue code.
       Correct and resubmit.

1058   The only well child exam    125 - Submission-billing error(s).       MA66 - Missing-incomplete-          21 - Missing or invalid information.
       billable through the                                                 invalid principal procedure code.
       Medicaid program is a
       Health Check Screen. For
       more information about
       billing Health Check,
       please call 1-800-688-6696.


1059   Ambulance claim form is   125 - Submission-billing error(s).         N34 - Incorrect claim form-format 21 - Missing or invalid information.
       no longer accepted.                                                  for this service.
       Please resubmit
       ambulance charges on the                                                                                   228 - Type of bill for UB claim
       UB92 claim.
1060   Admit hour-time of pickup 125 - Submission-billing error(s).         N46 - Missing-incomplete-invalid    21 - Missing or invalid information.
       is missing or invalid.                                               admission hour.
       Please correct and
       resubmit as a new claim.

1061   Only one date of service     125 - Submission-billing error(s).      M53 - Missing-incomplete-invalid 258 - Days-units for procedure-
       allowed per claim. Bill                                              days or units of service.        revenue code.
       each ambulance trip on a
       separate claim.




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                                                     EOB Code Crosswalk to HIPAA Standard Codes

1063   Therapeutic Abortion not     125 - Submission-billing error(s).       M51 - Missing-incomplete-invalid 21 - Missing or invalid information.
       done this DOS. Records                                                procedure code(s).
       state a post-abortion                                                 M64 - Missing-incomplete-invalid
       procedure was done.                                                   other diagnosis.                   187 - Date(s) of service.
       Correct your codes to
       post-abortion diagnosis-
       procedure and rebill.

1064   Units are not consistent     151 - Payment adjusted because the    M53 - Missing-incomplete-invalid 258 - Days-units for procedure-
       with procedure (s) billed.   payer deems the information submitted days or units of service.        revenue code.
       Verify your units, correct   does not support this many services.
       claim and resubmit.                                                                                                      476 - Missing or
                                                                                                           invalid units of service.

1065   Cap personal care            B15 - This service-procedure requires    N20 - Service not payable with    258 - Days-units for procedure-
       services not allowed on      that a qualifying service-procedure be   other service rendered on the     revenue code.
       same date of service as      received and covered. The qualifying     same date.
       Adult Care Home services.    other service-procedure has not been
                                    received-adjudicated.

1066   Cap in-home aide service     B15 - This service-procedure requires    N20 - Service not payable with    258 - Days-units for procedure-
       not allowed on same date     that a qualifying service-procedure be   other service rendered on the     revenue code.
       of service as Adult Care     received and covered. The qualifying     same date.
       Home services.               other service-procedure has not been
                                    received-adjudicated.

1067   Home health aide service     B15 - This service-procedure requires    N20 - Service not payable with    258 - Days-units for procedure-
       not allowed on same date     that a qualifying service-procedure be   other service rendered on the     revenue code.
       of service as Adult Care     received and covered. The qualifying     same date.
       Home services.               other service-procedure has not been
                                    received-adjudicated.

1068   Component(s) of              B15 - This service-procedure requires    N20 - Service not payable with    454 - Procedure code for services
       urinalysis recouped.         that a qualifying service-procedure be   other service rendered on the     rendered.
       Urinalysis; with             received and covered. The qualifying     same date.
       microscopy, which is the     other service-procedure has not been
       complete service, has        received-adjudicated.
       been paid for this date of
       service, this provider.


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                                                      EOB Code Crosswalk to HIPAA Standard Codes



1069   Components denied.            B15 - This service-procedure requires    N20 - Service not payable with   258 - Days-units for procedure-
       Urinalysis with               that a qualifying service-procedure be   other service rendered on the    revenue code.
       microscopy, which is a        received and covered. The qualifying     same date.
       complete procedure has        other service-procedure has not been
       already been paid for this    received-adjudicated.
       date of service, this
       provider.
1070   Urinalysis components         97 - The benefit for this service is     M80 - We cannot pay for this     454 - Procedure code for services
       billed for the same date of   included in the payment-allowance for    when performed during the        rendered.
       service must be combined      another service-procedure that has       same session as a previously
       under 81000. Please           already been adjudicated.                processed service for the
       submit adjustment request                                              patient
       to this effect for                                                         N1 - Alert- You may appeal
       components already paid.                                               this decision in writing within
                                                                              the required time limits
                                                                              following receipt of this notice
                                                                              by following the instructions
                                                                              included in your contract or
                                                                              plan benefit documents



1071   Urinalysis components         97 - The benefit for this service is     M80 - We cannot pay for this     454 - Procedure code for services
       billed for the same date of   included in the payment-allowance for    when performed during the        rendered.
       service must be combined      another service-procedure that has       same session as a previously
       under 81000. Please           already been adjudicated.                processed service for the
       submit adjustment request                                              patient
       to this effect for                                                         N1 - Alert- You may appeal
       components already paid.                                               this decision in writing within
                                                                              the required time limits
                                                                              following receipt of this notice
                                                                              by following the instructions
                                                                              included in your contract or
                                                                              plan benefit documents




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                                                     EOB Code Crosswalk to HIPAA Standard Codes




1072   Renin Stimulation Panel     18 - Duplicate claim-service.             M86 - Service denied because      259 - Frequency of service.
       has been paid for this date                                           payment already made for same-
       of service.                                                           similar procedure within set time
                                                                             frame.

1073   A negative dollar amount     125 - Submission-billing error(s).       M49 - Missing-incomplete-         21 - Missing or invalid information.
       was submitted on your                                                 invalid value code(s) or
       claim. Negative values are                                            amount(s).
       not permitted. Please
       correct and resubmit as a
       new claim.

1074   Components of                B15 - This service-procedure requires    N20 - Service not payable with    454 - Procedure code for services
       Comprehensive                that a qualifying service-procedure be   other service rendered on the     rendered.
       Audiometry and Speech        received and covered. The qualifying     same date.
       Recognition recouped.        other service-procedure has not been
       The complete service -       received-adjudicated.
       Comprehensive
       Audiometry eval and
       Speech Recognition, has
       already been paid for this
       date of service, this
       provider.
1075   Components denied.           B15 - This service-procedure requires    N20 - Service not payable with    454 - Procedure code for services
       Audiometry-Speech            that a qualifying service-procedure be   other service rendered on the     rendered.
       Recognition, which is a      received and covered. The qualifying     same date.
       complete procedure, has      other service-procedure has not been
       already been paid for this   received-adjudicated.
       date of service, this
       provider.




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                                                      EOB Code Crosswalk to HIPAA Standard Codes

1076   Audiometry components         B15 - This service-procedure requires    N20 - Service not payable with   454 - Procedure code for services
       billed for the same date of   that a qualifying service-procedure be   other service rendered on the    rendered.
       service must be combined      received and covered. The qualifying     same date.
       as 92557. Please submit       other service-procedure has not been
       an adjustment request to      received-adjudicated.
       this effect for component
       92556 already paid.



1077   Audiometry components         B15 - This service-procedure requires    N20 - Service not payable with   454 - Procedure code for services
       billed for the same date of   that a qualifying service-procedure be   other service rendered on the    rendered.
       service must be combined      received and covered. The qualifying     same date.
       as 92557. Please submit       other service-procedure has not been
       an adjustment request to      received-adjudicated.
       this effect for component
       92553 already paid.



1078   Optical claim form 372-017 125 - Submission-billing error(s).          N34 - Incorrect claim form-format 276 - UB04-HCFA-1450-1500
       is no longer accepted.                                                 for this service.                 claim form
       Please resubmit optical
       supply charges on the
       CMS-1500 claim.

1079   Detail units of RC229 must 151 - Payment adjusted because the          M52 - Missing-incomplete-invalid 258 - Days-units for procedure-
       equal the number of days payer deems the information submitted         “from” date(s) of service.       revenue code.
       calculated from the “from does not support this many services.
       & to” dates in form locator                                                                 M59 -                            476 - Missing or
       6 on approved UB. Correct                                              Missing-incomplete-invalid to    invalid units of service.
       your claim dates of                                                    date(s) of service.
       service and resubmit.


1080   Exceeds one per day           119 - Benefit maximum for this time    M86 - Service denied because      259 - Frequency of service.
       limitation.                   period or occurrence has been reached. payment already made for same-
                                                                            similar procedure within set time
                                                                            frame.


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                                                    EOB Code Crosswalk to HIPAA Standard Codes



1081   CAP MR-DD adult care        119 - Benefit maximum for this time    M86 - Service denied because      259 - Frequency of service.
       allowed once per day.       period or occurrence has been reached. payment already made for same-
                                                                          similar procedure within set time
                                                                          frame.

1082   Exceeds one per day         119 - Benefit maximum for this time    M86 - Service denied because      259 - Frequency of service.
       limitation.                 period or occurrence has been reached. payment already made for same-
                                                                          similar procedure within set time
                                                                          frame.

1083   Only one spine deformity    119 - Benefit maximum for this time    M86 - Service denied because      259 - Frequency of service.
       arthrodesis can be billed   period or occurrence has been reached. payment already made for same-
       per operative episode per                                          similar procedure within set time
       date of service.                                                   frame.

1084   Conflict in procedures     16 - Claim-service lacks information      M86 - Service denied because      21 - Missing or invalid information.
       billed. Anterior &         which is needed for adjudication.         payment already made for same-                           294 -
       Posterior procedures                                                 similar procedure within set time Supporting documentation
       billed for same DOS.                                                 frame.
       Review, Correct, Resubmit                                                                        N225
       or file an adjustment with                                           - Incomplete-invalid
       records.                                                             documentation-orders- notes-
                                                                            summary- report- chart.

1085   Service denied. Records     18 - Duplicate claim-service.            M86 - Service denied because      54 - Duplicate of a previously
       support segmental                                                    payment already made for same- processed claim-line.
       instrumentation                                                      similar procedure within set time
       previously paid for this                                             frame.
       date of service.

1086   Review procedures. Billed- 119 - Benefit maximum for this time       M86 - Service denied because      259 - Frequency of service.
       only one instrumentation   period or occurrence has been reached.    payment already made for same-
       proc allowed per day,                                                similar procedure within set time
       correct and resubmit as a                                            frame.
       new claim.




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                                                    EOB Code Crosswalk to HIPAA Standard Codes




1087   Insufficient documentation 150 - Payment adjusted because the        N29 - Missing documentation-     21 - Missing or invalid information.
       in records received to     payer deems the information submitted     orders-notes-summary-report-                   294 - Supporting
       support therapeutic        does not support this level of service.   chart.                           documentation
       abortion to save life of                                                   N206 - The supporting
       mother. Resubmit with                                                documentation does not match
       additional medical records                                           the claim
       as new day claim.


1088   CAP MR-DD adult day         B15 - This service-procedure requires    N20 - Service not payable with   258 - Days-units for procedure-
       health or developmental     that a qualifying service-procedure be   other service rendered on the    revenue code.
       day care not allowed on     received and covered. The qualifying     same date.
       same day as institutional   other service-procedure has not been
       respite.                    received-adjudicated.

1089   CAP MR-DD personal care     B15 - This service-procedure requires    N20 - Service not payable with   258 - Days-units for procedure-
       service not allowed on      that a qualifying service-procedure be   other service rendered on the    revenue code.
       same day as institutional   received and covered. The qualifying     same date.
       respite.                    other service-procedure has not been
                                   received-adjudicated.

1090   CAP MR-DD institutional    B15 - This service-procedure requires     N20 - Service not payable with   258 - Days-units for procedure-
       respite not allowed on     that a qualifying service-procedure be    other service rendered on the    revenue code.
       same day as personal care. received and covered. The qualifying      same date.
                                  other service-procedure has not been
                                  received-adjudicated.

1091   RC636 must be billed with   125 - Submission-billing error(s).       M51 - Missing-incomplete-      21 - Missing or invalid information.
       an approved HCPCS code                                               invalid procedure code(s) and-
       for vitrocert.                                                       or dates.
                                                                                           N59 - Alert-
                                                                            Please refer to your provider
                                                                            manual for additional program
                                                                            and provider information




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                                                     EOB Code Crosswalk to HIPAA Standard Codes

1092   This HCPCS code cannot       125 - Submission-billing error(s).      M20 - Missing-incomplete-         21 - Missing or invalid information.
       be billed with RC636.                                                invalid HCPCS


                                                                                           N59 - Alert-
                                                                            Please refer to your provider
                                                                            manual for additional program
                                                                            and provider information


1093   Antepartum package           18 - Duplicate claim-service.           M86 - Service denied because      259 - Frequency of service.
       59425 has already been                                               payment already made for same-
       paid for this gestation                                              similar procedure within set time
       period.                                                              frame.

1094   Stand-By service already     18 - Duplicate claim-service.           M86 - Service denied because      259 - Frequency of service.
       paid for this date of                                                payment already made for same-
       service. No additional                                               similar procedure within set time
       payment allowed for                                                  frame.
       prolonged service on
       same DOS.
1095   Observation service          18 - Duplicate claim-service.           M86 - Service denied because      259 - Frequency of service.
       already paid for this date                                           payment already made for same-
       of service. No additional                                            similar procedure within set time
       payment allowed for                                                  frame.
       prolonged service on
       same DOS.
1096   NICU already paid for this   97 - The benefit for this service is    M80 - Not covered when             454 - Procedure code for services
       date of service. No          included in the payment-allowance for   performed during the same          rendered.
       additional payment           another service-procedure that has      session-date as a previously
       allowed for prolonged        already been adjudicated.               processed service for the patient.
       service same DOS.

1097   Critical care has already    97 - The benefit for this service is    M80 - Not covered when             454 - Procedure code for services
       paid for this date of        included in the payment-allowance for   performed during the same          rendered.
       service. No additional       another service-procedure that has      session-date as a previously
       payment allowed for          already been adjudicated.               processed service for the patient.
       prolonged service same
       DOS.

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                                                       EOB Code Crosswalk to HIPAA Standard Codes


1098   Antepartum package has         18 - Duplicate claim-service.            M86 - Service denied because      259 - Frequency of service.
       already been paid for this                                              payment already made for same-
       gestation period.                                                       similar procedure within set time
                                                                               frame.

1099   NICU not allowed same          B15 - This service-procedure requires    N20 - Service not payable with    258 - Days-units for procedure-
       day as Evaluation and          that a qualifying service-procedure be   other service rendered on the     revenue code.
       Management code. E-M           received and covered. The qualifying     same date.
       already paid for this DOS.     other service-procedure has not been
                                      received-adjudicated.

1100   DTP-HIB immunization has 18 - Duplicate claim-service.                  M86 - Service denied because      259 - Frequency of service.
       already been paid for this                                              payment already made for same-
       date of service under code                                              similar procedure within set time
       Y2421.                                                                  frame.

1101   DTAP immunization has          18 - Duplicate claim-service.            M86 - Service denied because      259 - Frequency of service.
       already been paid for this                                              payment already made for same-
       date of service under                                                   similar procedure within set time
       Y2043.                                                                  frame.

1102   Initial viewing of the X-ray   97 - The benefit for this service is     M80 - Not covered when             454 - Procedure code for services
       by the ER physician is         included in the payment-allowance for    performed during the same          rendered.
       included in the ER visit       another service-procedure that has       session-date as a previously
       and will not be reimbursed     already been adjudicated.                processed service for the patient.
       separately.

1103   Quantity outside min-max. 119 - Benefit maximum for this time    No Mapping Required                      259 - Frequency of service.
                                 period or occurrence has been reached.

1104   Unacceptable price- unit.      151 - Payment adjusted because the    M51 - Missing-incomplete-invalid 21 - Missing or invalid information.
       Check quantity and price.      payer deems the information submitted procedure code(s) and-or dates.
                                      does not support this many services.
                                                                                    M53 - Missing-incomplete-
                                                                            invalid days or units of service.

1105   Partial dispensing of          B5 - Coverage-program guidelines         No Mapping Required               107 - Processed according to
       unbreakable pack.              were not met or were exceeded.                                             contract-plan provisions.


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                                                    EOB Code Crosswalk to HIPAA Standard Codes

1106   Exceeds limit of billings   119 - Benefit maximum for this time    No Mapping Required                259 - Frequency of service.
       for antepartum package 4-   period or occurrence has been reached.
       6 visits, by different
       providers.
1107   POS - Pharmacy initiated    B5 - Coverage-program guidelines         No Mapping Required              107 - Processed according to
       reversal.                   were not met or were exceeded.                                            contract-plan provisions.
1108   POS - Denial due to DUR     B5 - Coverage-program guidelines         No Mapping Required              107 - Processed according to
       Alert.                      were not met or were exceeded.                                            contract-plan provisions.
1109   HCPCS for manipulation      B15 - This service-procedure requires    N20 - Service not payable with   258 - Days-units for procedure-
       of spine Not allowed on     that a qualifying service-procedure be   other service rendered on the    revenue code.
       same date of service as     received and covered. The qualifying     same date.
       CPT chiropractic            other service-procedure has not been
       manipulative treatment      received-adjudicated.
       codes.

1110   Enhanced maternity care     B15 - This service-procedure requires    N20 - Service not payable with   258 - Days-units for procedure-
       coordination not allowed    that a qualifying service-procedure be   other service rendered on the    revenue code.
       on same day as related      received and covered. The qualifying     same date.
       service.                    other service-procedure has not been
                                   received-adjudicated.

1111   Enhanced child service      B15 - This service-procedure requires    N20 - Service not payable with   258 - Days-units for procedure-
       coordination not allowed    that a qualifying service-procedure be   other service rendered on the    revenue code.
       on same day as related      received and covered. The qualifying     same date.
       service.                    other service-procedure has not been
                                   received-adjudicated.

1112   Related services not        B15 - This service-procedure requires    N20 - Service not payable with   258 - Days-units for procedure-
       allowed on same date of     that a qualifying service-procedure be   other service rendered on the    revenue code.
       service                     received and covered. The qualifying     same date.
                                   other service-procedure has not been
                                   received-adjudicated.

1113   Enhanced maternity care     B15 - This service-procedure requires    N20 - Service not payable with   258 - Days-units for procedure-
       coordination not allowed    that a qualifying service-procedure be   other service rendered on the    revenue code.
       on same day as related      received and covered. The qualifying     same date.
       service.                    other service-procedure has not been
                                   received-adjudicated.



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                                                      EOB Code Crosswalk to HIPAA Standard Codes

1114   Enhanced child service        B15 - This service-procedure requires    N20 - Service not payable with    258 - Days-units for procedure-
       coordination not allowed      that a qualifying service-procedure be   other service rendered on the     revenue code.
       on same day as related        received and covered. The qualifying     same date.
       service.                      other service-procedure has not been
                                     received-adjudicated.

1115   Related service not           B15 - This service-procedure requires    N20 - Service not payable with    258 - Days-units for procedure-
       allowed on same day as        that a qualifying service-procedure be   other service rendered on the     revenue code.
       enhanced child service        received and covered. The qualifying     same date.
       coordination.                 other service-procedure has not been
                                     received-adjudicated.

1116   Maternal outreach visits      B15 - This service-procedure requires    N20 - Service not payable with    258 - Days-units for procedure-
       not allowed on the same       that a qualifying service-procedure be   other service rendered on the     revenue code.
       day as enhanced               received and covered. The qualifying     same date.
       maternity-child service       other service-procedure has not been
       coordination or maternity     received-adjudicated.
       care coordination home
       visit.


1117   Maternity care home visit,    B15 - This service-procedure requires    N20 - Service not payable with    258 - Days-units for procedure-
       enhanced maternity care       that a qualifying service-procedure be   other service rendered on the     revenue code.
       coordination or enhanced      received and covered. The qualifying     same date.
       child service coordination    other service-procedure has not been
       not allowed same day as       received-adjudicated.
       maternal outreach visit
       already paid.


1118   Maternal outreach worker      18 - Duplicate claim-service.            M86 - Service denied because      259 - Frequency of service.
       visit already billed by and                                            payment already made for same-
       paid to DEHNR for this                                                 similar procedure within set time
       date of service.                                                       frame.

1119   Maternal outreach worker 18 - Duplicate claim-service.                 M86 - Service denied because      259 - Frequency of service.
       visit already billed by and                                            payment already made for same-
       paid to RHC-FQHC for this                                              similar procedure within set time
       date of service.                                                       frame.


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                                                        EOB Code Crosswalk to HIPAA Standard Codes




1120   Duplicate billing of base       18 - Duplicate claim-service.            M86 - Service denied because      259 - Frequency of service.
       trip has previously been                                                 payment already made for same-
       paid. If multiple trips,                                                 similar procedure within set time
       submit with                                                              frame.
       documentation.
1121   POS - Denied due to same        B5 - Coverage-program guidelines         No Mapping Required                 107 - Processed according to
       week reversal.                  were not met or were exceeded.                                               contract-plan provisions.
1122   Duplicate billing of a miles    18 - Duplicate claim-service.            M86 - Service denied because        259 - Frequency of service.
       code has previously been                                                 payment already made for same-
       paid. If multiple trips, with                                            similar procedure within set time
       “out of base miles” on                                                   frame.
       same day, submit an
       adjustment with
       documentation.

1123   POS - metric decimal            B5 - Coverage-program guidelines         No Mapping Required                 21 - Missing or invalid information.
       quantity.                       were not met or were exceeded.
1124   POS - DUR Alert override        B5 - Coverage-program guidelines         No Mapping Required                 21 - Missing or invalid information.
       not found.                      were not met or were exceeded.
1125   Multiple diagnostic nasal       B15 - This service-procedure requires    M86 - Service denied because      258 - Days-units for procedure-
       Endoscopies are not             that a qualifying service-procedure be   payment already made for same- revenue code.
       allowed in the same day.        received and covered. The qualifying     similar procedure within set time
       Medicaid will consider the      other service-procedure has not been     frame.
       most complex (according         received-adjudicated.
       to CPT description) for
       reimbursement.

1126   Diagnostic nasal                B15 - This service-procedure requires    N20 - Service not payable with      258 - Days-units for procedure-
       endoscopy is not                that a qualifying service-procedure be   other service rendered on the       revenue code.
       reimbursed separately           received and covered. The qualifying     same date.
       from surgical nasal             other service-procedure has not been
       endoscopy billed for the        received-adjudicated.
       same date of service.




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                                                       EOB Code Crosswalk to HIPAA Standard Codes



1127   Control of nasal               B15 - This service-procedure requires    N20 - Service not payable with    258 - Days-units for procedure-
       hemorrhage is not              that a qualifying service-procedure be   other service rendered on the     revenue code.
       reimbursed separately          received and covered. The qualifying     same date.
       when billed in addition to     other service-procedure has not been
       surgical nasal endoscopy       received-adjudicated.
       with control of epistaxis.


1128   Surgery is included in         97 - The benefit for this service is     M80 - Not covered when             454 - Procedure code for services
       nasal endoscopy with           included in the payment-allowance for    performed during the same          rendered.
       dacryocystorhinostomy.         another service-procedure that has       session-date as a previously
                                      already been adjudicated.                processed service for the patient.

1129   Resection of turbinate is      B15 - This service-procedure requires    N20 - Service not payable with    258 - Days-units for procedure-
       included in surgical nasal     that a qualifying service-procedure be   other service rendered on the     revenue code.
       endoscopy with concha          received and covered. The qualifying     same date.
       bullosa resection billed for   other service-procedure has not been
       the same date of service.      received-adjudicated.

1130   Nasal endoscopy with           B15 - This service-procedure requires    N20 - Service not payable with    258 - Days-units for procedure-
       biopsy is not reimbursed       that a qualifying service-procedure be   other service rendered on the     revenue code.
       separately from other          received and covered. The qualifying     same date.
       surgical nasal endoscopy       other service-procedure has not been
       billed for the same date of    received-adjudicated.
       service.


1131   Nasal endoscopy with           B15 - This service-procedure requires    N20 - Service not payable with    258 - Days-units for procedure-
       sphenoidectomy is not          that a qualifying service-procedure be   other service rendered on the     revenue code.
       reimbursed separately          received and covered. The qualifying     same date.
       when performed on the          other service-procedure has not been
       same date of service as        received-adjudicated.
       endoscopy with removal
       of tissue from sphenoid
       sinus.




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1132   Craniotomy is not             B15 - This service-procedure requires    N20 - Service not payable with    258 - Days-units for procedure-
       reimbursed separately         that a qualifying service-procedure be   other service rendered on the     revenue code.
       when performed on the         received and covered. The qualifying     same date.
       same date of service as       other service-procedure has not been
       nasal endoscopy in            received-adjudicated.
       sphenoid region or
       endoscopy for repair of
       csf leak.

1133   Nasal endoscopy with          B15 - This service-procedure requires    N20 - Service not payable with    258 - Days-units for procedure-
       removal of tissue from        that a qualifying service-procedure be   other service rendered on the     revenue code.
       sphenoid sinus or             received and covered. The qualifying     same date.
       spenoidectomy not             other service-procedure has not been
       reimbursed separately         received-adjudicated.
       when billed in addition to
       endoscopy for other
       surgery in sphenoid
       region.

1134   This proc is included in      97 - The benefit for this service is     M80 - Not covered when             454 - Procedure code for services
       the nasal endoscopy with      included in the payment-allowance for    performed during the same          rendered.
       medial and-or inferior        another service-procedure that has       session-date as a previously
       orbital wall                  already been adjudicated.                processed service for the patient.
       decompression or optcal
       nerve decompression
       billed by your facility for
       this date.


1135   This endoscopy surgery is     B15 - This service-procedure requires    M80 - Not covered when             258 - Days-units for procedure-
       not reimbursed separately     that a qualifying service-procedure be   performed during the same          revenue code.
       when billed in addition to    received and covered. The qualifying     session-date as a previously
       nasal endoscopy with          other service-procedure has not been     processed service for the patient.
       medial and inferior wall      received-adjudicated.
       decompression for the
       same date of service.




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1136   This surgical endoscopy      B15 - This service-procedure requires    N20 - Service not payable with   258 - Days-units for procedure-
       procedure is not             that a qualifying service-procedure be   other service rendered on the    revenue code.
       reimbursed as a separate     received and covered. The qualifying     same date.
       procedure when billed in     other service-procedure has not been
       addition to endoscopy        received-adjudicated.
       with optic nerve
       decompression for the
       same date of service.

1137   This procedure is not        B15 - This service-procedure requires    N20 - Service not payable with   258 - Days-units for procedure-
       reimbursed separately        that a qualifying service-procedure be   other service rendered on the    revenue code.
       when billed for the same     received and covered. The qualifying     same date.
       date of service as more      other service-procedure has not been
       complex nasal endoscopy      received-adjudicated.
       (i.e with repair CSF leak,
       orbital wall
       decompression).


1138   POS - processor control      B5 - Coverage-program guidelines         No Mapping Required              21 - Missing or invalid information.
       number not found.            were not met or were exceeded.

1139   POS - VAN identification     B5 - Coverage-program guidelines         No Mapping Required              21 - Missing or invalid information.
       not on file.                 were not met or were exceeded.

1140   Component of x-ray (either   B15 - This service-procedure requires    N20 - Service not payable with   454 - Procedure code for services
       technical or professional)   that a qualifying service-procedure be   other service rendered on the    rendered.
       denied because same          received and covered. The qualifying     same date.
       procedure code has           other service-procedure has not been
       already been reimbursed      received-adjudicated.
       as a complete procedure
       for this date of service.




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1141   X-ray billed as 'complete'   B15 - This service-procedure requires    N20 - Service not payable with   454 - Procedure code for services
       denied. Technical            that a qualifying service-procedure be   other service rendered on the    rendered.
       component of this            received and covered. The qualifying     same date.
       procedure code has           other service-procedure has not been       N200 - The professional
       already been reimbursed      received-adjudicated.                    component must be billed
       for this date. Rebill for                                             separately.
       professional component
       only.

1142   X-ray billed as 'complete'   B15 - This service-procedure requires    N20 - Service not payable with   454 - Procedure code for services
       denied. Professional         that a qualifying service-procedure be   other service rendered on the    rendered.
       component of this            received and covered. The qualifying     same date.
       procedure code has           other service-procedure has not been                 N195 - The technical
       already been reimbursed      received-adjudicated.                    component must be billed
       for this date. Rebill for                                             separately.
       technical component only.



1143   POS - production claim       B5 - Coverage-program guidelines         No Mapping Required              107 - Processed according to
       submitted in test.           were not met or were exceeded.                                            contract-plan provisions.
1144   POS - test claim submitted   B5 - Coverage-program guidelines         No Mapping Required              107 - Processed according to
       in production.               were not met or were exceeded.                                            contract-plan provisions.

1145   Multichannel lab test not    B15 - This service-procedure requires    N20 - Service not payable with   258 - Days-units for procedure-
       allowed same date of         that a qualifying service-procedure be   other service rendered on the    revenue code.
       service as lab panel.        received and covered. The qualifying     same date.
                                    other service-procedure has not been
                                    received-adjudicated.

1146   Multichannel lab test        B15 - This service-procedure requires    N20 - Service not payable with   454 - Procedure code for services
       recouped to allow            that a qualifying service-procedure be   other service rendered on the    rendered.
       payment of lab panel.        received and covered. The qualifying     same date.
                                    other service-procedure has not been
                                    received-adjudicated.




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1147   Cystourethroscopy with        B15 - This service-procedure requires      M51 - Missing-incomplete-invalid 258 - Days-units for procedure-
       meatotomy not allowed on      that a qualifying service-procedure be     procedure code(s) and-or dates. revenue code.
       same day as Cysto. with       received and covered. The qualifying
       resection. Resubmit as an     other service-procedure has not been       N20 - Service not payable with
       adjustment with               received-adjudicated.                      other service rendered on the
       documentation supporting                                                 same date.
       second cystourethroscopy
       on same day.


1148   Cystourethroscopy with   18 - Duplicate claim-service.                   M86 - Service denied because      259 - Frequency of service.
       resection of ureterocele                                                 payment already made for same-
       paid. Cysto with                                                         similar procedure within set time
       meatotomy recouped..                                                     frame.
       Resubmit as an
       adjustment with
       documentation supporting
       second cystourethroscopy
       on same day.

1149   Claim denied, PA is           197 - Precertification-authorization-      N54 - Claim information is        48 - Referral-authorization.
       required for rental of        notification absent.                       inconsistent with pre-certified-                          84 -
       apnea monitor.                                                           authorized services.              Service not authorized.
1150   Banding for this recipient    18 - Duplicate claim-service.              M86 - Service denied because      259 - Frequency of service.
       was paid prior to the                                                    payment already made for same-
       November 1, 1997 fee                                                     similar procedure within set time
       revisions; therefore, the                                                frame.
       maintenance visit was
       paid according the fees in
       existence at that time.


1151   Probing of nasolacrimal       97 - The benefit for this service is       M80 - Not covered when             454 - Procedure code for services
       duct with or without          included in the payment-allowance for      performed during the same          rendered.
       irrigation is included in a   another service-procedure that has         session-date as a previously
       more comprehensive            already been adjudicated.                  processed service for the patient.
       procedure already paid.




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                                                     EOB Code Crosswalk to HIPAA Standard Codes

1152   Components denied. rebill 125 - Submission-billing error(s).           N56 - Procedure code billed is        21 - Missing or invalid information.
       using 92557 as complete                                                not correct-valid for the service
       procedure versus separate                                              billed or the date of service billed.
       components 92553 and
       92556.

1153   Comprehensive procedure      97 - The benefit for this service is      M80 - Not covered when             454 - Procedure code for services
       for probing nasolacrimal     included in the payment-allowance for     performed during the same          rendered.
       duct, which includes         another service-procedure that has        session-date as a previously
       irrigation paid. Separate    already been adjudicated.                 processed service for the patient.
       payment for component of
       comprehensive procedure
       recouped.


1154   Claim denied pending rate 133 - The disposition of this claim-         No Mapping Required                  3 - Claim has been adjudicated
       information from DMA.       service is pending further review.                                              and is awaiting payment cycle.
       Call EDS, Provider
       Services at 1-800-688-6696.

1155   Only one lab panel code      119 - Benefit maximum for this time    M86 - Service denied because      259 - Frequency of service.
       allowed per date of service. period or occurrence has been reached. payment already made for same-
                                                                           similar procedure within set time
                                                                           frame.

1156   A valid hysterectomy         16 - Claim-service lacks information      N29 - Missing-incomplete-invalid     21 - Missing or invalid information.
       statement is on file.        which is needed for adjudication.         documentation-orders-notes-                                   287 -
       Submit adjustment with                                                 summary-report-chart                 Medical necessity for service.
       records to support                                                                                                                        297 -
       medical necessity,                                                                                          Medical notes-report.
       include:
       H&P/physical/operative
       records/path report &
       discharge summary
1157   Delivery and-or              97 - The benefit for this service is      M80 - Not covered when             454 - Procedure code for services
       postpartum care included     included in the payment-allowance for     performed during the same          rendered.
       in total ob package.         another service-procedure that has        session-date as a previously
                                    already been adjudicated.                 processed service for the patient.



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                                                    EOB Code Crosswalk to HIPAA Standard Codes



1158   Antepartum package           97 - The benefit for this service is    M80 - Not covered when             454 - Procedure code for services
       recouped. Total ob           included in the payment-allowance for   performed during the same          rendered.
       package paid which           another service-procedure that has      session-date as a previously
       includes antepartum care.    already been adjudicated.               processed service for the patient.

1159   Total ob package, which      97 - The benefit for this service is    M80 - Not covered when             454 - Procedure code for services
       includes antepartum care,    included in the payment-allowance for   performed during the same          rendered.
       has already been paid for    another service-procedure that has      session-date as a previously
       this gestation period.       already been adjudicated.               processed service for the patient.

1160   Dates of service are later   27 - Expenses incurred after coverage   M59 - Missing-incomplete-invalid 187 - Date(s) of service.
       than the last certified date terminated.                             “to” date(s) of service.
       of service. Noncertified
       days are not reimbursable.
       For assistance contact
       FMH at 800-770-3084
       ext.3236.


1161   Zantac or Tag met given IV 107 - The related or qualifying claim-    N19 - Procedure code incidental   465 - Principal Procedure Code for
       or IM only allowed when    service was not identified on this claim. to primary procedure.             Service(s) Rendered.
       billed on same day as                                                         N161 - This drug-
       chemotherapy.                                                        service-supply is covered only
                                                                            when the associated service is
                                                                            covered.

1162   Postpartum package           97 - The benefit for this service is    M80 - Not covered when             454 - Procedure code for services
       recouped. Total ob           included in the payment-allowance for   performed during the same          rendered.
       package paid, which          another service-procedure that has      session-date as a previously
       includes postpartum care.    already been adjudicated.               processed service for the patient.

1163   Total ob package, which      97 - The benefit for this service is    M80 - Not covered when             454 - Procedure code for services
       includes postpartum care,    included in the payment-allowance for   performed during the same          rendered.
       has already been paid for    another service-procedure that has      session-date as a previously
       this gestation period.       already been adjudicated.               processed service for the patient.




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                                                      EOB Code Crosswalk to HIPAA Standard Codes



1164   Transposition of ovaries      97 - The benefit for this service is     M29 - Missing operative note-      294 - Supporting documentation.
       included in abdominal         included in the payment-allowance for    report.                            297 - Medical notes-report.
       hysterectomy. Resubmit        another service-procedure that has        M80 - Not covered when              421 - Medical review attachment-
       as an adjustment with         already been adjudicated.                performed during the same          information for service(s)
       records if ovaries were not                                            session-date as a previously
       returned to original                                                   processed service for the patient.
       placement.


1165   Abdominal hysterectomy        97 - The benefit for this service is     M29 - Missing operative note-      294 - Supporting documentation.
       includes the transposition    included in the payment-allowance for    report.                            297 - Medical notes-report.
       of ovaries resubmit as an     another service-procedure that has          M80 - Not covered when            421 - Medical review attachment-
       adjustment with records if    already been adjudicated.                performed during the same          information for service(s)
       ovaries were returned to                                               session-date as a previously
       original placement.                                                    processed service for the patient.


1166   Superficial Hyperthermia      B15 - This service-procedure requires    N20 - Service not payable with    454 - Procedure code for services
       recouped. Medicaid does       that a qualifying service-procedure be   other service rendered on the     rendered.
       not make separate             received and covered. The qualifying     same date.
       payment for procedures        other service-procedure has not been
       that are components of a      received-adjudicated.
       more comprehensive
       service for the same date
       of service.


1167   DME allowed once in four 119 - Benefit maximum for this time      No Mapping Required                    187 - Date(s) of service.
       years. If prior approval   period or occurrence has been reached.
       was obtained for this
       piece of equipment for                                                                                         259 - Frequency of service.
       dates of service prior to
       Nov 1, 1996, please
       resubmit as an Adjustment.




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                                                     EOB Code Crosswalk to HIPAA Standard Codes




1168   Arthrodesis, hip joint       97 - The benefit for this service is     M80 - Not covered when             454 - Procedure code for services
       included in fusion of hip    included in the payment-allowance for    performed during the same          rendered.
       joint.                       another service-procedure that has       session-date as a previously
                                    already been adjudicated.                processed service for the patient.

1169   Superficial Hyperthermia     B15 - This service-procedure requires    N20 - Service not payable with    454 - Procedure code for services
       denied. Medicaid does not    that a qualifying service-procedure be   other service rendered on the     rendered.
       make separate payment        received and covered. The qualifying     same date.
       for procedures that are      other service-procedure has not been
       components of a more         received-adjudicated.
       comprehensive procedure.



1170   This procedure or            125 - Submission-billing error(s).       M53 - Missing-incomplete-invalid 258 - Days-units for procedure-
       procedure-modifier                                                    days or units of service.        revenue code.
       combination is edited for
       units, therefore billing a                                                                                                453 -
       span of days is not                                                                                     Procedure code modifier(s) for
       allowed. Please bill each                                                                               service(s) rendered.
       date of service on a
       separate detail

1171   Diagnosis requires      16 - Claim-service lacks information          N29 - Missing documentation-      297 - Medical notes-report.
       supporting              which is needed for adjudication.             orders-notes-summary-report-
       documentation. Resubmit                                               chart.
       adjustment with medical                                                 N163 - Medical Record does
       records                                                               not support code billed per the
                                                                             code definition.
1172   Tenotomy for multiple        B15 - This service-procedure requires    N20 - Service not payable with    258 - Days-units for procedure-
       tendons can not be billed    that a qualifying service-procedure be   other service rendered on the     revenue code.
       same date of service as      received and covered. The qualifying     same date.
       single tendons.              other service-procedure has not been
                                    received-adjudicated.




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1173   Superficial hyperthermia     B15 - This service-procedure requires    N20 - Service not payable with    258 - Days-units for procedure-
       not allowed on same date     that a qualifying service-procedure be   other service rendered on the     revenue code.
       of service as                received and covered. The qualifying     same date.
       chemotherapy                 other service-procedure has not been
       administration.              received-adjudicated.

1174   Thanks for reporting         89 - Professional fees removed from      M41 - We do not pay for this as   19 - Entity acknowledges receipt
       vaccine to our database.     charges.                                 the patient has no legal          of claim-encounter.
       This vaccine is available at                                          obligation to pay for this.           598 - Non-payable Professional
       no charge through the                                                                                   Component Billed Amount.
       Vaccines For Children
       program and therefore is
       not reimbursable through
       Medicaid.


1175   Dialysis facility: this     125 - Submission-billing error(s).        M51 - Missing-incomplete-invalid 21 - Missing or invalid information.
       revenue code must be                                                  procedure code(s).
       billed with the appropriate                                                           N50 - Missing-
       5-digit CPT code. correct                                             incomplete-invalid discharge                  455 - Revenue code
       denied detail and refile as                                           information.                     for services rendered.
       a new day claim.


1176   This drug is included in     97 - The benefit for this service is     M80 - Not covered when             454 - Procedure code for services
       monthly dialysis rate.       included in the payment-allowance for    performed during the same          rendered.
                                    another service-procedure that has       session-date as a previously
                                    already been adjudicated.                processed service for the patient.

1177   Dialysis facility: This     125 - Submission-billing error(s).        M51 - Missing-incomplete-invalid 21 - Missing or invalid information.
       revenue code must be                                                  procedure code(s).
       billed with a valid 5 digit                                                            N50 - Missing-
       HCPCS drug code. Correct                                              incomplete-invalid discharge                  455 - Revenue code
       denied detail and refile as                                           information.                     for services rendered.
       a new day claim.




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                                                      EOB Code Crosswalk to HIPAA Standard Codes


1178   Rebill first date of on-  125 - Submission-billing error(s).              M45 - Missing-incomplete-invalid    21 - Missing or invalid information.
       going dialysis TX with                                                    occurrence code(s).                                213- Date of first
       occurrence code 51 on the                                                                     MA31 -          routine dialysis.              461 -
       approved UB before DOS                                                    Missing-incomplete-invalid          NUBC occurrence code(s) and
       06-01-03, occurrence code                                                 beginning and ending dates of       date(s).
       11 on and after 06-01-03.                                                 the period billed.
       CMS 1500: Add date in
       block 15.

1179   57505 Recouped,              97 - The benefit for this service is         M80 - Not covered when             454 - Procedure code for services
       Endocervical Curettage       included in the payment-allowance for        performed during the same          rendered.
       included in CPT codes        another service-procedure that has           session-date as a previously
       57454 and 57456.             already been adjudicated.                    processed service for the patient.

1180   57505-endocervical         97 - The benefit for this service is           M80 - Not covered when             454 - Procedure code for services
       curettage included in      included in the payment-allowance for          performed during the same          rendered.
       previous paid code, 57454. another service-procedure that has             session-date as a previously
                                  already been adjudicated.                      processed service for the patient.

1181   Service not covered by       185 - The rendering provider is not          N95 - This provider type -          91 - Entity not eligible-not
       Medicaid for dental or       eligible to perform the service billed.      provider specialty may not bill     approved for dates of service.
       physician providers.                                                      this service.


1182   This CPT code has been       45 - Charge exceeds fee schedule-            N10 - Claim-service adjusted       89 - Entity not eligible for dental
       reviewed and denied by       maximum allowable or contracted-             based on the findings of a review benefits for submitted dates of
       DMA dental consultant.       legislated fee arrangement. (Use             organization-professional consult- service.
                                    Group Codes PR or CO depending               manual adjudication-medical or
                                    upon liability).                             dental advisor.

1183   Not all procedures billed    B7 - This provider was not certified-        N59 - Alert- Please refer to        45 - Awaiting benefit determination.
       are currently covered for    eligible to be paid for this procedure-      your provider manual for
       dental providers. Claim is   service on this date of service.             additional program and
       under review by DMA.                                                      provider information.
       Upon their decision your                                                            N185 - Alert- Do not
       claim will be resubmitted                                                 resubmit this claim-service
       for you.



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1184   Insertion of vitrocert is   11 - The diagnosis is inconsistent with   M76 - Missing-incomplete-       255 - Diagnosis code.
       covered only for the        the procedure.                            invalid diagnosis or condition.
       diagnosis of                                                                      N59 - Alert- Please
       cytomegalovirus                                                       refer to your provider manual
       retinitis(CMV).                                                       for additional program and
                                                                             provider information

1185   Only one billing of         119 - Benefit maximum for this time    M86 - Service denied because      259 - Frequency of service.
       chiropractic manipulative   period or occurrence has been reached. payment already made for same-
       treatment allowed -day.                                            similar procedure within set time
                                                                          frame.

1186   This CPT procedure or       96 - Non-covered charge(s).               M51 - Missing-incomplete-invalid 453 - Procedure Code Modifier(s)
       procedure- modifier                                                   procedure code(s).               for Service(s) Rendered.
       combination is not
       covered for physicians or
       dentists.
1187   Injectable drug adm code    B15 - This service-procedure requires     N20 - Service not payable with   454 - Procedure code for services
       not allowed same DOS as     that a qualifying service-procedure be    other service rendered on the    rendered
       chemotherapy.               received and covered. The qualifying      same date.
                                   other service-procedure has not been
                                   received-adjudicated.

1188   Chemotherapy not allowed    B15 - This service-procedure requires     N20 - Service not payable with   454 - Procedure code for services
       same date of service as     that a qualifying service-procedure be    other service rendered on the    rendered
       injectable drug             received and covered. The qualifying      same date.
       administration code.        other service-procedure has not been
       Injectable drug             received-adjudicated.
       administration fee
       recouped.
1189   Medicaid does not make      B15 - This service-procedure requires     N20 - Service not payable with   453 - Procedure Code Modifier(s)
       separate payment for        that a qualifying service-procedure be    other service rendered on the    for Service(s) Rendered
       professional or technical   received and covered. The qualifying      same date
       component performed on      other service-procedure has not been
       the same DOS as the         received-adjudicated.
       complete procedure.




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1190   Complete proc performed      B15 - This service-procedure requires    N20 - Service not payable with    453 - Procedure Code Modifier(s)
       on the same DOS as the       that a qualifying service-procedure be   other service rendered on the     for Service(s) Rendered
       professional of technical    received and covered. The qualifying     same date
       component not allowed.       other service-procedure has not been
       Component recouped.          received-adjudicated.


1191   Arthrotomy, knee, with       97 - The benefit for this service is     M80 - Not covered when             454 - Procedure code for services
       synovial biopsy only         included in the payment-allowance for    performed during the same          rendered.
       included in joint            another service-procedure that has       session-date as a previously
       exploration, biopsy or       already been adjudicated.                processed service for the patient.
       removal.
1192   Medicaid does not make       B15 - This service-procedure requires    N20 - Service not payable with    453 - Procedure Code Modifier(s)
       separate payment for         that a qualifying service-procedure be   other service rendered on the     for Service(s) Rendered
       professional or technical    received and covered. The qualifying     same date.
       component performed on       other service-procedure has not been
       the same date of service     received-adjudicated.
       as the complete procedure.



1193   Complete procedure           B15 - This service-procedure requires    N20 - Service not payable with    453 - Procedure Code Modifier(s)
       performed on the same        that a qualifying service-procedure be   other service rendered on the     for Service(s) Rendered
       date of service as the       received and covered. The qualifying     same date.
       professional or technical    other service-procedure has not been
       component not allowed.       received-adjudicated.

1194   Arthrotomy with excision     97 - The benefit for this service is     M80 - Not covered when             454 - Procedure code for services
       of semilunar cartilage       included in the payment-allowance for    performed during the same          rendered.
       included in knee excision    another service-procedure that has       session-date as a previously
       semilunar cartilage.         already been adjudicated.                processed service for the patient.




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1195   Medicaid does not make       B15 - This service-procedure requires    N20 - Service not payable with    453 - Procedure Code Modifier(s)
       separate payment for         that a qualifying service-procedure be   other service rendered on the     for Service(s) Rendered
       professional or technical    received and covered. The qualifying     same date.
       component performed on       other service-procedure has not been
       the same date of service     received-adjudicated.
       as the complete procedure.



1196   Complete procedure           B15 - This service-procedure requires    N20 - Service not payable with    453 - Procedure Code Modifier(s)
       performed on the same        that a qualifying service-procedure be   other service rendered on the     for Service(s) Rendered
       date of service as the       received and covered. The qualifying     same date.
       professional or technical    other service-procedure has not been
       component not allowed.       received-adjudicated.

1197   Physician service and     125 - Submission-billing error(s).          N61 - Rebill services on separate 276 - UB04-HCFA-1450-1500
       visual aids cannot be                                                 claims.                           claim form.
       processed on the same                                                                                                  481 - Claim-
       claim. Resubmit physician                                                                               submission format is invalid.
       service on a separate CMS
       1500 claim.

1198   More than one entry for      B5 - Coverage-program guidelines         MA130 - Your claim contains       259 - Frequency of service.
       same DOS. If all entries     were not met or were exceeded.           incomplete and-or invalid         476 - Missing or invalid units of
       are correct, combine all                                              information, and no appeal        service
       units on one detail line                                              rights are afforded because
       and resubmit.                                                         the claim is unprocessable.
                                                                             Please submit a new claim
                                                                             with the complete-correct
                                                                             information. N130 - Alert-
                                                                             Consult plan benefit
                                                                             documents for information
                                                                             about restrictions for this
                                                                             service
1199   Related lab tests included 97 - The benefit for this service is       M80 - Not covered when             454 - Procedure code for services
       in fee for panel, same date included in the payment-allowance for     performed during the same          rendered.
       of service                  another service-procedure that has        session-date as a previously
                                   already been adjudicated.                 processed service for the patient.


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                                                     EOB Code Crosswalk to HIPAA Standard Codes

1200   Panel includes fees for      97 - The benefit for this service is    M80 - Not covered when             454 - Procedure code for services
       related lab tests, same      included in the payment-allowance for   performed during the same          rendered.
       date of service              another service-procedure that has      session-date as a previously
                                    already been adjudicated.               processed service for the patient.

1201   Patient is enrolled in a      24 - Payment for charges adjusted.     No Mapping Required                96 - No agreement with entity.
       HMO Plan. Delivery            Charges are covered under a capitation                                                           187 -
       charges have been made        agreement-managed care plan.                                              Date(s) of service.
       to the HMO. Facilities may                                                                              585 - Denied Charge or Non-
       bill fee for service for care                                                                           covered Charge.
       rendered on out-of-plan
       dates of service.

1202   Patient is enrolled in a      24 - Payment for charges adjusted.     No Mapping Required                187 - Date(s) of service.
       HMO plan. Delivery            Charges are covered under a capitation                                      585 - Denied Charge or Non-
       charges have been made        agreement-managed care plan.                                              covered Charge.
       to the HMO. Facilities may
       bill fee for service for care
       rendered on out-of-plan
       dates of service

1203   Iv sedation and general   B15 - This service-procedure requires      N20 - Service not payable with     258 - Days-units for procedure-
       anesthesia not allowed on that a qualifying service-procedure be     other service rendered on the      revenue code.
       same dates of service     received and covered. The qualifying       same date.
                                 other service-procedure has not been
                                 received-adjudicated.

1204   CLIA number is either      125 - Submission-billing error(s).        MA120 - Missing-incomplete-        21 - Missing or invalid information.
       incorrect-missing from the                                           invalid CLIA certification number.
       claim or you have billed a
       test-DOS outside your                                                                                    142 - Entitys license-certification
       CLIA certification.                                                                                     number.

                                                                                                               630 - Referring CLIA Number
1205   Arthrotomy with              97 - The benefit for this service is    M80 - Not covered when             454 - Procedure code for services
       synovectomy knee             included in the payment-allowance for   performed during the same          rendered.
       included in arthrotomy       another service-procedure that has      session-date as a previously
       knee anterior and            already been adjudicated.               processed service for the patient.
       posterior.

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                                                       EOB Code Crosswalk to HIPAA Standard Codes

1206   V diagnosis is not allowed 146 - Diagnosis was invalid for the          M76 - Missing-incomplete-invalid 21 - Missing or invalid information.
       as a principle diagnosis.  date(s) of service reported.                 diagnosis or condition.                                  255 -
                                                                                                                Diagnosis Code
1207   RC651 and RC652 must be 125 - Submission-billing error(s).              M49 - Missing-incomplete-        21 - Missing or invalid information.
       billed with value code 61                                               invalid value code(s) or                       463 - NUBC value
       with corresponding MSA                                                  amount(s).                       code(s) and-or amount(s).
       code.

1208   Invalid MSA code. Please       125 - Submission-billing error(s).       M49 - Missing-incomplete-         21 - Missing or invalid information.
       correct and resubmit as a                                               invalid value code(s) or
       new day claim.                                                          amount(s).

1209   Purchase of supplies           B15 - This service-procedure requires    M86 - Service denied because      258 - Days-units for procedure-
       related to suction             that a qualifying service-procedure be   payment already made for same- revenue code.
       equipment not allowed          received and covered. The qualifying     similar procedure within set time
       during the same month          other service-procedure has not been     frame.
       equipment is rented.           received-adjudicated.

1210   Service recouped.              97 - The benefit for this service is     N357 - Time frame requirements    259 - Frequency of service.
       Supplies related to suction    included in the payment-allowance for    between this service-procedure-   453 - Procedure Code Modifier(s)
       equipment can not be           another service-procedure that has       supply and a related service-     for Service(s) Rendered
       billed within the same         already been adjudicated.                procedure-supply have not been
       calendar month.                                                         met.
                                                                                       N381 - Consult our
                                                                               contractual agreement for
                                                                               restrictions-billing-payment
                                                                               information related to these
                                                                               charges
1211   Topical application of         B15 - This service-procedure requires    N20 - Service not payable with    258 - Days-units for procedure-
       fluoride not allowed to bill   that a qualifying service-procedure be   other service rendered on the     revenue code.
       on the same date of            received and covered. The qualifying     same date.
       service as prophylaxis         other service-procedure has not been
       application (0-20)             received-adjudicated.

1212   Tenotomy, single tendon        B15 - This service-procedure requires    N20 - Service not payable with    258 - Days-units for procedure-
       can not be billed same         that a qualifying service-procedure be   other service rendered on the     revenue code.
       date of service as multiple    received and covered. The qualifying     same date.
       tendons.                       other service-procedure has not been
                                      received-adjudicated.


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                                                       EOB Code Crosswalk to HIPAA Standard Codes



1213   Prophylaxis application of     B15 - This service-procedure requires    N20 - Service not payable with   258 - Days-units for procedure-
       flouride not allowed to bill   that a qualifying service-procedure be   other service rendered on the    revenue code.
       on the same date of            received and covered. The qualifying     same date.
       service as topical             other service-procedure has not been
       application (0-20).            received-adjudicated.

1214   Hamstring single and           B15 - This service-procedure requires    N20 - Service not payable with   258 - Days-units for procedure-
       multiple tendon                that a qualifying service-procedure be   other service rendered on the    revenue code.
       lengthening not allowed        received and covered. The qualifying     same date.
       same date of service           other service-procedure has not been
                                      received-adjudicated.

1215   Transplant, hamstring          B15 - This service-procedure requires    N20 - Service not payable with   258 - Days-units for procedure-
       tendon to patella; single      that a qualifying service-procedure be   other service rendered on the    revenue code.
       tendon not allowed on          received and covered. The qualifying     same date.
       same day as multiple           other service-procedure has not been
       tendons.                       received-adjudicated.

1216   Reconstruction of              B15 - This service-procedure requires    N20 - Service not payable with   258 - Days-units for procedure-
       dislocating patella not        that a qualifying service-procedure be   other service rendered on the    revenue code.
       allowed same as extensor       received and covered. The qualifying     same date.
       realignment with               other service-procedure has not been
       patellectomy and-or            received-adjudicated.
       revision removal of knee
       cap.
1217   Extensor realignment not       B15 - This service-procedure requires    N20 - Service not payable with   258 - Days-units for procedure-
       allowed same day as            that a qualifying service-procedure be   other service rendered on the    revenue code.
       reconstruction for             received and covered. The qualifying     same date.
       recurrent dislocating          other service-procedure has not been
       patella.                       received-adjudicated.

1218   Only one catheter or           119 - Benefit maximum for this time    M86 - Service denied because      259 - Frequency of service.
       reservoir-pump                 period or occurrence has been reached. payment already made for same-
       implantation allowed per                                              similar procedure within set time
       day, same or different                                                frame.
       provider.



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                                                    EOB Code Crosswalk to HIPAA Standard Codes



1219   Arthroplasty, femoral       B15 - This service-procedure requires    N20 - Service not payable with    258 - Days-units for procedure-
       condyles not allowed with   that a qualifying service-procedure be   other service rendered on the     revenue code.
       repair of knee joint.       received and covered. The qualifying     same date.
                                   other service-procedure has not been
                                   received-adjudicated.

1220   Revision of total knee      B15 - This service-procedure requires    N20 - Service not payable with    258 - Days-units for procedure-
       arthroplasty, with or       that a qualifying service-procedure be   other service rendered on the     revenue code.
       without allograft not       received and covered. The qualifying     same date.
       allowed same day as one     other service-procedure has not been
       component.                  received-adjudicated.

1221   Tenotomy, percutaneous,     B15 - This service-procedure requires    N20 - Service not payable with    258 - Days-units for procedure-
       Achilles tendon not         that a qualifying service-procedure be   other service rendered on the     revenue code.
       allowed same day as         received and covered. The qualifying     same date.
       general anesthesia.         other service-procedure has not been
                                   received-adjudicated.

1222   An electronic analysis of  18 - Duplicate claim-service.             M86 - Service denied because      259 - Frequency of service.
       cardioverter-defibrillator                                           payment already made for same-
       with programming                                                     similar procedure within set time
       procedure already paid for                                           frame.
       this date of service


1223   An electronic analysis of  18 - Duplicate claim-service.             M86 - Service denied because      259 - Frequency of service.
       cardioverter-defibrillator                                           payment already made for same-
       procedure already paid for                                           similar procedure within set time
       this date of service                                                 frame.

1224   Resubmit claim with         96 - Non-covered charge(s).              N29 - Missing documentation-      21 - Missing or invalid information.
       special report and                                                   orders-notes-summary-report-                  421 - Medical review
       operative notes and-or                                               chart.                            attachment-information for
       medical records                                                                 N225 - Incomplete-     service(s).
                                                                            invalid documentation-orders-
                                                                            notes-summary-report-chart



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                                                      EOB Code Crosswalk to HIPAA Standard Codes




1225   Arthrotomy, posterior         B15 - This service-procedure requires    N20 - Service not payable with   258 - Days-units for procedure-
       capsular release, ankle not   that a qualifying service-procedure be   other service rendered on the    revenue code.
       allowed on the same day       received and covered. The qualifying     same date.
       as lengthening or             other service-procedure has not been
       shortening of tendon.         received-adjudicated.

1226   Biopsy, soft tissue of leg    B15 - This service-procedure requires    N20 - Service not payable with   258 - Days-units for procedure-
       or ankle area not allowed     that a qualifying service-procedure be   other service rendered on the    revenue code.
       same day as superficial.      received and covered. The qualifying     same date.
                                     other service-procedure has not been
                                     received-adjudicated.

1227   Excision, tumor, leg or       B15 - This service-procedure requires    N20 - Service not payable with   258 - Days-units for procedure-
       ankle area not allowed        that a qualifying service-procedure be   other service rendered on the    revenue code.
       same day as excision          received and covered. The qualifying     same date.
       benign tumor deep             other service-procedure has not been
       subfacial.                    received-adjudicated.

1228   Repair, flexor tendon, leg,   B15 - This service-procedure requires    N20 - Service not payable with   258 - Days-units for procedure-
       primary, without graft, not   that a qualifying service-procedure be   other service rendered on the    revenue code.
       allowed same day as           received and covered. The qualifying     same date.
       secondary with or without     other service-procedure has not been
       graft.                        received-adjudicated.




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                                                      EOB Code Crosswalk to HIPAA Standard Codes



1229   Repair, extensor tendon,      B15 - This service-procedure requires    N20 - Service not payable with     258 - Days-units for procedure-
       legs; primary without graft   that a qualifying service-procedure be   other service rendered on the      revenue code.
       not allowed same day as       received and covered. The qualifying     same date.
       secondary with or without     other service-procedure has not been
       graft.                        received-adjudicated. - This service-
                                     procedure requires that a qualifying
                                     service-procedure be received and
                                     covered. The qualifying other service-
                                     procedure has not been received-
                                     adjudicated. - Payment adjusted
                                     because this service-procedure
                                     requires that a qualifying service-
                                     procedure be received and covered.
                                     The qualifying other service-procedure
                                     has not been received-adjudicated.


1230   Tenolysis, flexor or          B15 - This service-procedure requires    N20 - Service not payable with     258 - Days-units for procedure-
       extension tendon not          that a qualifying service-procedure be   other service rendered on the      revenue code.
       allowed same day as           received and covered. The qualifying     same date.
       multiple.                     other service-procedure has not been
                                     received-adjudicated.

1231   Dental exam not allowed       B15 - This service-procedure requires    N20 - Service not payable with     258 - Days-units for procedure-
       same date of service as       that a qualifying service-procedure be   other service rendered on the      revenue code.
       initial hospital care.        received and covered. The qualifying     same date.
                                     other service-procedure has not been
                                     received-adjudicated.

1232   Non-ER service billed for   125 - Submission-billing error(s).         N54 - Claim information is         21 - Missing or invalid information.
       CA recipient with incorrect                                            inconsistent with pre-certified-
       authorization # on CMS                                                 authorized services.
       1500. If Mon-Fri between                                                                                     276 - UB04-HCFA-1450-1500
       5PM and 8AM or Sat-Sun                                                                                    claim form
       contact PCP for
       Authorization



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                                                    EOB Code Crosswalk to HIPAA Standard Codes


1233   Non-ER service billed for   15 - Payment adjusted because the           N54 - Claim information is         21 - Missing or invalid information.
       CA recipient without auth   submitted authorization number is           inconsistent with pre-certified-    48 - Referral-authorization.
       if mon-fri between 5PM      missing, invalid, or does not apply to      authorized services.               515 - Managed Care review
       and 8AM or Sat-Sun          the billed services or provider.
       contact PCP for auth or
       submit claim to the
       managed care section of
       DMA for retro-review.


1234   Single tendon lengthening B15 - This service-procedure requires         N20 - Service not payable with     258 - Days-units for procedure-
       or shortening not allowed that a qualifying service-procedure be        other service rendered on the      revenue code.
       same day as multiple.     received and covered. The qualifying          same date.
                                 other service-procedure has not been
                                 received-adjudicated.

1235   Superficial and deep        B15 - This service-procedure requires       N20 - Service not payable with     258 - Days-units for procedure-
       transfer or transplant of   that a qualifying service-procedure be      other service rendered on the      revenue code.
       single tendon not allowed   received and covered. The qualifying        same date.
       on the same date of         other service-procedure has not been
       service.                    received-adjudicated.

1236    Allow one application of   119 - Benefit maximum for this time    M86 - Service denied because      259 - Frequency of service.
       flouride within six         period or occurrence has been reached. payment already made for same- 483 - Maximum coverage amount
       calendar months                                                    similar procedure within set time met or exceeded for benefit period
                                                                          frame.
                                                                          N59 - Alert- Please refer to
                                                                          your provider manual for
                                                                          additional program and
                                                                          provider information


1237   Repair, secondary           B15 - This service-procedure requires       N20 - Service not payable with     258 - Days-units for procedure-
       disrupted ligament, ankle   that a qualifying service-procedure be      other service rendered on the      revenue code.
       not allowed same day as     received and covered. The qualifying        same date.
       primary and both            other service-procedure has not been
       collateral ligaments.       received-adjudicated.



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                                                    EOB Code Crosswalk to HIPAA Standard Codes




1238   Arthroplasty, ankle,      B15 - This service-procedure requires      N20 - Service not payable with    258 - Days-units for procedure-
       revision not allowed same that a qualifying service-procedure be     other service rendered on the     revenue code.
       day as repair of ankle.   received and covered. The qualifying       same date.
                                 other service-procedure has not been
                                 received-adjudicated.

1239   Paring or cutting of benign 119 - Benefit maximum for this time      M86 - Service denied because      259 - Frequency of service.
       hyperkeratotic lesions or   period or occurrence has been reached.   payment already made for same-
       lesion allowed only once                                             similar procedure within set time
       per day                                                              frame.

1240   Arrest, epiphyseal, any     B15 - This service-procedure requires    N20 - Service not payable with    258 - Days-units for procedure-
       method not allowed same     that a qualifying service-procedure be   other service rendered on the     revenue code.
       day as repair lower leg     received and covered. The qualifying     same date.
       epiphyses.                  other service-procedure has not been
                                   received-adjudicated.

1241   Incision and drainage       B15 - This service-procedure requires    N20 - Service not payable with    258 - Days-units for procedure-
       below fascia not allowed    that a qualifying service-procedure be   other service rendered on the     revenue code.
       same day as drainage of     received and covered. The qualifying     same date.
       foot.                       other service-procedure has not been
                                   received-adjudicated.

1242   Tenotomy, percutaneous,     B15 - This service-procedure requires    N20 - Service not payable with    258 - Days-units for procedure-
       toe, single tendon not      that a qualifying service-procedure be   other service rendered on the     revenue code.
       allowed same day as         received and covered. The qualifying     same date.
       multiple.                   other service-procedure has not been
                                   received-adjudicated.

1243   Excision, tumor, foot not   B15 - This service-procedure requires    N20 - Service not payable with    258 - Days-units for procedure-
       allowed same day as         that a qualifying service-procedure be   other service rendered on the     revenue code.
       benign tumor deep           received and covered. The qualifying     same date.
       subfascial intramuscular.   other service-procedure has not been
                                   received-adjudicated.




                                                                       Page 208
                                                     EOB Code Crosswalk to HIPAA Standard Codes



1244   Fasciectomy, plantar         B15 - This service-procedure requires    N20 - Service not payable with   258 - Days-units for procedure-
       facia; partial not allowed   that a qualifying service-procedure be   other service rendered on the    revenue code.
       same day as removal of       received and covered. The qualifying     same date.
       foot fascia.                 other service-procedure has not been
                                    received-adjudicated.

1245   Single or two segment        B15 - This service-procedure requires    N20 - Service not payable with   258 - Days-units for procedure-
       kyphectomy not allowed       that a qualifying service-procedure be   other service rendered on the    revenue code.
       same date of service as      received and covered. The qualifying     same date.
       three or more segment        other service-procedure has not been
       kyphectomy.                  received-adjudicated.

1246   Three or more segment        B15 - This service-procedure requires    N20 - Service not payable with   258 - Days-units for procedure-
       kyphectomy not allowed       that a qualifying service-procedure be   other service rendered on the    revenue code.
       same date of service as      received and covered. The qualifying     same date.
       single or two segment        other service-procedure has not been
       kyphectomy.                  received-adjudicated.

1247   Ostectomy, complete          B15 - This service-procedure requires    N20 - Service not payable with   258 - Days-units for procedure-
       excision not allowed same    that a qualifying service-procedure be   other service rendered on the    revenue code.
       day as partial removal       received and covered. The qualifying     same date.
       metatarsal.                  other service-procedure has not been
                                    received-adjudicated.

1248   Suture codes exclusively     B15 - This service-procedure requires    N20 - Service not payable with   258 - Days-units for procedure-
       for would repair; not        that a qualifying service-procedure be   other service rendered on the    revenue code.
       allowed for extractions-     received and covered. The qualifying     same date.
       surgery sites.               other service-procedure has not been
                                    received-adjudicated.

1249   Tenolysis, extensor, foot;   B15 - This service-procedure requires    N20 - Service not payable with   258 - Days-units for procedure-
       single tendon not allowed    that a qualifying service-procedure be   other service rendered on the    revenue code.
       same day as multiple.        received and covered. The qualifying     same date.
                                    other service-procedure has not been
                                    received-adjudicated.




                                                                        Page 209
                                                      EOB Code Crosswalk to HIPAA Standard Codes




1250   Osteotomy, tarsal bones,      B15 - This service-procedure requires    N20 - Service not payable with   258 - Days-units for procedure-
       other than calcaneous or      that a qualifying service-procedure be   other service rendered on the    revenue code.
       talus not allowed same        received and covered. The qualifying     same date.
       day as autograft.             other service-procedure has not been
                                     received-adjudicated.

1251   Osteotomy, with or            B15 - This service-procedure requires    N20 - Service not payable with   258 - Days-units for procedure-
       without lengthening,          that a qualifying service-procedure be   other service rendered on the    revenue code.
       metatarsal not allowed        received and covered. The qualifying     same date.
       same day as first             other service-procedure has not been
       metatarsal with autograft     received-adjudicated.
       of multiple.
1252   Injectable drug               B15 - This service-procedure requires    N20 - Service not payable with   258 - Days-units for procedure-
       administration not allowed    that a qualifying service-procedure be   other service rendered on the    revenue code.
       same date of service as       received and covered. The qualifying     same date.
       office visit.                 other service-procedure has not been
                                     received-adjudicated.

1253   Office visit not allowed on   B15 - This service-procedure requires    N20 - Service not payable with   258 - Days-units for procedure-
       same DOS as inj drug          that a qualifying service-procedure be   other service rendered on the    revenue code.
       adm. Inj drug adm fee         received and covered. The qualifying     same date.
       recouped.                     other service-procedure has not been
                                     received-adjudicated.

1254   Transesophageal               B15 - This service-procedure requires    N20 - Service not payable with   454 - Procedure code for services
       echocardiography for          that a qualifying service-procedure be   other service rendered on the    rendered.
       congenital cardiac            received and covered. The qualifying     same date.
       anomalies complete            other service-procedure has not been
       procedure includes            received-adjudicated.
       components for probe

       placement and-or image
       acquisition.




                                                                         Page 210
                                                      EOB Code Crosswalk to HIPAA Standard Codes




1255   Components of                 B15 - This service-procedure requires    N20 - Service not payable with   454 - Procedure code for services
       transesophageal               that a qualifying service-procedure be   other service rendered on the    rendered.
       echocardiography are          received and covered. The qualifying     same date.
       included in the complete      other service-procedure has not been
       procedure already paid for    received-adjudicated.
       this date of
                service.

1256   Physician interpretation of   B15 - This service-procedure requires    N20 - Service not payable with   258 - Days-units for procedure-
       cervical or vaginal           that a qualifying service-procedure be   other service rendered on the    revenue code.
       cytopathology not allowed     received and covered. The qualifying     same date.
       same DOS as related           other service-procedure has not been
       complete proc.                received-adjudicated.

1257   Service recouped.             B15 - This service-procedure requires    N20 - Service not payable with   258 - Days-units for procedure-
       Complete cytopathology        that a qualifying service-procedure be   other service rendered on the    revenue code.
       procedure not allowed         received and covered. The qualifying     same date.
       same DOS as physician‟s       other service-procedure has not been
       interpretation.               received-adjudicated.


1258   Osteotomy, with or            B15 - This service-procedure requires    N20 - Service not payable with   258 - Days-units for procedure-
       without lengthening, each     that a qualifying service-procedure be   other service rendered on the    revenue code.
       other than first metarsal     received and covered. The qualifying     same date.
       not allowed same day as       other service-procedure has not been
       multiple.                     received-adjudicated.

1259   Reoperation, more than 1      107 - The related or qualifying claim-    N19 - Procedure code incidental 465 - Principal Procedure Code for
       month after original          service was not identified on this claim. to primary procedure.              Service(s) Rendered.
       operation must bill with                                                         N161 - This drug-service-
       primary procedure.                                                      supply is covered only when the
                                                                               associated service is covered.




                                                                         Page 211
                                                     EOB Code Crosswalk to HIPAA Standard Codes



1260   Medicaid does not make       B15 - This service-procedure requires    N20 - Service not payable with   258 - Days-units for procedure-
       separate payment for         that a qualifying service-procedure be   other service rendered on the    revenue code.
       professional or technical    received and covered. The qualifying     same date.
       component performed on       other service-procedure has not been
       the same date of service     received-adjudicated.
       as complete service.


1261   Complete procedure           B15 - This service-procedure requires    N20 - Service not payable with   258 - Days-units for procedure-
       performed on the same        that a qualifying service-procedure be   other service rendered on the    revenue code.
       date of service as           received and covered. The qualifying     same date.
       professional or technical    other service-procedure has not been
       component not allowed.       received-adjudicated.
       component recouped.

1262   Related bypass            B15 - This service-procedure requires       N20 - Service not payable with   258 - Days-units for procedure-
       procedures not allowed to that a qualifying service-procedure be      other service rendered on the    revenue code.
       bill same DOS.            received and covered. The qualifying        same date.
                                 other service-procedure has not been
                                 received-adjudicated.

1263   Medicaid does not make       B15 - This service-procedure requires    N20 - Service not payable with   258 - Days-units for procedure-
       separate payment for         that a qualifying service-procedure be   other service rendered on the    revenue code.
       professional or technical    received and covered. The qualifying     same date.
       component performed on       other service-procedure has not been
       the same date of service     received-adjudicated.
       as the complete procedure.



1264   Complete procedure           B15 - This service-procedure requires    N20 - Service not payable with   258 - Days-units for procedure-
       performed on the same        that a qualifying service-procedure be   other service rendered on the    revenue code.
       date of service as the       received and covered. The qualifying     same date.
       professional or technical    other service-procedure has not been
       component not allowed.       received-adjudicated.




                                                                        Page 212
                                                      EOB Code Crosswalk to HIPAA Standard Codes



1265   Chromatography, single    B15 - This service-procedure requires        N20 - Service not payable with   258 - Days-units for procedure-
       analytes not allowed same that a qualifying service-procedure be       other service rendered on the    revenue code.
       DOS as multiple analytes. received and covered. The qualifying         same date.
                                 other service-procedure has not been
                                 received-adjudicated.

1266   Medicaid does not make        B15 - This service-procedure requires    N20 - Service not payable with   258 - Days-units for procedure-
       separate payment for          that a qualifying service-procedure be   other service rendered on the    revenue code.
       professional or technical     received and covered. The qualifying     same date.
       component performed on        other service-procedure has not been
       the same date of service      received-adjudicated.
       as the complete procedure.



1267   Complete procedure            B15 - This service-procedure requires    N20 - Service not payable with   258 - Days-units for procedure-
       performed on the same         that a qualifying service-procedure be   other service rendered on the    revenue code.
       date of service as the        received and covered. The qualifying     same date.
       professional of technical     other service-procedure has not been
       component not allowed,        received-adjudicated.
       component recouped.

1268   Very long chain fatty acids   B15 - This service-procedure requires    N20 - Service not payable with   258 - Days-units for procedure-
       not allowed same DOS as       that a qualifying service-procedure be   other service rendered on the    revenue code.
       fatty acids, No Mapping       received and covered. The qualifying     same date.
       Requiredsterified.            other service-procedure has not been
                                     received-adjudicated.

1269   Medicaid does not make        B15 - This service-procedure requires    N20 - Service not payable with   258 - Days-units for procedure-
       separate payment for          that a qualifying service-procedure be   other service rendered on the    revenue code.
       professional or technical     received and covered. The qualifying     same date.
       component performed on        other service-procedure has not been
       the same date of service      received-adjudicated.
       as the complete procedure.




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                                                     EOB Code Crosswalk to HIPAA Standard Codes

1270   Complete procedure           B15 - This service-procedure requires    N20 - Service not payable with     258 - Days-units for procedure-
       performed on the same        that a qualifying service-procedure be   other service rendered on the      revenue code.
       date of service as the       received and covered. The qualifying     same date.
       professional or technical    other service-procedure has not been
       component not allowed.       received-adjudicated.
       component recouped.

1271   For the same tooth,          119 - Benefit maximum for this time    N188 - The approved level of         259 - Frequency of service.
       payment is limited to 1      period or occurrence has been reached. care does not match the
       time per surface per                                                procedure code submitted.
       episode of treatment.
       connecting surfaces must
       be billed under 1
       procedure code.If
       necessary, complete an
       EDS adj form.
1272   Medicaid does not make       B15 - This service-procedure requires    N20 - Service not payable with     258 - Days-units for procedure-
       separate payment for         that a qualifying service-procedure be   other service rendered on the      revenue code.
       professional or technical    received and covered. The qualifying     same date.
       component performed on       other service-procedure has not been
       the same date of service     received-adjudicated.
       as the complete procedure.



1273   Complete procedure           B15 - This service-procedure requires    N20 - Service not payable with     258 - Days-units for procedure-
       performed on the same        that a qualifying service-procedure be   other service rendered on the      revenue code.
       date of service as the       received and covered. The qualifying     same date
       professional or technical    other service-procedure has not been
       component not allowed.       received-adjudicated.
       component recouped.

1274   For recipients with          22 - This care may be covered by         MA04 - Secondary payment           116 - Claim submitted to incorrect
       Medicare, Medicaid will      another payer per coordination of        cannot be considered without the payer.
       only reimburse for this      benefits.                                identity of or payment information
       DME item if Medicare has                                              from the primary payer. The
       allowed or paid                                                       information was either not
                                                                             reported or was illegible.



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                                                      EOB Code Crosswalk to HIPAA Standard Codes


1275   Patient monthly liability    142 - Monthly Medicaid patient liability   N58 - Missing-incomplete-invalid   21 - Missing or invalid information.
       not on eligibility file.     amount.                                    patient liability amount.
       contact county dss.

1276   Medicaid does not make       B15 - This service-procedure requires      N20 - Service not payable with     258 - Days-units for procedure-
       separate payment for         that a qualifying service-procedure be     other service rendered on the      revenue code.
       professional or technical    received and covered. The qualifying       same date.
       component performed on       other service-procedure has not been
       the same date of service     received-adjudicated.
       as the complete procedure.



1277   Complete procedure           B15 - This service-procedure requires      N20 - Service not payable with     259 - Frequency of service.
       performed on the same        that a qualifying service-procedure be     other service rendered on the
       date of service as the       received and covered. The qualifying       same date.
       professional or technical    other service-procedure has not been
       component not allowed,       received-adjudicated.
       component recouped.

1278   Combined units of RC679, 125 - Submission-billing error(s).             M52 - Missing-incomplete-invalid   12 - One or more originally
       RC599 or RC183 must                                                     from date(s) of service. M53 -     submitted procedure codes have
       equal number of days                                                    Missing-incomplete-invalid days    been combined.
       calculated from the 'from'                                              or units of service.
       & 'to' dates in form locator                                               M59 - Missing-incomplete-              258 - Days-units for
       6 on approved UB.                                                       invalid to date(s) of service.     procedure-revenue code.
       Correct claim dates &
       resubmit

1279   Medicaid does not make       B15 - This service-procedure requires      N20 - Service not payable with     258 - Days-units for procedure-
       separate payment for         that a qualifying service-procedure be     other service rendered on the      revenue code.
       professional or technical    received and covered. The qualifying       same date.
       component performed on       other service-procedure has not been
       the same date of service     received-adjudicated.
       as the complete procedure.




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                                                     EOB Code Crosswalk to HIPAA Standard Codes



1280   Complete procedure           B15 - This service-procedure requires    N20 - Service not payable with      258 - Days-units for procedure-
       performed on the same        that a qualifying service-procedure be   other service rendered on the       revenue code.
       date of service as the       received and covered. The qualifying     same date.
       professional or technical    other service-procedure has not been
       component not allowed.       received-adjudicated.
       component recouped.

1281   Helicobacter pylori breath   B15 - This service-procedure requires    N20 - Service not payable with      258 - Days-units for procedure-
       test analysis not allowed    that a qualifying service-procedure be   other service rendered on the       revenue code.
       to bill on same DOS as       received and covered. The qualifying     same date.
       drug administration and      other service-procedure has not been
       sample collection.           received-adjudicated.

1282   Medicaid does not make       B15 - This service-procedure requires    N20 - Service not payable with      258 - Days-units for procedure-
       separate payment for         that a qualifying service-procedure be   other service rendered on the       revenue code.
       professional or technical    received and covered. The qualifying     same date.
       component performed on       other service-procedure has not been
       the same date of service     received-adjudicated.
       as the complete procedure.



1283   Completed procedure          B15 - This service-procedure requires    N20 - Service not payable with      258 - Days-units for procedure-
       performed on the same        that a qualifying service-procedure be   other service rendered on the       revenue code.
       date of service as the       received and covered. The qualifying     same date.
       professional or technical    other service-procedure has not been
       component not allowed.       received-adjudicated.
       Component recouped

1284   Outpatient drug and          52 - The referring-prescribing-rendering N95 - This provider type -          84 - Service not authorized.
       alcohol rehab services are   provider is not eligible to refer-       provider specialty may not bill
       only contracted through      prescribe-order-perform the service      this service.
       the area mental health       billed.                                      N201 - A mental health
       program.                                                              facility is responsible for payment
                                                                             of outside providers who furnish
                                                                             these services-supplies to
                                                                             residents.



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                                                     EOB Code Crosswalk to HIPAA Standard Codes


1285   Components of basic          B15 - This service-procedure requires    N20 - Service not payable with     454 - Procedure code for services
       metabolic panel recouped     that a qualifying service-procedure be   other service rendered on the      rendered.
       to allow reimbursement of    received and covered. The qualifying     same date.
       panel code.                  other service-procedure has not been
                                    received-adjudicated.

1286   This lab test is included in 97 - The benefit for this service is     M80 - Not covered when             54 - Duplicate of a previously
       fee for metabolic panel.     included in the payment-allowance for    performed during the same          processed claim-line.
                                    another service-procedure that has       session-date as a previously
                                    already been adjudicated.                processed service for the patient.

1287   Component of electrolyte     97 - The benefit for this service is     M80 - Not covered when             54 - Duplicate of a previously
       panel recouped to allow      included in the payment-allowance for    performed during the same          processed claim-line.
       reimbursement of panel       another service-procedure that has       session-date as a previously
       code.                        already been adjudicated.                processed service for the patient.

1288   This lab test is included in 97 - The benefit for this service is     M80 - Not covered when             54 - Duplicate of a previously
       fee for electrolyte panel.   included in the payment-allowance for    performed during the same          processed claim-line.
                                    another service-procedure that has       session-date as a previously
                                    already been adjudicated.                processed service for the patient.

1289   Components of                97 - The benefit for this service is     M80 - Not covered when             54 - Duplicate of a previously
       comprehensive metabolic      included in the payment-allowance for    performed during the same          processed claim-line.
       panel recouped to allow      another service-procedure that has       session-date as a previously
       reimbursement for panel      already been adjudicated.                processed service for the patient.
       code.

1290   This lab test is included in 97 - The benefit for this service is     M80 - Not covered when             54 - Duplicate of a previously
       the fee for comprehensive included in the payment-allowance for       performed during the same          processed claim-line.
       metabolic panel.             another service-procedure that has       session-date as a previously
                                    already been adjudicated.                processed service for the patient.

1291   Chemiluminescent assay       B15 - This service-procedure requires    N20 - Service not payable with     258 - Days-units for procedure-
       and molecular diagnostics    that a qualifying service-procedure be   other service rendered on the      revenue code.
       not allowed same date of     received and covered. The qualifying     same date.
       service as hiv-1             other service-procedure has not been
       quantification.              received-adjudicated.



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                                                    EOB Code Crosswalk to HIPAA Standard Codes




1292   Related Lipo protein        B15 - This service-procedure requires    N20 - Service not payable with    258 - Days-units for procedure-
       procedures not allowed      that a qualifying service-procedure be   other service rendered on the     revenue code.
       same DOS as primary         received and covered. The qualifying     same date.
       procedure.                  other service-procedure has not been
                                   received-adjudicated.

1293   Service recouped. HIV      97 - The benefit for this service is      M80 - Not covered when             454 - Procedure code for services
       quantification includes    included in the payment-allowance for     performed during the same          rendered.
       amplified probe technique. another service-procedure that has        session-date as a previously
                                  already been adjudicated.                 processed service for the patient.

1294   Amplified probe technique 97 - The benefit for this service is       M80 - Not covered when             454 - Procedure code for services
       included in HIV           included in the payment-allowance for      performed during the same          rendered.
       quantification.           another service-procedure that has         session-date as a previously
                                 already been adjudicated.                  processed service for the patient.

1295   Related molecular           B15 - This service-procedure requires    N20 - Service not payable with    258 - Days-units for procedure-
       diagnostics procedures      that a qualifying service-procedure be   other service rendered on the     revenue code.
       not allowed same DOS as     received and covered. The qualifying     same date.
       primary procedure.          other service-procedure has not been
                                   received-adjudicated.

1296   Case management             97 - The benefit for this service is     M80 - Not covered when             259 - Frequency of service.
       recouped to allow           included in the payment-allowance for    performed during the same
       payment for Case            another service-procedure that has       session-date as a previously
       Management to a CAP         already been adjudicated.                processed service for the patient.
       provider within the same
       calendar month.
1297   Related patient nucleic     B15 - This service-procedure requires    N20 - Service not payable with    258 - Days-units for procedure-
       acid procedures not         that a qualifying service-procedure be   other service rendered on the     revenue code.
       allowed same DOS as         received and covered. The qualifying     same date.
       primary procedures.         other service-procedure has not been
                                   received-adjudicated.




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                                                      EOB Code Crosswalk to HIPAA Standard Codes


1298   Destruction of benign or      B15 - This service-procedure requires    N20 - Service not payable with   258 - Days-units for procedure-
       premalignant lesions          that a qualifying service-procedure be   other service rendered on the    revenue code.
       numbering one to fourteen     received and covered. The qualifying     same date.
       not allowed same date of      other service-procedure has not been
       service as destruction of     received-adjudicated.
       fifteen or more lesions.


1299   Service recouped.             B15 - This service-procedure requires    N20 - Service not payable with   258 - Days-units for procedure-
       destruction of fifteen or     that a qualifying service-procedure be   other service rendered on the    revenue code.
       more lesions not allowed      received and covered. The qualifying     same date.
       same.                         other service-procedure has not been
                                     received-adjudicated.

1300   Immunization update and       B15 - This service-procedure requires    N20 - Service not payable with   258 - Days-units for procedure-
       Health Check screen not       that a qualifying service-procedure be   other service rendered on the    revenue code.
       allowed same day by same      received and covered. The qualifying     same date.
       or different health           other service-procedure has not been
       department.                   received-adjudicated.

1301   Immunization update and       B15 - This service-procedure requires    N20 - Service not payable with   258 - Days-units for procedure-
       Health Check not allowed      that a qualifying service-procedure be   other service rendered on the    revenue code.
       on same date of service by    received and covered. The qualifying     same date.
       same provider before 3-1-     other service-procedure has not been
       95.                           received-adjudicated.

1302   Incision and drainage of      B15 - This service-procedure requires    N20 - Service not payable with   258 - Days-units for procedure-
       pilonidal cyst can not be     that a qualifying service-procedure be   other service rendered on the    revenue code.
       billed same day as            received and covered. The qualifying     same date.
       complicated incision and      other service-procedure has not been
       drainage of pilonidal cyst.   received-adjudicated.

1303   Prostate specific antigen     B15 - This service-procedure requires    N20 - Service not payable with   258 - Days-units for procedure-
       (psa) free not allowed        that a qualifying service-procedure be   other service rendered on the    revenue code.
       same DOS as total.            received and covered. The qualifying     same date.
                                     other service-procedure has not been
                                     received-adjudicated.



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                                                       EOB Code Crosswalk to HIPAA Standard Codes

1304   Debridement of infected        B15 - This service-procedure requires    N20 - Service not payable with     258 - Days-units for procedure-
       skin up to 10% of body         that a qualifying service-procedure be   other service rendered on the      revenue code.
       surface not allowed same       received and covered. The qualifying     same date.
       day as each additional         other service-procedure has not been
       10%.                           received-adjudicated.

1305   Sugars; single qualitative     B15 - This service-procedure requires    N20 - Service not payable with     258 - Days-units for procedure-
       cannot be billed same          that a qualifying service-procedure be   other service rendered on the      revenue code.
       DOS as multiple                received and covered. The qualifying     same date.
       qualitative.                   other service-procedure has not been
                                      received-adjudicated.

1306   Injection, intralesional; up   B15 - This service-procedure requires    N20 - Service not payable with     258 - Days-units for procedure-
       to and including seven         that a qualifying service-procedure be   other service rendered on the      revenue code.
       lesions can not be billed      received and covered. The qualifying     same date.
       same day as more than          other service-procedure has not been
       seven lesions.                 received-adjudicated.

1307   Provider number invalid        125 - Submission-billing error(s).       N77 - Missing-incomplete-invalid   21 - Missing or invalid information.
       for CSHS code(s) billed.                                                designated provider number.

                                                                                                                               132 - Entitys Medicaid
                                                                                                                  provider id.
1308   Debridement of nail(s) by      B15 - This service-procedure requires    N20 - Service not payable with     258 - Days-units for procedure-
       any method(s): one to five     that a qualifying service-procedure be   other service rendered on the      revenue code.
       can not be billed same day     received and covered. The qualifying     same date.
       as more than six.              other service-procedure has not been
                                      received-adjudicated.

1309   Sugars, single quanitative     B15 - This service-procedure requires    N20 - Service not payable with     258 - Days-units for procedure-
       cannot be billed same          that a qualifying service-procedure be   other service rendered on the      revenue code.
       DOS as multiple                received and covered. The qualifying     same date.
       quanitative.                   other service-procedure has not been
                                      received-adjudicated.

1310   Only one simple repair         119 - Benefit maximum for this time    M86 - Service denied because      259 - Frequency of service.
       code for each group of         period or occurrence has been reached. payment already made for same-
       anatomic sites is allowed                                             similar procedure within set time                          612 -
       per date of service                                                   frame.                            Per Day Limit Amount


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                                                     EOB Code Crosswalk to HIPAA Standard Codes

1311   Simple pulmonary stress      B15 - This service-procedure requires    N20 - Service not payable with     258 - Days-units for procedure-
       testing not allowed same     that a qualifying service-procedure be   other service rendered on the      revenue code.
       DOS as complex testing.      received and covered. The qualifying     same date.
                                    other service-procedure has not been
                                    received-adjudicated.

1312   Treatment of simple          B15 - This service-procedure requires    N20 - Service not payable with     258 - Days-units for procedure-
       closure not allowed same     that a qualifying service-procedure be   other service rendered on the      revenue code.
       day as with packing.         received and covered. The qualifying     same date.
                                    other service-procedure has not been
                                    received-adjudicated.

1313   Date is missing. Please      125 - Submission-billing error(s).     MA31 - Missing-incomplete-        21 - Missing or invalid information.
       correct and submit as a                                             invalid beginning and ending
       new claim.                                                          dates of the period billed.
1314   Only one intermediate        119 - Benefit maximum for this time    M86 - Service denied because      259 - Frequency of service.
       repair code allowed per      period or occurrence has been reached. payment already made for same-
       DOS.                                                                similar procedure within set time                             612 -
                                                                           frame.                            Per Day Limit Amount

1315   Selective catheter           107 - The related or qualifying claim-    N19 - Procedure code incidental   465 - Principal Procedure Code for
       placement, add'l 2nd, 3rd    service was not identified on this claim. to primary procedure.             Service(s) Rendered.
       and beyond order must                                                        N161 - This drug-service-
       bill with primary                                                      supply is covered only when the
       procedure.                                                             associated service is covered.


1316   Repair, complex, trunk; 1.1 B15 - This service-procedure requires     N20 - Service not payable with     258 - Days-units for procedure-
       cm to 2.5 cm not allowed    that a qualifying service-procedure be    other service rendered on the      revenue code.
       same day as 2.6 to 7.5 cm. received and covered. The qualifying       same date.
                                   other service-procedure has not been
                                   received-adjudicated.

1317   Multiple canula declotting B15 - This service-procedure requires      M86 - Service denied because      258 - Days-units for procedure-
       procedures not allowed on that a qualifying service-procedure be      payment already made for same- revenue code.
       same date.                 received and covered. The qualifying       similar procedure within set time
                                  other service-procedure has not been       frame.
                                  received-adjudicated.



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                                                       EOB Code Crosswalk to HIPAA Standard Codes



1318   Repair complex scalp           B15 - This service-procedure requires    N20 - Service not payable with      258 - Days-units for procedure-
       arms and or legs; 1.1cm to     that a qualifying service-procedure be   other service rendered on the       revenue code.
       2.5 cm not allowed same        received and covered. The qualifying     same date.
       day as 2.6 to 7.5cm.           other service-procedure has not been
                                      received-adjudicated.

1319   Procedure code without      151 - Payment adjusted because the    M53 - Missing-incomplete-invalid 476 - Missing or invalid units of
       units denied, correct claim payer deems the information submitted days or units of service.        service
       and resubmit as a new       does not support this many services.
       claim.

1320   Complex repair 1.1 cm to       B15 - This service-procedure requires    N20 - Service not payable with      258 - Days-units for procedure-
       2.5 cm not allowed same        that a qualifying service-procedure be   other service rendered on the       revenue code.
       date of service as related     received and covered. The qualifying     same date.
       procedure.                     other service-procedure has not been
                                      received-adjudicated.

1321   Complex repair of over 2.6     B15 - This service-procedure requires    N20 - Service not payable with      258 - Days-units for procedure-
       cm to 7.5 cm not allowed       that a qualifying service-procedure be   other service rendered on the       revenue code.
       same date of service as        received and covered. The qualifying     same date.
       related procedure.             other service-procedure has not been
                                      received-adjudicated.

1322   OB package paid.               97 - The benefit for this service is     M80 - Not covered when             454 - Procedure code for services
       Previously paid labs,          included in the payment-allowance for    performed during the same          rendered.
       office visits, consultations   another service-procedure that has       session-date as a previously
       or other services included     already been adjudicated.                processed service for the patient.
       in ob package will be
       recouped.

1323   Transcatheter placement        107 - The related or qualifying claim-    N19 - Procedure code incidental    465 - Principal Procedure Code for
       of an intravascular stent,     service was not identified on this claim. to primary procedure.              Service(s) Rendered.
       each additional vessel                                                          N161 - This drug-service-
       must bill with primary                                                   supply is covered only when the
       procedure.                                                               associated service is covered.




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                                                     EOB Code Crosswalk to HIPAA Standard Codes



1324   Claims must be processed 109 - Claim not covered by this payer-       N59 - Alert- Please refer to     116 - Claim submitted to incorrect
       through DEHNR. Refer to  contractor. You must send the claim to       your provider manual for         payer.
       your manual for          the correct payer-contractor.                additional program and
       processing instructions.                                              provider information

1325   Punch graft for hair         B15 - This service-procedure requires    N20 - Service not payable with   258 - Days-units for procedure-
       transplant not allowed       that a qualifying service-procedure be   other service rendered on the    revenue code.
       same day of service as       received and covered. The qualifying     same date.
       grafts for hair transplant   other service-procedure has not been
       of more than fifteen punch   received-adjudicated.
       grafts.

1326   Punch graft for hair         B15 - This service-procedure requires    N20 - Service not payable with   258 - Days-units for procedure-
       transplant not allowed       that a qualifying service-procedure be   other service rendered on the    revenue code.
       same day of service as       received and covered. The qualifying     same date.
       grafts for hair transplant   other service-procedure has not been
       from 1-15 punch grafts.      received-adjudicated.

1327   Salabrasion not allowed     B15 - This service-procedure requires     N20 - Service not payable with   258 - Days-units for procedure-
       same day of service if less that a qualifying service-procedure be    other service rendered on the    revenue code.
       than 20sq. cm.              received and covered. The qualifying      same date.
                                   other service-procedure has not been
                                   received-adjudicated.

1328   Salabrasion not allowed     B15 - This service-procedure requires     N20 - Service not payable with   258 - Days-units for procedure-
       same day of service if over that a qualifying service-procedure be    other service rendered on the    revenue code.
       20sq cm.                    received and covered. The qualifying      same date.
                                   other service-procedure has not been
                                   received-adjudicated.

1329   Treatment of burn wound      B15 - This service-procedure requires    N20 - Service not payable with   258 - Days-units for procedure-
       up to one percent of body    that a qualifying service-procedure be   other service rendered on the    revenue code.
       area not allowed same day    received and covered. The qualifying     same date.
       of service as related        other service-procedure has not been
       procedure.                   received-adjudicated.




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                                                     EOB Code Crosswalk to HIPAA Standard Codes



1330   Treatment of burn wound      B15 - This service-procedure requires    N20 - Service not payable with     258 - Days-units for procedure-
       up to nine percent of body   that a qualifying service-procedure be   other service rendered on the      revenue code.
       area not allowed same day    received and covered. The qualifying     same date.
       of service as related        other service-procedure has not been
       procedure.                   received-adjudicated.

1331   Complex repair 1.0 cm or     B15 - This service-procedure requires    N20 - Service not payable with     258 - Days-units for procedure-
       less not allowed same        that a qualifying service-procedure be   other service rendered on the      revenue code.
       date of service as related   received and covered. The qualifying     same date.
       procedure.                   other service-procedure has not been
                                    received-adjudicated.

1332   Complex repair 1.1 cm to     B15 - This service-procedure requires    N20 - Service not payable with     258 - Days-units for procedure-
       2.5 cm not allowed same      that a qualifying service-procedure be   other service rendered on the      revenue code.
       date of service as related   received and covered. The qualifying     same date.
       procedures.                  other service-procedure has not been
                                    received-adjudicated.

1333   Complex repair 2.6 cm to     B15 - This service-procedure requires    N20 - Service not payable with     258 - Days-units for procedure-
       7.5 cm not allowed same      that a qualifying service-procedure be   other service rendered on the      revenue code.
       date of service as related   received and covered. The qualifying     same date.
       procedure                    other service-procedure has not been
                                    received-adjudicated.

1334   Encounter. provider          125 - Submission-billing error(s).       MA130 - Your claim contains       132 - Entitys Medicaid provider id.
       specialty number missing                                              incomplete and-or invalid         144 - Entitys specialty license
       or invalid. refer to                                                  information, and no appeal rights number.
       appendix A. Choose the                                                are afforded because the claim is
       appropriate specialty for                                             unprocessable. Please submit a
       the provider performing                                               new claim with the complete-
       the service and resubmit.                                             correct information.


1335   Encounter. Provider          125 - Submission-billing error(s).       N77 - Missing-incomplete-invalid   132 - Entitys Medicaid provider id.
       number is missing. Enter                                              designated provider number.
       provider number and
       resubmit.


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                                                    EOB Code Crosswalk to HIPAA Standard Codes




1336   CAP respite not allowed     B15 - This service-procedure requires    N20 - Service not payable with    258 - Days-units for procedure-
       same date as Adult Care     that a qualifying service-procedure be   other service rendered on the     revenue code.
       Homes, PCS or               received and covered. The qualifying     same date.
       therapeutic leave.          other service-procedure has not been
                                   received-adjudicated.

1337   Adult Care Homes PCS        B15 - This service-procedure requires    N20 - Service not payable with    258 - Days-units for procedure-
       and Therapeutic Leave not   that a qualifying service-procedure be   other service rendered on the     revenue code.
       allowed same date as CAP    received and covered. The qualifying     same date.
       respite.                    other service-procedure has not been
                                   received-adjudicated.

1338   Enterectomy, each           107 - The related or qualifying claim-    N19 - Procedure code incidental 465 - Principal Procedure Code for
       additional resection must   service was not identified on this claim. to primary procedure.              Service(s) Rendered.
       bill with primary                                                              N161 - This drug-service-
       procedure.                                                            supply is covered only when the
                                                                             associated service is covered.


1339   Client behavior             169 - Payment adjusted because an        M86 - Service denied because       258 - Days-units for procedure-
       intervention services not   alternate benefit has been provided      payment already made for same- revenue code.
       allowed within the same                                              similar procedure within set time
       month as assertive                                                   frame.                      N357 -
       community treatment.                                                  Time frame requirements
                                                                            between this service-procedure-
                                                                            supply and a related service-
                                                                            procedure-supply have not been
                                                                            met

1340   Client behavior           11 - The diagnosis is inconsistent with    M76 - Missing-incomplete-invalid 255 - Diagnosis code.
       intervention services not the procedure.                             diagnosis or condition.
       allowed without a mental
       health or substance abuse
       diagnosis.




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                                                      EOB Code Crosswalk to HIPAA Standard Codes


1341   Periodic services and-or 169 - Payment adjusted because an              M86 - Service denied because       258 - Days-units for procedure-
       high risk intervention   alternate benefit has been provided            payment already made for same- revenue code.
       services not allowed                                                    similar procedure within set time
       within the same calendar                                                frame.                      N357 -
       month as assertive                                                       Time frame requirements
       community treatment team                                                between this service-procedure-
       services.                                                               supply and a related service-
                                                                               procedure-supply have not been
                                                                               met

1342   Assertive community           169 - Payment adjusted because an         M86 - Service denied because       258 - Days-units for procedure-
       treatment team services       alternate benefit has been provided       payment already made for same- revenue code.
       not allowed within the                                                  similar procedure within set time
       same calendar month as                                                  frame.                      N357 -
       periodic services and-or                                                 Time frame requirements
       high risk intervention                                                  between this service-procedure-
       services.                                                               supply and a related service-
                                                                               procedure-supply have not been
                                                                               met

1343   Residential high risk          169 - Payment adjusted because an        N20 - Service not payable with    258 - Days-units for procedure-
       intervention not allowed       alternate benefit has been provided      other service rendered on the     revenue code.
       the same day as                                                         same date.
       professional treatment
       services in crisis facilities.

1344   Service not allowed           11 - The diagnosis is inconsistent with   M76 - Missing-incomplete-invalid 488 - Diagnosis code(s) for the
       without a mental disorder     the procedure.                            diagnosis or condition.          services rendered
       diagnosis.
1345   Unit limitation exceeded      119 - Benefit maximum for this time       N362 - The number of Days or      255 - Diagnosis code.
       for diagnosis billed.         period or occurrence has been reached. Units of Service exceeds our          259 - Frequency of service.
                                                                               acceptable maximum
1346   Excision, each additional     107 - The related or qualifying claim-    N19 - Procedure code incidental   465 - Principal Procedure Code for
       lesion must bill with         service was not identified on this claim. to primary procedure.             Service(s) Rendered.
       primary proc                                                                  N161 - This drug-service-
                                                                               supply is covered only when the
                                                                               associated service is covered.



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1347   Hysterectomy after          107 - The related or qualifying claim-    N19 - Procedure code incidental        465 - Principal Procedure Code for
       cesarean delivery must bill service was not identified on this claim. to primary procedure.                  Service(s) Rendered.
       with primary procedure.                                                     N161 - This drug-service-
                                                                             supply is covered only when the
                                                                             associated service is covered.


1348   Capsulotomy, midfoot not       B15 - This service-procedure requires     N20 - Service not payable with      258 - Days-units for procedure-
       allowed with tendon            that a qualifying service-procedure be    other service rendered on the       revenue code.
       lengthening.                   received and covered. The qualifying      same date.
                                      other service-procedure has not been
                                      received-adjudicated.

1349   Transection or ligation        107 - The related or qualifying claim-    N19 - Procedure code incidental 465 - Principal Procedure Code for
       procedures must be billed      service was not identified on this claim. to primary procedure.             Service(s) Rendered.
       with primary.                                                                    N161 - This drug-service-
                                                                                supply is covered only when the
                                                                                associated service is covered.


1350   Provider signature not on      16 - Claim-service lacks information      MA81 - Missing-incomplete-          21 - Missing or invalid information.
       file. Sign claim and           which is needed for adjudication.         invalid provider-supplier signature               117 - Claim requires
       resubmit or complete                                                                                         signature-on-file indicator.
       'certification for signature                                                                                                  466 - Entities
       on file' form located on                                                                                     original signature.
       DMA's website under
       provider links, provider
       forms

1351   Provider signature not on      16 - Claim-service lacks information      MA81 - Missing-incomplete-          21 - Missing or invalid information.
       file. Sign claim and           which is needed for adjudication.         invalid provider-supplier signature                117 - Claim requires
       resubmit or complete                                                                                         signature-on-file indicator.
       'certification for signature                                                                                                      466 - Entities
       on file' form located on                                                                                     original signature.
       DMA's website under
       provider links, provider
       forms



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                                                      EOB Code Crosswalk to HIPAA Standard Codes


1352   Laminotomy, each           107 - The related or qualifying claim-    N19 - Procedure code incidental      465 - Principal Procedure Code for
       additional interspace must service was not identified on this claim. to primary procedure.                Service(s) Rendered.
       bill with primary                                                        N161 - This drug-service-
       procedure.                                                           supply is covered only when the
                                                                            associated service is covered.

1353   Laminotomy, each             107 - The related or qualifying claim-    N19 - Procedure code incidental    465 - Principal Procedure Code for
       additional segment must      service was not identified on this claim. to primary procedure.              Service(s) Rendered.
       bill with primary                                                            N161 - This drug-service-
       procedure.                                                             supply is covered only when the
                                                                              associated service is covered.

1354   Transpedicular, each         107 - The related or qualifying claim-    N19 - Procedure code incidental 465 - Principal Procedure Code for
       additional segment must      service was not identified on this claim. to primary procedure.              Service(s) Rendered.
       bill with primary                                                               N161 - This drug-service-
       procedure.                                                             supply is covered only when the
                                                                              associated service is covered.


1355   PA number or amount          197 - Precertification-authorization-      M62 - Missing-incomplete-invalid 48 - Referral-authorization.
       billed does not match the    notification absent.                       treatment authorization code.                          178 -
       CMNPA form. Review,                                                                                        Submitted charges.
       correct and resubmit as a                                                                     N54 - Claim
       new claim.                                                              information is inconsistent with
                                                                               pre-certified-authorized services.

1356   Incision and drainage of     B15 - This service-procedure requires      N20 - Service not payable with    258 - Days-units for procedure-
       abscess can not be billed    that a qualifying service-procedure be     other service rendered on the     revenue code.
       same day as complicated      received and covered. The qualifying       same date.
       or multiple incision and     other service-procedure has not been
       drainage of abscess.         received-adjudicated.

1357   Diskectomy, thoracic,       107 - The related or qualifying claim-    N19 - Procedure code incidental     465 - Principal Procedure Code for
       single interspace must bill service was not identified on this claim. to primary procedure.               Service(s) Rendered.
       with primary procedure.                                                   N161 - This drug-service-
                                                                             supply is covered only when the
                                                                             associated service is covered.



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                                                     EOB Code Crosswalk to HIPAA Standard Codes

1358   Medicaid considers this      97 - The benefit for this service is     M80 - Not covered when             54 - Duplicate of a previously
       code to be an integral       included in the payment-allowance for    performed during the same          processed claim-line.
       component to the total       another service-procedure that has       session-date as a previously
       procedure. Separate          already been adjudicated.                processed service for the patient.
       reimbursement is not
       made.

1359   Vertebral corpectomy,        107 - The related or qualifying claim-    N19 - Procedure code incidental 465 - Principal Procedure Code for
       cervical, each additional    service was not identified on this claim. to primary procedure.             Service(s) Rendered.
       segment must bill with                                                         N161 - This drug-service-
       primary procedure.                                                     supply is covered only when the
                                                                              associated service is covered.


1360   92551 and-or 92552 is not    B15 - This service-procedure requires    N20 - Service not payable with     258 - Days-units for procedure-
       allowed on the same date     that a qualifying service-procedure be   other service rendered on the      revenue code.
       of service as W8014.         received and covered. The qualifying     same date.
                                    other service-procedure has not been
                                    received-adjudicated.

1361   Destruction of lesions by    B15 - This service-procedure requires    N20 - Service not payable with     258 - Days-units for procedure-
       any method second            that a qualifying service-procedure be   other service rendered on the      revenue code.
       through fourteen not         received and covered. The qualifying     same date.
       allowed same date of         other service-procedure has not been
       service as related           received-adjudicated.
       procedure.
1362   Destruction of lesions by    B15 - This service-procedure requires    N20 - Service not payable with     258 - Days-units for procedure-
       any method fifteen or        that a qualifying service-procedure be   other service rendered on the      revenue code.
       more not allowed same        received and covered. The qualifying     same date.
       date of service as related   other service-procedure has not been
       procedure.                   received-adjudicated.

1363   Vertebral corpectomy,        107 - The related or qualifying claim-    N19 - Procedure code incidental   465 - Principal Procedure Code for
       thoracic, each additional    service was not identified on this claim. to primary procedure.             Service(s) Rendered.
       segment.                                                                        N161 - This drug-
                                                                              service-supply is covered only
                                                                              when the associated service is
                                                                              covered.



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                                                      EOB Code Crosswalk to HIPAA Standard Codes



1364   Destruction of warts,         B15 - This service-procedure requires    N20 - Service not payable with   258 - Days-units for procedure-
       molluscum contagiosum,        that a qualifying service-procedure be   other service rendered on the    revenue code.
       or millia by any method up    received and covered. The qualifying     same date.
       to 14 lesions not allowed     other service-procedure has not been
       same date of service as       received-adjudicated.
       related procedure.


1365   Destruction of warts,         B15 - This service-procedure requires    N20 - Service not payable with   258 - Days-units for procedure-
       molluscum contagiosum,        that a qualifying service-procedure be   other service rendered on the    revenue code.
       or millia by any method of    received and covered. The qualifying     same date.
       fifteen or more lesions not   other service-procedure has not been
       allowed same date of          received-adjudicated.
       service as related
       procedure.

1366   Excision of chest wall        B15 - This service-procedure requires    N20 - Service not payable with   258 - Days-units for procedure-
       tumor without mediastinal     that a qualifying service-procedure be   other service rendered on the    revenue code.
       lymphadenectomy not           received and covered. The qualifying     same date.
       allowed same date of          other service-procedure has not been
       service as related            received-adjudicated.
       procedure.

1367   Excision of chest will        B15 - This service-procedure requires    N20 - Service not payable with   258 - Days-units for procedure-
       tumor without mediastinal     that a qualifying service-procedure be   other service rendered on the    revenue code.
       lymphadenectomy not           received and covered. The qualifying     same date.
       allowed same date of          other service-procedure has not been
       service as related            received-adjudicated.
       procedures.

1368   Vertbebral corpectomy,        107 - The related or qualifying claim-    N19 - Procedure code incidental 465 - Principal Procedure Code for
       partial or complete, each     service was not identified on this claim. to primary procedure.             Service(s) Rendered.
       additional segment must                                                         N161 - This drug-service-
       bill with primary                                                       supply is covered only when the
       procedure.                                                              associated service is covered.




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                                                     EOB Code Crosswalk to HIPAA Standard Codes

1369   Injection, anesthetic        107 - The related or qualifying claim-    N19 - Procedure code incidental    465 - Principal Procedure Code for
       agent; trigeminal nerve,     service was not identified on this claim. to primary procedure.              Service(s) Rendered.
       paravertebral facet joint                                                       N161 - This drug-
       nerve, each additional                                                 service-supply is covered only
       level must bill with                                                   when the associated service is
       primary.                                                               covered.

1370   Code W8014 is not            B15 - This service-procedure requires    N20 - Service not payable with      258 - Days-units for procedure-
       allowed on the same date     that a qualifying service-procedure be   other service rendered on the       revenue code.
       of service as 92551 or       received and covered. The qualifying     same date.
       92552                        other service-procedure has not been
                                    received-adjudicated.

1371   Destruction by neurolytic    107 - The related or qualifying claim-    N19 - Procedure code incidental    465 - Principal Procedure Code for
       agent; paravertebral facet   service was not identified on this claim. to primary procedure.              Service(s) Rendered.
       joint nerve, each                                                         N161 - This drug-service-
       additional level must bill                                             supply is covered only when the
       with primary procedure.                                                associated service is covered.


1372   Excision of neuroma;         107 - The related or qualifying claim-    N19 - Procedure code incidental    465 - Principal Procedure Code for
       digital nerve, each          service was not identified on this claim. to primary procedure.              Service(s) Rendered.
       additional digit must bill                                                    N161 - This drug-service-
       with primary procedure.                                                supply is covered only when the
                                                                              associated service is covered.


1373   Excision of neuroma, hand 107 - The related or qualifying claim-    N19 - Procedure code incidental       465 - Principal Procedure Code for
       or foot, each additional  service was not identified on this claim. to primary procedure.                 Service(s) Rendered.
       nerve must bill with                                                         N161 - This drug-
       primary procedure.                                                  service-supply is covered only
                                                                           when the associated service is
                                                                           covered.

1374   Suture of digital nerve,     107 - The related or qualifying claim-    N19 - Procedure code incidental    465 - Principal Procedure Code for
       hand or foot, each           service was not identified on this claim. to primary procedure.              Service(s) Rendered.
       additional digital nerve                                                     N161 - This drug-service-
       must bill with primary                                                 supply is covered only when the
       procedure.                                                             associated service is covered.


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                                                     EOB Code Crosswalk to HIPAA Standard Codes




1375   Fetal nonstress included      97 - The benefit for this service is     M80 - Not covered when             454 - Procedure code for services
       in fetal biophysical profile. included in the payment-allowance for    performed during the same          rendered.
                                     another service-procedure that has       session-date as a previously
                                     already been adjudicated.                processed service for the patient.

1376   Suture of each additional    107 - The related or qualifying claim-    N19 - Procedure code incidental    465 - Principal Procedure Code for
       nerve; hand or foot, must    service was not identified on this claim. to primary procedure.              Service(s) Rendered.
       bill with primary                                                             N161 - This drug-service-
       procedure.                                                             supply is covered only when the
                                                                              associated service is covered.


1377   Suture of each additional    107 - The related or qualifying claim-    N19 - Procedure code incidental    465 - Principal Procedure Code for
       major peripheral nerve       service was not identified on this claim. to primary procedure.              Service(s) Rendered.
       must bill with primary                                                        N161 - This drug-service-
       procedure.                                                             supply is covered only when the
                                                                              associated service is covered.


1378   Related DME procedures       B15 - This service-procedure requires     N20 - Service not payable with     258 - Days-units for procedure-
       are not allowed on the       that a qualifying service-procedure be    other service rendered on the      revenue code.
       same date of service.        received and covered. The qualifying      same date.
                                    other service-procedure has not been
                                    received-adjudicated.

1379   Service included in ob       97 - The benefit for this service is      M80 - Not covered when             454 - Procedure code for services
       package code.                included in the payment-allowance for     performed during the same          rendered.
                                    another service-procedure that has        session-date as a previously
                                    already been adjudicated.                 processed service for the patient.

1380   Refile claim on paper with   16 - Claim-service lacks information      N225 - Incomplete-invalid          277 - Paper claim.
       itemized breakdown of        which is needed for adjudication.         documentation-orders- notes-         279 - Itemized claim.
       charges.                                                               summary- report- chart.




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                                                     EOB Code Crosswalk to HIPAA Standard Codes




1381   Refile claim with itemized   A1 - Claim-Service denied. At least one   MA130 - Your claim contains       279 - Itemized claim.
       breakdown of charges.        Remark Code must be provided (may         incomplete and-or invalid                               481 -
                                    be comprised of either the Remittance     information, and no appeal rights Claim-submission format is invalid.
                                    Advice Remark Code or NCPDP Reject        are afforded because the claim is
                                    Reason Code.) This change to be           unprocessable. Please submit a
                                    effective 7-1-2010- Claim-Service         new claim with the complete-
                                    denied. At least one Remark Code          correct information.
                                    must be provided (may be comprised              N26 - Missing-incomplete-
                                    of either the NCPDP Reject Reason         invalid itemized bill
                                    Code, or Remittance Advice Remark
                                    Code that is not an ALERT.)


1382   Itemized bill does not       125 - Submission-billing error(s).        M79 - Missing-incomplete-invalid 178 - Submitted charges.
       support charges billed.                                                charge.
       Please review charges,                                                       N152 - Missing-incomplete-
       correct claim, and                                                     invalid replacement claim        279 - Itemized claim.
       resubmit for processing.                                               information.

1383   Nerve graft, each            107 - The related or qualifying claim-    N19 - Procedure code incidental   465 - Principal Procedure Code for
       additional nerve, single     service was not identified on this claim. to primary procedure.             Service(s) Rendered.
       strand must bill with                                                      N161 - This drug-service-
       primary procedure.                                                     supply is covered only when the
                                                                              associated service is covered.

1384   Related strabismus           107 - The related or qualifying claim-    N19 - Procedure code incidental 465 - Principal Procedure Code for
       surgery must be billed       service was not identified on this claim. to primary procedure.             Service(s) Rendered.
       with primary.                                                                  N161 - This drug-service-
                                                                              supply is covered only when the
                                                                              associated service is covered.




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                                                      EOB Code Crosswalk to HIPAA Standard Codes




1385   DMA-PCG recovery            133 - The disposition of this claim-       No Mapping Required                  3 - Claim has been adjudicated
       project, at DMAs request    service is pending further review.                                              and is awaiting payment cycle.
       on claims where other
       insurance was available to
       pay medical expenses.
       For questions, call Sue St.
       John, PCG, 1-800-372-0878.


1386   Exceeds 50 procedures         119 - Benefit maximum for this time       M86 - Service denied because        259 - Frequency of service.
       per day limitation.           period or occurrence has been reached. payment already made for same-         612 - Per Day Limit Amount
                                                                               similar procedure within set time
                                                                               frame
1387   Related strabismus            107 - The related or qualifying claim-    N19 - Procedure code incidental     465 - Principal Procedure Code for
       surgery must be billed        service was not identified on this claim. to primary procedure.               Service(s) Rendered.
       with primary.                                                             N161 - This drug-service-supply
                                                                               is covered only when the
                                                                               associated service is covered.

1388   Thoracic, add‟l 2nd, 3rd      107 - The related or qualifying claim-    N19 - Procedure code incidental     465 - Principal Procedure Code for
       and beyond order must         service was not identified on this claim. to primary procedure.               Service(s) Rendered.
       bill with primary                                                           N161 - This drug-service-
       procedure.                                                              supply is covered only when the
                                                                               associated service is covered.

1389   Exceeds three procedures 119 - Benefit maximum for this time     M86 - Service denied because      259 - Frequency of service.
       per three day limitation. period or occurrence has been reached. payment already made for same-
                                                                        similar procedure within set time
                                                                        frame.                       N357
                                                                        - Time frame requirements
                                                                        between this service-procedure-
                                                                        supply and a related service-
                                                                        procedure-supply have not been
                                                                        met




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                                                      EOB Code Crosswalk to HIPAA Standard Codes




1390   Medicare payment              148 - Information from another provider N4 - Missing-incomplete-invalid       286 - Other payers Explanation of
       information for this detail   was not provided or was insufficient-   prior insurance carrier EOB.          Benefits-payment information.
       is not listed on attached     incomplete. At least one Remark Code
       medicare voucher.             must be provided (may be comprised
                                     of either the Remittance Advice
                                     Remark Code or NCPDP Reject
                                     Reason Code.)
1391   Family planning should        125 - Submission-billing error(s).      N56 - Procedure code billed is        21 - Missing or invalid information.
       not be indicated. Please                                              not correct-valid for the service
       correct and resubmit as a                                             billed or the date of service billed.
       new day claim.                                                                                              568 - Family Planning Indicator

1392   Additional hour for work      107 - The related or qualifying claim-    N19 - Procedure code incidental 465 - Principal Procedure Code for
       hardening-conditional         service was not identified on this claim. to primary procedure.             Service(s) Rendered.
       must be billed with                                                             N161 - This drug-service-
       primary procedure.                                                      supply is covered only when the
                                                                               associated service is covered.


1393   Previous state payout.        A1 - Claim-Service denied. At least one   MA130 - Your claim contains       446 - Documentation from prior
       Resubmit claim with RA to     Remark Code must be provided (may         incomplete and-or invalid         claim(s) related to service(s)
       DMA, claims analysis unit,    be comprised of either the Remittance     information, and no appeal rights
       see billing guidelines.       Advice Remark Code or NCPDP Reject        are afforded because the claim is
                                     Reason Code.) This change to be           unprocessable. Please submit a
                                     effective 7-1-2010- Claim-Service         new claim with the complete-
                                     denied. At least one Remark Code          correct information.
                                     must be provided (may be comprised
                                     of either the NCPDP Reject Reason
                                     Code, or Remittance Advice Remark
                                     Code that is not an ALERT.)




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                                                    EOB Code Crosswalk to HIPAA Standard Codes

1394   Three teleconsult visits    119 - Benefit maximum for this time    M86 - Service denied because      259 - Frequency of service.
       allowed per day.            period or occurrence has been reached. payment already made for same-
                                                                          similar procedure within set time                          612 -
                                                                          frame.                       N357 Per Day Limit Amount
                                                                          - Time frame requirements
                                                                          between this service-procedure-
                                                                          supply and a related service-
                                                                          procedure-supply have not been
                                                                          met

1395   Please correct your claim   125 - Submission-billing error(s).        N56 - Procedure code billed is        454 - Procedure code for services
       by using a more specific                                              not correct-valid for the service     rendered.
       hysterectomy procedure                                                billed or the date of service billed.
       code.
1396   Observation is not          16 - Claim-service lacks information      N29 - Missing documentation-       21 - Missing or invalid information.
       routinely allowed. Submit   which is needed for adjudication.         orders- notes- summary- report-                           287 - Medical
       as adjustment with                                                    chart                              necessity for service.
       documentation to                                                                                                       294 - Supporting
       substantiate the medical                                                                                 documentation.
       necessity.
1397   Routine observation room    78 - Non-Covered days-Room charge         M79 - Missing-incomplete-invalid 258 - Days-units for procedure-
       is noncovered.              adjustment.                               charge.                          revenue code.

1398   Preventive medicine,        119 - Benefit maximum for this time    M86 - Service denied because      259 - Frequency of service.
       individual and group        period or occurrence has been reached. payment already made for same-
       counseling not allowed                                             similar procedure within set time
       more than 10 per calendar                                          frame.                       N357
       year.                                                              - Time frame requirements
                                                                          between this service-procedure-
                                                                          supply and a related service-
                                                                          procedure-supply have not been
                                                                          met

1399   Bill Medicare carrier.      22 - This care may be covered by          MA04 - Secondary payment           116 - Claim submitted to incorrect
                                   another payer per coordination of         cannot be considered without the payer.
                                   benefits.                                 identity of or payment information
                                                                             from the primary payer. The
                                                                             information was either not
                                                                             reported or was illegible.


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                                                     EOB Code Crosswalk to HIPAA Standard Codes

1400   Claim was specially priced   45 - Charge exceeds fee schedule-        N45 - Payment based on           64 - Re-pricing information.
       according to agreement       maximum allowable or contracted-         authorized amount.
       between the provider and     legislated fee arrangement. (Use
       the division of medical      Group Codes PR or CO depending
       assistance.                  upon liability).

1401   Detailed and extensive       B15 - This service-procedure requires    N20 - Service not payable with   258 - Days-units for procedure-
       oral evaluation-problem      that a qualifying service-procedure be   other service rendered on the    revenue code.
       focused, by report not       received and covered. The qualifying     same date.
       allowed same date of         other service-procedure has not been
       service as dental exam.      received-adjudicated.


1402   Dental exam not allowed      B15 - This service-procedure requires    N20 - Service not payable with   258 - Days-units for procedure-
       on the same date of          that a qualifying service-procedure be   other service rendered on the    revenue code.
       service detailed and         received and covered. The qualifying     same date.
       extensive oral evaluation.   other service-procedure has not been
                                    received-adjudicated.

1403   Only one reduction per       119 - Benefit maximum for this time    M86 - Service denied because      259 - Frequency of service.
       arch allowed on the same     period or occurrence has been reached. payment already made for same-
       date of service.                                                    similar procedure within set time                          612 -
                                                                           frame.                            Per Day Limit Amount

1404   Private insurance payment 22 - This care may be covered by            MA04 - Secondary payment        116 - Claim submitted to incorrect
       indicated on claim. No    another payer per coordination of           cannot be considered without payer.
       record of TPL on file.    benefits.                                   the identity of or payment
       correct claim or update                                               information from the primary
       recipient TPL using DMA                                               payer. The information was
       form 2057 and resubmit                                                either not reported or was
       claim.                                                                illegible.
                                                                                N155 - Alert- Our records do
                                                                             not indicate that other
                                                                             insurance is on file. Please
                                                                             submit other insurance
                                                                             information for our records




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                                                    EOB Code Crosswalk to HIPAA Standard Codes




1405   Cap respite not allowed     169 - Payment adjusted because an        N20 - Service not payable with     258 - Days-units for procedure-
       same DOS as adult care      alternate benefit has been provided      other service rendered on the      revenue code.
       and TL.                                                              same date.

1406   Large volume nebulizer      B15 - This service-procedure requires    M86 - Service denied because      258 - Days-units for procedure-
       not allowed same month      that a qualifying service-procedure be   payment already made for same- revenue code.
       as compressor.              received and covered. The qualifying     similar procedure within set time
                                   other service-procedure has not been     frame.
                                   received-adjudicated.

1407   Only one continuous        119 - Benefit maximum for this time    M86 - Service denied because      259 - Frequency of service.
       epidural analgesia allowed period or occurrence has been reached. payment already made for same-
       per 270 days.                                                     similar procedure within set time
                                                                         frame.
                                                                         N357 - Time frame requirements
                                                                         between this service-procedure-
                                                                         supply and a related service-
                                                                         procedure-supply have not been
                                                                         met

1408   Reflects overpayments for 198 - Payment Adjusted for exceeding       N54 - Claim information is         64 - Re-pricing information.
       non-authorized ach        precertification- authorization            inconsistent with pre-certified-
       enhanced care.                                                       authorized services.

1409   HCPC code not               125 - Submission-billing error(s).       M56 - Missing-incomplete-invalid 21 - Missing or invalid information.
       appropriate with non-                                                payer identifier
       Medicare beneficiary.
       Please correct and                                                                                      454 - Procedure code for
       resubmit.                                                                                             services rendered.
1410   Revenue code must be        125 - Submission-billing error(s).       M20 - Missing-incomplete-invalid 454 - Procedure code for services
       billed with a skilled                                                HCPCS.                           rendered.
       nursing visit HCPC code.                                                      M50 - Missing-                 455 - Revenue code for
                                                                            incomplete-invalid revenue       services rendered.
                                                                            code(s).




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                                                    EOB Code Crosswalk to HIPAA Standard Codes




1411   Allow one oral evaluation   119 - Benefit maximum for this time    M86 - Service denied because      259 - Frequency of service.
       every three months.         period or occurrence has been reached. payment already made for same-
                                                                          similar procedure within set time
                                                                          frame.
                                                                          N357 - Time frame requirements
                                                                          between this service-procedure-
                                                                          supply and a related service-
                                                                          procedure-supply have not been
                                                                          met

1412   Only six oral evaluations   149 - Lifetime benefit maximum has         N362 - The number of Days or     259 - Frequency of service.
       and flouride varnish        been reached for this service-benefit      Units of Service exceeds our
       applications allowed per    category                                   acceptable maximum
       recipient's lifetime.

1413   DMA-PCG repayment of        198 - Payment Adjusted for exceeding       N45 - Payment based on           64 - Re-pricing information.
       recoupment. Claim           precertification- authorization            authorized amount.
       originally recouped with
       EOB 1385. For questions,
       call PCG, 1-800-372-0878.

1414   Provider initiated        45 - Charge exceeds fee schedule-            N45 - Payment based on           64 - Re-pricing information.
       repayment of claim        maximum allowable or contracted-             authorized amount.
       originally recouped with  legislated fee arrangement. (Use
       EOB 1385.                 Group Codes PR or CO depending
                                 upon liability).
1415   Meniscetomy and-or        B15 - This service-procedure requires        N20 - Service not payable with   258 - Days-units for procedure-
       arthrotomy not allowed on that a qualifying service-procedure be       other service rendered on the    revenue code.
       the same date of service  received and covered. The qualifying         same date.
       as arthroplasty.          other service-procedure has not been
                                 received-adjudicated.




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                                                      EOB Code Crosswalk to HIPAA Standard Codes




1416   Exceeds 20 unit per year      119 - Benefit maximum for this time    N357 - Time frame requirements 259 - Frequency of service.
       limitation.                   period or occurrence has been reached. between this service-procedure-
                                                                            supply and a related service-
                                                                            procedure-supply have not been
                                                                            met.                       N362 -
                                                                            The number of Days or Units of
                                                                            Service exceeds our acceptable
                                                                            maximum

1417   Diagnostic arthroscopy        B15 - This service-procedure requires    N20 - Service not payable with      258 - Days-units for procedure-
       not allowed on the same       that a qualifying service-procedure be   other service rendered on the       revenue code.
       date of service as surgical   received and covered. The qualifying     same date.
       arthroscopy.                  other service-procedure has not been
                                     received-adjudicated.

1418   No payment allowed for        B15 - This service-procedure requires    N20 - Service not payable with      258 - Days-units for procedure-
       special services              that a qualifying service-procedure be   other service rendered on the       revenue code.
       procedure when e-m            received and covered. The qualifying     same date.
       service is not paid for the   other service-procedure has not been
       same date of service,         received-adjudicated.
       same provider.

1419   Surgical arthroscopy          B15 - This service-procedure requires    N20 - Service not payable with      258 - Days-units for procedure-
       (D7873, 29804) not allowed    that a qualifying service-procedure be   other service rendered on the       revenue code.
       on the same date of           received and covered. The qualifying     same date.
       service as TMJ.               other service-procedure has not been
                                     received-adjudicated.

1420   Unit cutback - exceeds        119 - Benefit maximum for this time    N362 - The number of Days or          258 - Days-units for procedure-
       max units allowed.            period or occurrence has been reached. Units of Service exceeds our          revenue code.
                                                                            acceptable maximum.                    259 - Frequency of service.
                                                                            N381 - Consult our contractual        476 - Missing or invalid units of
                                                                            agreement for restrictions-billing-   service
                                                                            payment information related to
                                                                            these charges




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                                                       EOB Code Crosswalk to HIPAA Standard Codes

1421   Repair of maxillofacial soft   B15 - This service-procedure requires    N20 - Service not payable with     258 - Days-units for procedure-
       or hard tissue defects         that a qualifying service-procedure be   other service rendered on the      revenue code.
       (d7955) not allowed on the     received and covered. The qualifying     same date.
       same date of service as        other service-procedure has not been
       d7610, d7620, d7650,           received-adjudicated.
       d7660, d7680, d7710,
       d7720, d7750, d7760 or
       d7780.

1422   Immunization                   B15 - This service-procedure requires    N59 - Alert- Please refer to       21 - Missing or invalid information.
       administration not allowed     that a qualifying service-procedure be   your provider manual for           490 - Other proedure code for
       without billing the            received and covered. The qualifying     additional program and             service(s) rendered.
       appropriate immunization       other service-procedure has not been     provider information
       code. Refer to the latest      received-adjudicated.
       Health Check Billing Guide.


1423   d7850, d7860 or d7865 not      B15 - This service-procedure requires    N20 - Service not payable with     258 - Days-units for procedure-
       allowed on the same date       that a qualifying service-procedure be   other service rendered on the      revenue code.
       of service as arthroplasty     received and covered. The qualifying     same date.
       (21242 or 21243).              other service-procedure has not been
                                      received-adjudicated.

1424   Reflects overpayments for 198 - Payment Adjusted for exceeding          N54 - Claim information is         64 - Re-pricing information.
       ach enhanced care PCS       precertification- authorization             inconsistent with pre-certified-
       billed at higher level than                                             authorized services.
       authorized.

1425   Athroplasty is only       119 - Benefit maximum for this time           M86 - Service denied because      259 - Frequency of service.
       allowed once for the same period or occurrence has been reached.        payment already made for same-
       joint on the same date of                                               similar procedure within set time
       service.                                                                frame.

1426   Injectable drug                B15 - This service-procedure requires    N20 - Service not payable with     258 - Days-units for procedure-
       administration not allowed     that a qualifying service-procedure be   other service rendered on the      revenue code.
       on same date of service as     received and covered. The qualifying     same date.
       iv infusion therapy.           other service-procedure has not been
                                      received-adjudicated.



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                                                     EOB Code Crosswalk to HIPAA Standard Codes




1427   Iv infusion therapy not      B15 - This service-procedure requires    N20 - Service not payable with     258 - Days-units for procedure-
       allowed on same date of      that a qualifying service-procedure be   other service rendered on the      revenue code.
       service as injectable drug   received and covered. The qualifying     same date.
       administration. injectable   other service-procedure has not been
       drug administration fee      received-adjudicated.
       recouped.


1428   Additional burn and          107 - The related or qualifying claim-    N19 - Procedure code incidental 465 - Principal Procedure Code for
       wound preparation must       service was not identified on this claim. to primary procedure.             Service(s) Rendered.
       be billed same date of                                                   N161 - This drug-service-supply
       service as primary                                                     is covered only when the
       procedure.                                                             associated service is covered.

1429   Additional application of   107 - The related or qualifying claim-    N19 - Procedure code incidental    465 - Principal Procedure Code for
       allograft, skin must be     service was not identified on this claim. to primary procedure.              Service(s) Rendered.
       billed same date of service                                                 N161 - This drug-service-
       as primary procedure.                                                 supply is covered only when the
                                                                             associated service is covered.

1430   Additional application of   107 - The related or qualifying claim-    N19 - Procedure code incidental    465 - Principal Procedure Code for
       xenogaft, skin must be      service was not identified on this claim. to primary procedure.              Service(s) Rendered.
       billed same date of service                                                  N161 - This drug-service-
       as primary procedure.                                                 supply is covered only when the
                                                                             associated service is covered.


1431   Additional vein related      107 - The related or qualifying claim-    N19 - Procedure code incidental   465 - Principal Procedure Code for
       procedures must be billed    service was not identified on this claim. to primary procedure.             Service(s) Rendered.
       same date of service as                                                      N161 - This drug-service-
       primary procedures.                                                    supply is covered only when the
                                                                              associated service is covered.




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                                                       EOB Code Crosswalk to HIPAA Standard Codes




1432   Detail billed with incorrect   4 - The procedure code is inconsistent     No Mapping Required              453 - Procedure code modifier(s)
       or no modifier. Correct        with the modifier or a required modifier                                    for service(s) rendered.
       detail and resubmit as a       is missing.
       new day claim. If
       reimbursement affected
       request a full recoupment
       and resubmit claim.


1433   Exceeds 4 units per 270        119 - Benefit maximum for this time    M86 - Service denied because      259 - Frequency of service.
       day limitation.                period or occurrence has been reached. payment already made for same-
                                                                             similar procedure within set time
                                                                             frame.
                                                                             N357 - Time frame requirements
                                                                             between this service-procedure-
                                                                             supply and a related service-
                                                                             procedure-supply have not been
                                                                             met.                      N362 -
                                                                             The number of Days or Units of
                                                                             Service exceeds our acceptable
                                                                             maximum


1434   Related dialysis graft         B15 - This service-procedure requires      N20 - Service not payable with   258 - Days-units for procedure-
       procedures not allowed         that a qualifying service-procedure be     other service rendered on the    revenue code.
       same DOS.                      received and covered. The qualifying       same date.
                                      other service-procedure has not been
                                      received-adjudicated.

1435   Related pelvic exenteraton B15 - This service-procedure requires          N20 - Service not payable with   258 - Days-units for procedure-
       procedures not allowed to that a qualifying service-procedure be          other service rendered on the    revenue code.
       bill with same DOS.        received and covered. The qualifying           same date.
                                  other service-procedure has not been
                                  received-adjudicated.




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                                                     EOB Code Crosswalk to HIPAA Standard Codes



1436   Related vaginectomy          B15 - This service-procedure requires    N20 - Service not payable with     258 - Days-units for procedure-
       procedures not allowed       that a qualifying service-procedure be   other service rendered on the      revenue code.
       same DOS.                    received and covered. The qualifying     same date.
                                    other service-procedure has not been
                                    received-adjudicated.

1437   Thyroid carcinoma            107 - The related or qualifying claim-    N19 - Procedure code incidental   454 - Procedure code for services
       metastases uptake must       service was not identified on this claim. to primary procedure.             rendered.
       be billed same DOS as                                                        N161 - This drug-service-
       imaging whole body.                                                    supply is covered only when the
                                                                              associated service is covered.

1438   Related cardiac blood pool 107 - The related or qualifying claim-    N19 - Procedure code incidental     465 - Principal Procedure Code for
       imaging must be billed     service was not identified on this claim. to primary procedure.               Service(s) Rendered.
       same DOS as primary                                                        N161 - This drug-service-
       procedure.                                                           supply is covered only when the
                                                                            associated service is covered.


1439   Amino acids; single          B15 - This service-procedure requires    N20 - Service not payable with     258 - Days-units for procedure-
       qualitative, each specimen   that a qualifying service-procedure be   other service rendered on the      revenue code.
       not allowed same DOS as      received and covered. The qualifying     same date.
       multiple.                    other service-procedure has not been
                                    received-adjudicated.

1440   Bilirubin; total or direct   B15 - This service-procedure requires    N20 - Service not payable with     258 - Days-units for procedure-
       not allowed same DOS as      that a qualifying service-procedure be   other service rendered on the      revenue code.
       total and direct.            received and covered. The qualifying     same date.
                                    other service-procedure has not been
                                    received-adjudicated.

1441   2 to 5 amino acids not       B15 - This service-procedure requires    N20 - Service not payable with     258 - Days-units for procedure-
       allowed same DOS as 6 or     that a qualifying service-procedure be   other service rendered on the      revenue code.
       more amino acids.            received and covered. The qualifying     same date.
                                    other service-procedure has not been
                                    received-adjudicated.




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                                                     EOB Code Crosswalk to HIPAA Standard Codes

1442   One unit allowed with        119 - Benefit maximum for this time    No Mapping Required                259 - Frequency of service.
       base code, correct all       period or occurrence has been reached.
       units on your claim and
       resubmit.
1443   Specially priced claim       125 - Submission-billing error(s).       MA30 - Missing-incomplete-       21 - Missing or invalid information.
       through div. Of medical                                               invalid type of bill.
       assistance: bill type must
       be 111, 112, 113 or 114.
       Correct the bill type and
       resubmit claim to EDS.


1444   Group speech-language        B15 - This service-procedure requires    N20 - Service not payable with   258 - Days-units for procedure-
       therapy service not          that a qualifying service-procedure be   other service rendered on the    revenue code.
       allowed same date of         received and covered. The qualifying     same date.
       service as individual        other service-procedure has not been
       speech-language therapy      received-adjudicated.
       service.

1445   Group speech-language        B15 - This service-procedure requires    N20 - Service not payable with   258 - Days-units for procedure-
       therapy services             that a qualifying service-procedure be   other service rendered on the    revenue code.
       recouped. Group speech-      received and covered. The qualifying     same date.
       language treatment not       other service-procedure has not been
       allowed same day as          received-adjudicated.
       individual speech-
       language treatment.

1446   Only one Case                B15 - This service-procedure requires    N20 - Service not payable with   454 - Procedure code for services
       Management allowed per       that a qualifying service-procedure be   other service rendered on the    rendered.
       month. Case management       received and covered. The qualifying     same date.
       billed through another       other service-procedure has not been
       program has already been     received-adjudicated.
       paid this month.

1447   Stable isotope dilution not B15 - This service-procedure requires     N20 - Service not payable with   258 - Days-units for procedure-
       allowed to bill with        that a qualifying service-procedure be    other service rendered on the    revenue code.
       multiple.                   received and covered. The qualifying      same date.
                                   other service-procedure has not been
                                   received-adjudicated.


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                                                       EOB Code Crosswalk to HIPAA Standard Codes



1448   Parathyroid                    107 - The related or qualifying claim-    N19 - Procedure code incidental   465 - Principal Procedure Code for
       autotransplantation must       service was not identified on this claim. to primary procedure.             Service(s) Rendered.
       bill with primary proc.                                                       N161 - This drug-service-
                                                                                supply is covered only when the
                                                                                associated service is covered.

1449   Related procedures and         B15 - This service-procedure requires    N20 - Service not payable with     258 - Days-units for procedure-
       DHS dental clinic visit not    that a qualifying service-procedure be   other service rendered on the      revenue code.
       allowed on same DOS            received and covered. The qualifying     same date.
                                      other service-procedure has not been
                                      received-adjudicated.

1450   Reflects overpayments for 197 - Precertification-authorization-         N54 - Claim information is         64 - Re-pricing information.
       ach enhanced care PCS     notification absent.                          inconsistent with pre-certified-
       billed for non-authorized                                               authorized services.
       dates of service.


1451   Radiologic exam, knee;         B15 - This service-procedure requires    N20 - Service not payable with     258 - Days-units for procedure-
       minimum of 3 views not         that a qualifying service-procedure be   other service rendered on the      revenue code.
       allowed to bill with related   received and covered. The qualifying     same date.
       procedure.                     other service-procedure has not been
                                      received-adjudicated.

1452   Radiologic exam, knee,         B15 - This service-procedure requires    N20 - Service not payable with     258 - Days-units for procedure-
       complete view not allowed      that a qualifying service-procedure be   other service rendered on the      revenue code.
       to bill with related           received and covered. The qualifying     same date.
       procedure.                     other service-procedure has not been
                                      received-adjudicated.

1453   Intravascular ultrasound,    107 - The related or qualifying claim-    N19 - Procedure code incidental     465 - Principal Procedure Code for
       radiological interpretation, service was not identified on this claim. to primary procedure.               Service(s) Rendered.
       each add‟l vessel must be                                                    N161 - This drug-service-
       billed with primary proc.                                              supply is covered only when the
                                                                              associated service is covered.




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                                                      EOB Code Crosswalk to HIPAA Standard Codes



1454   Less severe duplicate.        18 - Duplicate claim-service.            M86 - Service denied because      54 - Duplicate of a previously
       professional.                                                          payment already made for same- processed claim-line.
                                                                              similar procedure within set time
                                                                              frame.

1455   Transluminal balloon          107 - The related or qualifying claim-    N19 - Procedure code incidental    465 - Principal Procedure Code for
       angioplasty, each             service was not identified on this claim. to primary procedure.              Service(s) Rendered.
       additional peripheral                                                          N161 - This drug-service-
       artery must bill with                                                   supply is covered only when the
       primary procedure                                                       associated service is covered.


1456   Transluminal                  107 - The related or qualifying claim-    N19 - Procedure code incidental    465 - Principal Procedure Code for
       artherectomy, ea add‟l        service was not identified on this claim. to primary procedure.              Service(s) Rendered.
       peripheral artery must bill                                                  N161 - This drug-service-
       with primary proc.                                                      supply is covered only when the
                                                                               associated service is covered.

1457   Transluminal                  107 - The related or qualifying claim-    N19 - Procedure code incidental    465 - Principal Procedure Code for
       artherectomy, each add‟l      service was not identified on this claim. to primary procedure.              Service(s) Rendered.
       visceral artery must bill                                                     N161 - This drug-service-
       with primary procedure.                                                 supply is covered only when the
                                                                               associated service is covered.


1458   Liver imaging procedures      B15 - This service-procedure requires    N20 - Service not payable with      258 - Days-units for procedure-
       not allowed to bill with      that a qualifying service-procedure be   other service rendered on the       revenue code.
       same DOS.                     received and covered. The qualifying     same date.
                                     other service-procedure has not been
                                     received-adjudicated.

1459   Liver imaging with            B15 - This service-procedure requires    N20 - Service not payable with      258 - Days-units for procedure-
       vascular flow not allowed     that a qualifying service-procedure be   other service rendered on the       revenue code.
       to bill with same DOS.        received and covered. The qualifying     same date.
                                     other service-procedure has not been
                                     received-adjudicated.




                                                                          Page 247
                                                     EOB Code Crosswalk to HIPAA Standard Codes



1460   Cardiac blood pool           B15 - This service-procedure requires    N20 - Service not payable with      258 - Days-units for procedure-
       imaging, gated equilibrium   that a qualifying service-procedure be   other service rendered on the       revenue code.
       not allowed to bill with     received and covered. The qualifying     same date.
       multiple studies.            other service-procedure has not been
                                    received-adjudicated.

1461   Performance of the test      97 - The benefit for this service is     M80 - Not covered when             454 - Procedure code for services
       physician supervision,       included in the payment-allowance for    performed during the same          rendered.
       report and interpretation    another service-procedure that has       session-date as a previously
       included in the cardiac      already been adjudicated.                processed service for the patient.
       stress test.

1462   Myocardial perfusion         107 - The related or qualifying claim-    N19 - Procedure code incidental    454 - Procedure code for services
       study must bill with         service was not identified on this claim. to primary procedure.              rendered.
       related procedure.                                                            N161 - This drug-service-
                                                                              supply is covered only when the
                                                                              associated service is covered.


1463   Only one special services    119 - Benefit maximum for this time    M86 - Service denied because      259 - Frequency of service.
       visit allowed per day.       period or occurrence has been reached. payment already made for same-
                                                                           similar procedure within set time                          612 -
                                                                           frame.                            Per Day Limit Amount

1464   Amino acids, qualitative     B15 - This service-procedure requires    N20 - Service not payable with      258 - Days-units for procedure-
       not allowed to bill with     that a qualifying service-procedure be   other service rendered on the       revenue code.
       multiple.                    received and covered. The qualifying     same date.
                                    other service-procedure has not been
                                    received-adjudicated.

1465   Chromatography,              B15 - This service-procedure requires    N20 - Service not payable with      258 - Days-units for procedure-
       quantitative, column not     that a qualifying service-procedure be   other service rendered on the       revenue code.
       allowed to bill with         received and covered. The qualifying     same date.
       multiple.                    other service-procedure has not been
                                    received-adjudicated.




                                                                        Page 248
                                                     EOB Code Crosswalk to HIPAA Standard Codes



1466   Immunoassay for analyte      B15 - This service-procedure requires    N20 - Service not payable with   258 - Days-units for procedure-
       other than antibody agent    that a qualifying service-procedure be   other service rendered on the    revenue code.
       antigen, multiple step       received and covered. The qualifying     same date.
       method not allowed to bill   other service-procedure has not been
       with single                  received-adjudicated.

1467   Immunoassay for analyte      B15 - This service-procedure requires    N20 - Service not payable with   258 - Days-units for procedure-
       other than infectious        that a qualifying service-procedure be   other service rendered on the    revenue code.
       agent for single step        received and covered. The qualifying     same date.
       method not allowed with      other service-procedure has not been
       multiple step method.        received-adjudicated.

1468   Chromatography,              B15 - This service-procedure requires    N20 - Service not payable with   258 - Days-units for procedure-
       quantitative, column,        that a qualifying service-procedure be   other service rendered on the    revenue code.
       multiple analytes not        received and covered. The qualifying     same date.
       allowed same DOS as          other service-procedure has not been
       single analyte.              received-adjudicated.

1469   Infectious agent analysis    B15 - This service-procedure requires    N20 - Service not payable with   258 - Days-units for procedure-
       not allowed with HIV         that a qualifying service-procedure be   other service rendered on the    revenue code.
       resistance testing.          received and covered. The qualifying     same date.
                                    other service-procedure has not been
                                    received-adjudicated.

1470   Molecular diagnostics not    B15 - This service-procedure requires    N20 - Service not payable with   258 - Days-units for procedure-
       allowed to bill with         that a qualifying service-procedure be   other service rendered on the    revenue code.
       multiplex.                   received and covered. The qualifying     same date.
                                    other service-procedure has not been
                                    received-adjudicated.

1471   Components of HIV            B15 - This service-procedure requires    N20 - Service not payable with   258 - Days-units for procedure-
       resistance testing           that a qualifying service-procedure be   other service rendered on the    revenue code.
       recouped. components         received and covered. The qualifying     same date.
       not allowed same day as      other service-procedure has not been
       HIV resistance testing.      received-adjudicated.




                                                                        Page 249
                                                      EOB Code Crosswalk to HIPAA Standard Codes

1472   IV infusion for therapy-      107 - The related or qualifying claim-    N19 - Procedure code incidental    454 - Procedure code for services
       diagnosis must be billed      service was not identified on this claim. to primary procedure.              rendered.
       with primary.                                                                N161 - This drug-service-
                                                                               supply is covered only when the
                                                                               associated service is covered.

1473   Use of vertical electrodes    107 - The related or qualifying claim-    N19 - Procedure code incidental 454 - Procedure code for services
       must bill with primary        service was not identified on this claim. to primary procedure.             rendered.
       procedures.                                                                     N161 - This drug-service-
                                                                               supply is covered only when the
                                                                               associated service is covered.


1474   Transcatheter placement     107 - The related or qualifying claim-    N19 - Procedure code incidental      454 - Procedure code for services
       of an intracoronary stent,  service was not identified on this claim. to primary procedure.                rendered.
       each add‟l vessel must bill                                                N161 - This drug-service-
       with primary procedure.                                               supply is covered only when the
                                                                             associated service is covered.

1475   Percutaneous                  107 - The related or qualifying claim-    N19 - Procedure code incidental    454 - Procedure code for services
       transluminal coronary         service was not identified on this claim. to primary procedure.              rendered.
       balloon angioplasty;                                                        N161 - This drug-service-
       single vessel must bill                                                 supply is covered only when the
       with primary procedure.                                                 associated service is covered.

1476   Percutaneous balloon        107 - The related or qualifying claim-    N19 - Procedure code incidental 454 - Procedure code for services
       valvuloplasty; aortic valve service was not identified on this claim. to primary procedure.              rendered.
       must bill with primary                                                         N161 - This drug-service-
       procedure.                                                            supply is covered only when the
                                                                             associated service is covered.


1477   Percutaneous                107 - The related or qualifying claim-      N19 - Procedure code incidental    454 - Procedure code for services
       transluminal pulmonary      service was not identified on this claim.   to primary procedure.              rendered.
       artery balloon angioplasty,                                                    N161 - This drug-service-
       each add‟l vessel must bill                                             supply is covered only when the
       with primary procedure.                                                 associated service is covered.




                                                                         Page 250
                                                      EOB Code Crosswalk to HIPAA Standard Codes

1478   Doppler                       107 - The related or qualifying claim-    N19 - Procedure code incidental    454 - Procedure code for services
       echocardiography, pulsed      service was not identified on this claim. to primary procedure.              rendered.
       wave; complete must bill                                                     N161 - This drug-service-
       with related procedure.                                                 supply is covered only when the
                                                                               associated service is covered.

1479   Doppler                       107 - The related or qualifying claim-    N19 - Procedure code incidental    454 - Procedure code for services
       echocardiography, pulsed      service was not identified on this claim. to primary procedure.              rendered.
       wave: follow up must bill                                                     N161 - This drug-service-
       with related procedure.                                                 supply is covered only when the
                                                                               associated service is covered.


1480   Pulmonary stress testing,     B15 - This service-procedure requires    N20 - Service not payable with      454 - Procedure code for services
       simple not allowed to bill    that a qualifying service-procedure be   other service rendered on the       rendered.
       with complex.                 received and covered. The qualifying     same date.
                                     other service-procedure has not been
                                     received-adjudicated.

1481   Cardiac stress test           97 - The benefit for this service is     M80 - Not covered when             454 - Procedure code for services
       includes performance of       included in the payment-allowance for    performed during the same          rendered.
       the test, physician           another service-procedure that has       session-date as a previously
       supervision, interpretation   already been adjudicated.                processed service for the patient.
       and report.

1482   Intraoperative                107 - The related or qualifying claim-    N19 - Procedure code incidental    454 - Procedure code for services
       neurophysilogy testing,       service was not identified on this claim. to primary procedure.              rendered.
       per hour must be billed                                                        N161 - This drug-service-
       with primary procedure.                                                 supply is covered only when the
                                                                               associated service is covered.


1483   Doppler color flow velocity 107 - The related or qualifying claim-    N19 - Procedure code incidental      454 - Procedure code for services
       mapping must bill with      service was not identified on this claim. to primary procedure.                rendered.
       related procedure.                                                           N161 - This drug-service-
                                                                             supply is covered only when the
                                                                             associated service is covered.




                                                                          Page 251
                                                       EOB Code Crosswalk to HIPAA Standard Codes

1484   Hepatitis a vaccine,          107 - The related or qualifying claim-    N19 - Procedure code incidental     454 - Procedure code for services
       pediatric-adolescent          service was not identified on this claim. to primary procedure.               rendered.
       dosage, 2 dose schedule                                                       N161 - This drug-service-
       must bill with primary                                                  supply is covered only when the
       procedure.                                                              associated service is covered.


1485   Hepatitis a vaccine, adult    107 - The related or qualifying claim-    N19 - Procedure code incidental     454 - Procedure code for services
       dosage, for intramuscular     service was not identified on this claim. to primary procedure.               rendered.
       use must bill with primary                                                     N161 - This drug-service-
       procedure.                                                              supply is covered only when the
                                                                               associated service is covered.


1486   Impotence drugs not           197 - Precertification-authorization-      N54 - Claim information is         475 - Procedure code not valid for
       covered for males under       notification absent.                       inconsistent with pre-certified-   patient age.
       age 25, The physician (or                                                authorized services.
       designee) must obtain
       prior approval.

1487   Electronic analysis of    107 - The related or qualifying claim-    N19 - Procedure code incidental         454 - Procedure code for services
       implanted neurostimulator service was not identified on this claim. to primary procedure.                   rendered.
       pulse generated must bill                                                N161 - This drug-service-
       with primary procedure.                                             supply is covered only when the
                                                                           associated service is covered.

1488   Intravascular doppler         107 - The related or qualifying claim-    N19 - Procedure code incidental     454 - Procedure code for services
       velocity must bill with       service was not identified on this claim. to primary procedure.               rendered.
       primary procedure.                                                          N161 - This drug-service-
                                                                               supply is covered only when the
                                                                               associated service is covered.

1489   Rotavirus vaccine,            107 - The related or qualifying claim-    N19 - Procedure code incidental     454 - Procedure code for services
       tentravalent, live for oral   service was not identified on this claim. to primary procedure.               rendered.
       use must bill with primary                                                       N161 - This drug-
       procedure.                                                              service-supply is covered only
                                                                               when the associated service is
                                                                               covered.



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                                                       EOB Code Crosswalk to HIPAA Standard Codes



1490   Use of operating               107 - The related or qualifying claim-    N20 - Service not payable with      454 - Procedure code for services
       microscope not allowed         service was not identified on this claim. other service rendered on the       rendered.
       with primary procedure.                                                  same date.

1491   Prolonged physician            107 - The related or qualifying claim-    N19 - Procedure code incidental     454 - Procedure code for services
       service in the inpatient       service was not identified on this claim. to primary procedure.               rendered.
       setting must bill with                                                         N161 - This drug-service-
       primary procedure.                                                       supply is covered only when the
                                                                                associated service is covered.


1492   Prolonged physician            107 - The related or qualifying claim-    N19 - Procedure code incidental     454 - Procedure code for services
       service in the office must     service was not identified on this claim. to primary procedure.               rendered.
       bill with primary                                                              N161 - This drug-service-
       procedure.                                                               supply is covered only when the
                                                                                associated service is covered.


1493   Critical care, evaluation      107 - The related or qualifying claim-    N19 - Procedure code incidental     454 - Procedure code for services
       and mgmt must bill with        service was not identified on this claim. to primary procedure.               rendered.
       primary procedure.                                                           N161 - This drug-service-
                                                                                supply is covered only when the
                                                                                associated service is covered.

1494   Payment included in          97 - The benefit for this service is         M80 - Not covered when             54 - Duplicate of a previously
       multiple tendons, bilateral. included in the payment-allowance for        performed during the same          processed claim-line.
                                    another service-procedure that has           session-date as a previously
                                    already been adjudicated.                    processed service for the patient.

1495   Chemotherapy                  107 - The related or qualifying claim-      N19 - Procedure code incidental    454 - Procedure code for services
       administration, intra-        service was not identified on this claim.   to primary procedure.              rendered.
       arterial; infusion tech, 1 to                                                 N161 - This drug-service-
       8 hours; each additional                                                  supply is covered only when the
       hour must bill with                                                       associated service is covered.
       primary procedure.




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                                                      EOB Code Crosswalk to HIPAA Standard Codes



1496   Chemotherapy                107 - The related or qualifying claim-      N19 - Procedure code incidental    454 - Procedure code for services
       administration,             service was not identified on this claim.   to primary procedure.              rendered.
       intravenous, infusion tech,                                                N161 - This drug-service-
       up to 1 hour must bill with                                             supply is covered only when the
       primary procedure.                                                      associated service is covered.

1497   Each additional hour of       107 - The related or qualifying claim-    N19 - Procedure code incidental    454 - Procedure code for services
       physician attendance          service was not identified on this claim. to primary procedure.              rendered.
       must bill with primary                                                         N161 - This drug-service-
       procedure.                                                              supply is covered only when the
                                                                               associated service is covered.


1498   Strabismus surgery, repair 107 - The related or qualifying claim-    N19 - Procedure code incidental       454 - Procedure code for services
       of detached extraocular    service was not identified on this claim. to primary procedure.                 rendered.
       muscle must bill with                                                  N161 - This drug-service-
       primary procedure.                                                   supply is covered only when the
                                                                            associated service is covered.

1499   Bill Medicare Part B or       22 - This care may be covered by          MA04 - Secondary payment           116 - Claim submitted to incorrect
       Prescription Drug Plan        another payer per coordination of         cannot be considered without the payer.
                                     benefits.                                 identity of or payment information
                                                                               from the primary payer. The
                                                                               information was either not
                                                                               reported or was illegible.

1500   Medicaid does not make        B15 - This service-procedure requires     N20 - Service not payable with     454 - Procedure code for services
       separate payment for          that a qualifying service-procedure be    other service rendered on the      rendered.
       procedures that are           received and covered. The qualifying      same date.
       components of a more          other service-procedure has not been
       comprehensive service         received-adjudicated.
       already paid
                 for the same
       date of service.




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                                                      EOB Code Crosswalk to HIPAA Standard Codes

1501   Enterectomy, resection of     107 - The related or qualifying claim-    N19 - Procedure code incidental   454 - Procedure code for services
       small intestine, each add‟l   service was not identified on this claim. to primary procedure.             rendered.
       resection must bill with                                                      N161 - This drug-service-
       primary procedure.                                                      supply is covered only when the
                                                                               associated service is covered.

1502   Components denied.            B15 - This service-procedure requires    N20 - Service not payable with     454 - Procedure code for services
       Rebill using 81000 as the     that a qualifying service-procedure be   other service rendered on the      rendered.
       complete procedure,           received and covered. The qualifying     same date.
       versus multiple               other service-procedure has not been
       components of urinalysis.     received-adjudicated.

1503   Diskectomy, cervical, each 107 - The related or qualifying claim-    N19 - Procedure code incidental 465 - Principal Procedure Code for
       add‟l interspace must bill service was not identified on this claim. to primary procedure.             Service(s) Rendered.
       with primary procedure.                                                      N161 - This drug-service-
                                                                            supply is covered only when the
                                                                            associated service is covered.


1504   Cytopathology definitive      107 - The related or qualifying claim-    N19 - Procedure code incidental   454 - Procedure code for services
       hormonal evaluation           service was not identified on this claim. to primary procedure.             rendered.
       related p codes must be                                                     N161 - This drug-service-
       billed same DOS.                                                        supply is covered only when the
                                                                               associated service is covered.

1505   Tenotomy, single included 97 - The benefit for this service is         M80 - Not covered when             454 - Procedure code for services
       in multiple.              included in the payment-allowance for        performed during the same          rendered.
                                 another service-procedure that has           session-date as a previously
                                 already been adjudicated.                    processed service for the patient.

1506   Procedure denied.             107 - The related or qualifying claim-    N19 - Procedure code incidental   465 - Principal Procedure Code for
       bronchoplasty procedure       service was not identified on this claim. to primary procedure.             Service(s) Rendered.
       only allowed when billed                                                      N161 - This drug-service-
       in addition to primary                                                  supply is covered only when the
       surgery procedure.                                                      associated service is covered.
       Review claim, correct and
       resubmit as a new claim.



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                                                        EOB Code Crosswalk to HIPAA Standard Codes


1507   Multiple osteotomy of           B15 - This service-procedure requires    N20 - Service not payable with    258 - Days-units for procedure-
       metatarsals not allowed         that a qualifying service-procedure be   other service rendered on the     revenue code.
       on same date.                   received and covered. The qualifying     same date.
                                       other service-procedure has not been
                                       received-adjudicated.

1508   Multiple arthrodesis      B15 - This service-procedure requires          N20 - Service not payable with    258 - Days-units for procedure-
       procedures not allowed on that a qualifying service-procedure be         other service rendered on the     revenue code.
       same date.                received and covered. The qualifying           same date.
                                 other service-procedure has not been
                                 received-adjudicated.

1509   Multiple related          B15 - This service-procedure requires          N20 - Service not payable with    258 - Days-units for procedure-
       arthrodesis procedures    that a qualifying service-procedure be         other service rendered on the     revenue code.
       not allowed on same date. received and covered. The qualifying           same date.
                                 other service-procedure has not been
                                 received-adjudicated.

1510   Multiple capsulodesis     B15 - This service-procedure requires          N20 - Service not payable with    258 - Days-units for procedure-
       procedures not allowed on that a qualifying service-procedure be         other service rendered on the     revenue code.
       same date.                received and covered. The qualifying           same date.
                                 other service-procedure has not been
                                 received-adjudicated.

1511   Tenotomy, multiple, 1 leg       97 - The benefit for this service is     M80 - Not covered when             454 - Procedure code for services
       included in bilateral.          included in the payment-allowance for    performed during the same          rendered.
                                       another service-procedure that has       session-date as a previously
                                       already been adjudicated.                processed service for the patient.

1512   Medicaid has paid the           119 - Benefit maximum for this time    N362 - The number of Days or        259 - Frequency of service.
       maximum allowable for           period or occurrence has been reached. Units of Service exceeds our
       procedure.                                                             acceptable maximum
1513   Professional treatment          119 - Benefit maximum for this time    N362 - The number of Days or        259 - Frequency of service.
       services in crisis facilities   period or occurrence has been reached. Units of Service exceeds our
       limited to 15 consecutive                                              acceptable maximum
       days. Correct claim and
       rebill.



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                                                    EOB Code Crosswalk to HIPAA Standard Codes




1514   Separate reimbursement      B15 - This service-procedure requires    N20 - Service not payable with     258 - Days-units for procedure-
       not allowed when other      that a qualifying service-procedure be   other service rendered on the      revenue code.
       services are paid on the    received and covered. The qualifying     same date.
       same date of service.       other service-procedure has not been
                                   received-adjudicated.

1515   Bypass graft, composite     107 - The related or qualifying claim-    N19 - Procedure code incidental   465 - Principal Procedure Code for
       must bill with primary      service was not identified on this claim. to primary procedure.             Service(s) Rendered.
       procedure.                                                                N161 - This drug-service-
                                                                             supply is covered only when the
                                                                             associated service is covered.

1516   Foreskin manipulation       B15 - This service-procedure requires    N20 - Service not payable with     258 - Days-units for procedure-
       included in related         that a qualifying service-procedure be   other service rendered on the      revenue code.
       procedure same DOS.         received and covered. The qualifying     same date.
                                   other service-procedure has not been
                                   received-adjudicated.

1517   Removal of vitreous         B15 - This service-procedure requires    N20 - Service not payable with     258 - Days-units for procedure-
       included in extracapsular   that a qualifying service-procedure be   other service rendered on the      revenue code.
       cataract procedure same     received and covered. The qualifying     same date.
       DOS                         other service-procedure has not been
                                   received-adjudicated.

1518   Enterolysis included in     B15 - This service-procedure requires    N20 - Service not payable with     258 - Days-units for procedure-
       intestinal procedures       that a qualifying service-procedure be   other service rendered on the      revenue code.
       same date of service        received and covered. The qualifying     same date.
                                   other service-procedure has not been
                                   received-adjudicated.




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                                                      EOB Code Crosswalk to HIPAA Standard Codes

1519   Component of procedure        B15 - This service-procedure requires    N20 - Service not payable with      454 - Procedure code for services
       (either technical or          that a qualifying service-procedure be   other service rendered on the       rendered.
       professional denied           received and covered. The qualifying     same date.
       because same procedure        other service-procedure has not been             N184 - Rebill technical
       code has already been         received-adjudicated.                    and professional components
                                                                              separately.
       reimbursed as a complete
       procedure for this date of
       service.


1520   Technical component of        B15 - This service-procedure requires    N20 - Service not payable with      454 - Procedure code for services
       this procedure has already    that a qualifying service-procedure be   other service rendered on the       rendered.
       been reimbursed for this      received and covered. The qualifying     same date.
       date. Rebill for              other service-procedure has not been          N200 - The professional
       professional component        received-adjudicated.                    component must be billed
       only.                                                                  separately.

1521   Professional component        B15 - This service-procedure requires    N20 - Service not payable with      454 - Procedure code for services
       of this procedure code has    that a qualifying service-procedure be   other service rendered on the       rendered.
       already been reimbursed       received and covered. The qualifying     same date.
       for this date. Rebill for     other service-procedure has not been           N195 - The technical
       technical component only.     received-adjudicated.                    component must be billed
                                                                              separately


1522   No payment for add-on         107 - The related or qualifying claim-    N19 - Procedure code incidental    454 - Procedure code for services
       (zzz) code allowed if         service was not identified on this claim. to primary procedure.              rendered.
       'primary' code in series is                                                  N161 - This drug-service-
       not paid for the same                                                   supply is covered only when the
       DOS, same provider.                                                     associated service is covered.

1523   No payment for add-on         107 - The related or qualifying claim-    N19 - Procedure code incidental    454 - Procedure code for services
       (zzz) code allowed if         service was not identified on this claim. to primary procedure.              rendered.
       'primary' code in series is                                                    N161 - This drug-service-
       not paid for the same                                                   supply is covered only when the
       DOS, same provider.                                                     associated service is covered.




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                                                      EOB Code Crosswalk to HIPAA Standard Codes



1524   No payment for add-on         107 - The related or qualifying claim-    N19 - Procedure code incidental 454 - Procedure code for services
       (zzz) code allowed if         service was not identified on this claim. to primary procedure.             rendered.
       'primary' code in series is                                                     N161 - This drug-service-
       not paid for the same                                                   supply is covered only when the
       DOS, same provider.                                                     associated service is covered.


1525   Related removal of venous B15 - This service-procedure requires        N20 - Service not payable with     258 - Days-units for procedure-
       access device not allowed that a qualifying service-procedure be       other service rendered on the      revenue code.
       on same DOS.              received and covered. The qualifying         same date.
                                 other service-procedure has not been
                                 received-adjudicated.

1526   Related removal of venous B15 - This service-procedure requires        N20 - Service not payable with     258 - Days-units for procedure-
       access device not allowed that a qualifying service-procedure be       other service rendered on the      revenue code.
       on same DOS.              received and covered. The qualifying         same date.
                                 other service-procedure has not been
                                 received-adjudicated.

1527   No payment for add-on         107 - The related or qualifying claim-    N19 - Procedure code incidental   454 - Procedure code for services
       (zzz) code allowed if         service was not identified on this claim. to primary procedure.             rendered.
       'primary' code in series is                                               N161 - This drug-service-
       not paid for the same                                                   supply is covered only when the
       DOS, same provider.                                                     associated service is covered.

1528   Reimbursement for             97 - The benefit for this service is     M80 - Not covered when             454 - Procedure code for services
       monthly rental of DME         included in the payment-allowance for    performed during the same          rendered.
       includes payment for          another service-procedure that has       session-date as a previously
       related supplies.             already been adjudicated.                processed service for the patient.

1529   Payment for supplies          B15 - This service-procedure requires    M86 - Service denied because      258 - Days-units for procedure-
       recouped to allow             that a qualifying service-procedure be   payment already made for same- revenue code.
       reimbursement for             received and covered. The qualifying     similar procedure within set time
       monthly rental of related     other service-procedure has not been     frame.
       DME.                          received-adjudicated.




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                                                      EOB Code Crosswalk to HIPAA Standard Codes



1530   No payment for add-on         107 - The related or qualifying claim-    N19 - Procedure code incidental   454 - Procedure code for services
       (size) code allowed if        service was not identified on this claim. to primary procedure.             rendered.
       'primary' code in series is                                                 N161 - This drug-service-
       not paid for the same                                                   supply is covered only when the
       DOS, same provider.                                                     associated service is covered.

1531    No payment for add-on        107 - The related or qualifying claim-    N19 - Procedure code incidental   454 - Procedure code for services
       (size) code allowed if        service was not identified on this claim. to primary procedure.             rendered.
       'primary' code in series is                                                   N161 - This drug-service-
       not paid for the same                                                   supply is covered only when the
       DOS, same provider.                                                     associated service is covered.

1532   Residential evaluation        B15 - This service-procedure requires    N20 - Service not payable with     258 - Days-units for procedure-
       service not allowed same      that a qualifying service-procedure be   other service rendered on the      revenue code.
       DOS as CAP Case               received and covered. The qualifying     same date.
       Management.                   other service-procedure has not been
                                     received-adjudicated.

1533   Residential evaluation        B15 - This service-procedure requires    N20 - Service not payable with     258 - Days-units for procedure-
       service recouped. Service     that a qualifying service-procedure be   other service rendered on the      revenue code.
       not allowed same DOS as       received and covered. The qualifying     same date.
       CAP case management.          other service-procedure has not been
                                     received-adjudicated.

1534   Residential evaluation    B15 - This service-procedure requires        N20 - Service not payable with     258 - Days-units for procedure-
       services not allowed same that a qualifying service-procedure be       other service rendered on the      revenue code.
       DOS as HRI.               received and covered. The qualifying         same date.
                                 other service-procedure has not been
                                 received-adjudicated.

1535   Residential evaluation        B15 - This service-procedure requires    M2 - Not paid separately when      258 - Days-units for procedure-
       services not allowed          that a qualifying service-procedure be   the patient is an inpatient.       revenue code.
       during inpatient or nursing   received and covered. The qualifying
       home stay.                    other service-procedure has not been
                                     received-adjudicated.




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                                                     EOB Code Crosswalk to HIPAA Standard Codes




1536   Residential evaluation       B15 - This service-procedure requires     M2 - Not paid separately when         258 - Days-units for procedure-
       service recouped. Service    that a qualifying service-procedure be    the patient is an inpatient.          revenue code.
       not allowed during           received and covered. The qualifying
       inpatient or nursing home    other service-procedure has not been
       stay.                        received-adjudicated.

1537   Units were changed to        119 - Benefit maximum for this time       N362 - The number of Days or          258 - Days-units for procedure-
       allow a maximum of 14        period or occurrence has been reached. Units of Service exceeds our             revenue code.
       units per day.                                                         acceptable maximum.                                259 - Frequency of
                                                                              N381 - Consult our contractual        service.
                                                                              agreement for restrictions-billing-
                                                                              payment information related to               612 - Per Day Limit Amount
                                                                              these charges
1538   Graft procedure denied.      107 - The related or qualifying claim-    N19 - Procedure code incidental       454 - Procedure code for services
       Graft procedure only         service was not identified on this claim. to primary procedure.                 rendered.
       allowed when billed in                                                          N161 - This drug-
       addition to spinal                                                     service-supply is covered only
       operative session, same                                                when the associated service is
       date of service.                                                       covered.

1539   D1203 is limited to the      B15 - This service-procedure requires     N20 - Service not payable with        258 - Days-units for procedure-
       application of topical       that a qualifying service-procedure be    other service rendered on the         revenue code.
       fluoride varnish. Medicaid   received and covered. The qualifying      same date.
       does not cover other         other service-procedure has not been
       topical fluorides as a       received-adjudicated.
       separate procedure.

1540   D1203 is limited to the      125 - Submission-billing error(s).        MA66 - Missing-incomplete-            21 - Missing or invalid information.
       application of topical                                                 invalid principal procedure code
       fluoride varnish. Rebill                                               or date.
       prophy and fluoride with
       correct combination
       procedure code (D1201 or
       D1205).




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                                                    EOB Code Crosswalk to HIPAA Standard Codes

1541   E-M visit not allowed same B15 - This service-procedure requires    N20 - Service not payable with     258 - Days-units for procedure-
       date of service as clinic  that a qualifying service-procedure be   other service rendered on the      revenue code.
       visit.                     received and covered. The qualifying     same date.
                                  other service-procedure has not been
                                  received-adjudicated.

1542   Clinic visit not allowed   B15 - This service-procedure requires    N20 - Service not payable with     258 - Days-units for procedure-
       same date of service as E- that a qualifying service-procedure be   other service rendered on the      revenue code.
       M visit.                   received and covered. The qualifying     same date.
                                  other service-procedure has not been
                                  received-adjudicated.

1543   Only 14 units allowed per   119 - Benefit maximum for this time    N362 - The number of Days or        259 - Frequency of service.
       date of service.            period or occurrence has been reached. Units of Service exceeds our
                                                                          acceptable maximum                                            612 -
                                                                                                              Per Day Limit Amount
1544   Recipient has reached       119 - Benefit maximum for this time    N362 - The number of Days or        259 - Frequency of service.
       21st birthday and has       period or occurrence has been reached. Units of Service exceeds our
       exceeded 8 unmanaged                                               acceptable maximum
       visits. PA from Value
       Options (888-510-1150) is
       required. Retrospective
       review is not allowed.


1545   Additional compound         18 - Duplicate claim-service.           M86 - Service denied because      259 - Frequency of service.
       ingredient or repeat                                                payment already made for same-
       medication, professional                                            similar procedure within set time
       fee previously paid.                                                frame.

1546   Psychotherapy & E-M         97 - The benefit for this service is    M80 - Not covered when             54 - Duplicate of a previously
       cannot be billed as         included in the payment-allowance for   performed during the same          processed claim-line.
       separate procedure.         another service-procedure that has      session-date as a previously
       Previously billed E-M       already been adjudicated.               processed service for the patient.
       procedure will be
       recouped. Rebill the
       appropriate
       psychotherapy code that
       includes medical E-M.


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                                                   EOB Code Crosswalk to HIPAA Standard Codes



1547   Service recouped. E-M       97 - The benefit for this service is    M80 - Not covered when             54 - Duplicate of a previously
       billed on same date of      included in the payment-allowance for   performed during the same          processed claim-line.
       service as psychotherapy.   another service-procedure that has      session-date as a previously
       Rebill using the            already been adjudicated.               processed service for the patient.
       appropriate
       psychotherapy code that
       includes medical
       evaluation and
       management.
1548   Exceeds unmanaged           119 - Benefit maximum for this time    M86 - Service denied because      259 - Frequency of service.
       mental health visit         period or occurrence has been reached. payment already made for same-
       limitation.                                                        similar procedure within set time
                                                                          frame.

1549   Recipient must have         B5 - Coverage-program guidelines        N19 - Procedure code incidental    21 - Missing or invalid information.
       received EPO therapy on     were not met or were exceeded.          to primary procedure.                             454 - Procedure
       the same date of service                                                          N161 - This drug-    code for services rendered.
       or within 3 months prior to                                         service-supply is covered only
       the date of service of                                              when the associated service is
       ferrlecit or iron sucrose.                                          covered.


1550   DME equipment allowed       108 - Rent-purchase guidelines were     M86 - Service denied because      259 - Frequency of service.
       twice per year.             not met.                                payment already made for same-
                                                                           similar procedure within set time
                                                                           frame.

1551   8 psychiatric outpatient    119 - Benefit maximum for this time    M86 - Service denied because      259 - Frequency of service.
       visits allowed without      period or occurrence has been reached. payment already made for same-
       prior approval.                                                    similar procedure within set time
                                                                          frame.
                                                                          N357 - Time frame requirements
                                                                          between this service-procedure-
                                                                          supply and a related service-
                                                                          procedure-supply have not been
                                                                          met




                                                                      Page 263
                                                    EOB Code Crosswalk to HIPAA Standard Codes

1552   DME equipment allowed       108 - Rent-purchase guidelines were      M86 - Service denied because      259 - Frequency of service.
       twice per three years.      not met.                                 payment already made for same-
                                                                            similar procedure within set time
                                                                            frame.

1553   REFER to 1998 CPT for       125 - Submission-billing error(s).       MA66 - Missing-incomplete-            21 - Missing or invalid information.
       HIV viral load codes and                                             invalid principal procedure code
       refile.                                                              or date.
1554   Service recouped. nursing   B15 - This service-procedure requires    M2 - Not paid separately when         258 - Days-units for procedure-
       home-ach service not        that a qualifying service-procedure be   the patient is an inpatient.          revenue code.
       allowed during inpatient    received and covered. The qualifying
       stay.                       other service-procedure has not been
                                   received-adjudicated.

1555   DME equipment allowed       108 - Rent-purchase guidelines were      M86 - Service denied because      259 - Frequency of service.
       twice in two years.         not met.                                 payment already made for same-
                                                                            similar procedure within set time
                                                                            frame.

1556   Other diagnosis code 6      146 - Diagnosis was invalid for the      M81 - You are required to code        255 - Diagnosis code.
       must be further             date(s) of service reported.             to the highest level of specificity
       subdivided. (the code
       must have four or five
       digits)
1557   Other diagnosis code 7      146 - Diagnosis was invalid for the      M81 - You are required to code        255 - Diagnosis code.
       must be further             date(s) of service reported.             to the highest level of specificity
       subdivided. (the code
       must have four or five
       digits)
1558   Other diagnosis code 8      146 - Diagnosis was invalid for the      M81 - You are required to code        255 - Diagnosis code.
       must be further             date(s) of service reported.             to the highest level of specificity
       subdivided. (the code
       must have four or five
       digits)
1559   Other diagnosis code 9      146 - Diagnosis was invalid for the      M81 - You are required to code        255 - Diagnosis code.
       must be further             date(s) of service reported.             to the highest level of specificity
       subdivided. (the code
       must have four or five
       digits)

                                                                         Page 264
                                                     EOB Code Crosswalk to HIPAA Standard Codes


1560   Provider must split details 125 - Submission-billing error(s).        MA130 - Your claim contains       21 - Missing or invalid information.
       between UB with the                                                   incomplete and-or invalid                     481 - Claim submission
       revenue code and CMS-                                                 information, and no appeal rights format is invalid.
       1500 with the HCPCS code.                                             are afforded because the claim is
                                                                             unprocessable. Please submit a
                                                                             new claim with the complete-
                                                                             correct information.

1561   RES not allowed same         B15 - This service-procedure requires    N20 - Service not payable with     258 - Days-units for procedure-
       DOS as maternity care        that a qualifying service-procedure be   other service rendered on the      revenue code.
       coordination.                received and covered. The qualifying     same date.
                                    other service-procedure has not been
                                    received-adjudicated.

1562   RES recouped. service not    B15 - This service-procedure requires    N20 - Service not payable with     258 - Days-units for procedure-
       allowed during same DOS      that a qualifying service-procedure be   other service rendered on the      revenue code.
       as maternity care            received and covered. The qualifying     same date.
       coordination.                other service-procedure has not been
                                    received-adjudicated.

1563   Revenue Code for Skilled     125 - Submission-billing error(s).       M50 - Missing-incomplete-invalid   454 - Procedure code for services
       Nursing Visit has been                                                revenue code(s).                   rendered.             455 -
       billed with an invalid                                                                M51 - Missing-     Revenue code for services
       HCPCS code                                                            incomplete-invalid, procedure      rendered.
                                                                             code(s) and-or dates

1564   RES recouped. service not B15 - This service-procedure requires       N20 - Service not payable with     258 - Days-units for procedure-
       allowed same DOS as HRI. that a qualifying service-procedure be       other service rendered on the      revenue code.
                                 received and covered. The qualifying        same date.
                                 other service-procedure has not been
                                 received-adjudicated.

1565   Miscellaneous charges not B15 - This service-procedure requires       N20 - Service not payable with     454 - Procedure code for services
       allowed with prolonged     that a qualifying service-procedure be     other service rendered on the      rendered.
       services or critical care. received and covered. The qualifying       same date.
                                  other service-procedure has not been
                                  received-adjudicated.



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                                                     EOB Code Crosswalk to HIPAA Standard Codes




1566   Adjustment cannot be      125 - Submission-billing error(s).          MA130 - Your claim contains       21 - Missing or invalid information.
       processed. Explanation to                                             incomplete and-or invalid
       follow.                                                               information, and no appeal rights
                                                                             are afforded because the claim is
                                                                             unprocessable. Please submit a
                                                                             new claim with the complete-
                                                                             correct information.

1567   Alcohol-drug intensive       B15 - This service-procedure requires    N20 - Service not payable with     258 - Days-units for procedure-
       outpatient services not      that a qualifying service-procedure be   other service rendered on the      revenue code.
       allowed during inpatient     received and covered. The qualifying     same date.
       stay                         other service-procedure has not been
                                    received-adjudicated.

1568   Personal Care Services      16 - Claim-service lacks information       N34 - Incorrect claim form-       481 - Claim-submission format is
       and Private Duty Nursing    which is needed for adjudication.         format for this service.           invalid.
       are no longer billed on the
       UB. Rebill on the CMS
       1500.

1569   PCS not allowed same         B15 - This service-procedure requires    N20 - Service not payable with     259 - Frequency of service.
       days as HRI-RI facility.     that a qualifying service-procedure be   other service rendered on the
                                    received and covered. The qualifying     same date.
                                    other service-procedure has not been
                                    received-adjudicated.

1570   Recoup PCS when HRI-RI       B15 - This service-procedure requires    N20 - Service not payable with     259 - Frequency of service.
       is paid.                     that a qualifying service-procedure be   other service rendered on the
                                    received and covered. The qualifying     same date.
                                    other service-procedure has not been
                                    received-adjudicated.




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1571   Adj. Denied. Records do    B13 - Previously paid. Payment for this   N20 - Service not payable with          267 - Number of miles patient was
       not support individual     claim-service may have been provided      other service rendered on the           transported
       transports. A recoupment in a previous payment.                      same date.
       has been initiated for the                                            N56 - Procedure code billed is         294 - Supporting documentation.
       individual transport                                                 not correct-valid for the services      472 - Ambulance Run Sheet
       previously paid. Resubmit                                            billed or the date of service billed.
       claim for round trip trans
       after recoup occurs                                                                             N152 -
                                                                             Missing-incomplete-invalid
                                                                            replacement claim information.

1572   Units cutback. Units billed 119 - Benefit maximum for this time    N362 - The number of Days or              258 - Days-units for procedure-
       exceed maximum units        period or occurrence has been reached. Units of Service exceeds our              revenue code.
       allowed                                                            acceptable maximum.                                      259 - Frequency of
                                                                          N381 - Consult our contractual            service.
                                                                          agreement for restrictions-billing-
                                                                          payment information related to
                                                                          these charges
1573                               B15 - This service-procedure requires N20 - Service not payable with             258 - Days-units for procedure-
       Case Management paid to that a qualifying service-procedure be     other service rendered on the             revenue code.
       DMH recouped to allow       received and covered. The qualifying   same date.
       payment for Case            other service-procedure has not been
       Management to CAP           received-adjudicated.
       provider for the same date
       of service
1574                               119 - Benefit maximum for this time    M86 - Service denied because              258 - Days-units for procedure-
       Adjustment of immediate     period or occurrence has been reached. payment already made for same-            revenue code.
       dentures not allowed until                                         similar procedure within set time
       six months after receipt of                                        frame.                                    454 - Procedure code for services
       denture per State limit                                                                                      rendered.
1575                               B15 - This service-procedure requires N20 - Service not payable with             259 - Frequency of service.
                                   that a qualifying service-procedure be other service rendered on the
                                   received and covered. The qualifying   same date.
                                   other service-procedure has not been
       Inpatient services billed   received-adjudicated.
       same day PDN, not allowed
1576                               177 - Patient has not met the required N30 - Patient ineligible for this         90 - Entity not eligible for medical
       CAP Recipients are not      eligibility requirements.              service.                                  benefits for submitted dates of
       eligible for at-risk case                                                                                    service.
       management services

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                                                      EOB Code Crosswalk to HIPAA Standard Codes




1577                                 97 - The benefit for this service is      M80 - Not covered when             454 - Procedure code for services
       Canal and pulpotomy           included in the payment-allowance for     performed during the same          rendered.
       procedures not allowed        another service-procedure that has        session-date as a previously
       for the same tooth, same      already been adjudicated.                 processed service for the patient.
       date of service
1578                               97 - The benefit for this service is        M80 - Not covered when             454 - Procedure code for services
                                   included in the payment-allowance for       performed during the same          rendered.
       Pulpotomy procedure         another service-procedure that has          session-date as a previously
       included in reimbursement already been adjudicated.                     processed service for the patient.
       for root canal
1579                               119 - Benefit maximum for this time         M86 - Service denied because      258 - Days-units for procedure-
       Adjustment of immediate     period or occurrence has been reached.      payment already made for same- revenue code.
       dentures not allowed until                                              similar procedure within set time
       six months after receipt of                                             frame.                            454 - Procedure code for services
       denture per State limit                                                                                   rendered.
1580   Recipient must be           107 - The related or qualifying claim-      N161 - This drug-service-supply 454 - Procedure code for services
       undergoing chronic          service was not identified on this claim.   is covered only when the          rendered.
       hemodialysis (RC821).                                                   associated service is covered.

1581   Hospice patient. Contact      96 - Non-covered charge(s).               MA66 - Missing-incomplete-         457 - Non-Covered Day(s)
       hospice responsible for                                                 invalid principal procedure code
       patient care. Refile claim                                              or date.
       only for date(s) of service
       not covered by Hospice
       Benefit.

1582   Exceeds maximum               119 - Benefit maximum for this time    M86 - Service denied because      259 - Frequency of service.
       number of physical            period or occurrence has been reached. payment already made for same-
       therapy modalities (6)                                               similar procedure within set time
       allowed per day for dental                                           frame.                            442 - Modalities of service.
       provider.                                                            N362 - The number of Days or
                                                                            Units of Service exceeds our                                   612 -
                                                                            acceptable maximum                Per Day Limit Amount




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                                                    EOB Code Crosswalk to HIPAA Standard Codes



1583   PDN recouped. Hospice        96 - Non-covered charge(s).             MA66 - Missing-incomplete-           457 - Non-Covered Day(s)
       patient. Contact hospice                                             invalid principal procedure code
       responsible for patient.                                             or date.
       Refile claim only for
       date(s) of service not
       covered by Hospice
       Benefit.

1584   Procedure allowed once       119 - Benefit maximum for this time    M86 - Service denied because      259 - Frequency of service.
       per day.                     period or occurrence has been reached. payment already made for same-
                                                                           similar procedure within set time                          612 -
                                                                           frame.                            Per Day Limit Amount

1585   Only one x-ray procedure     119 - Benefit maximum for this time    M86 - Service denied because          259 - Frequency of service.
       allowed for this provider    period or occurrence has been reached. payment already made for same-
       within a 6 month period.                                            similar procedure within set time                                  294 -
       Resubmit as an                                                      frame.                        N29 -   Supporting documentation. 411 -
       adjustment with                                                      Missing documentation-orders-        Medical necessity for non-routine
       documentation to support                                            notes-summary-report-chart.           service(s).
       necessity.
                                                                              N357 - Time frame
                                                                            requirements between this
                                                                            service-procedure-supply and a
                                                                            related service-procedure-supply
                                                                            have not been met.

1586   1 repair of laceration of    119 - Benefit maximum for this time    M86 - Service denied because      259 - Frequency of service.
       palate allowed per date of   period or occurrence has been reached. payment already made for same-
       service.                                                            similar procedure within set time                          612 -
                                                                           frame.                            Per Day Limit Amount

1587   1 repair of laceration of    119 - Benefit maximum for this time    M86 - Service denied because      259 - Frequency of service.
       palate allowed per date of   period or occurrence has been reached. payment already made for same-
       service.                                                            similar procedure within set time                          612 -
                                                                           frame.                            Per Day Limit Amount




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1588   Claim denied. Treatment       B20 - Procedure-service was partially      M86 - Service denied because      258 - Days-units for procedure-
       has been rendered by          or fully furnished by another provider.    payment already made for same- revenue code.
       another provider for this                                                similar procedure within set time
       date of service                                                          frame.

1589   Only one incision allowed     119 - Benefit maximum for this time    M86 - Service denied because      259 - Frequency of service.
       per date of service.          period or occurrence has been reached. payment already made for same-
                                                                            similar procedure within set time                          612 -
                                                                            frame.                            Per Day Limit Amount

1590   No PASARR number on           197 - Precertification-authorization-      N54 - Claim information is         48 - Referral-authorization.
       file at EDS. Contact First    notification absent.                       inconsistent with pre-certified-
       Health Services at 1-800-                                                authorized services.
       639-6514.

1591   Dates of service not within 197 - Precertification-authorization-        N54 - Claim information is         48 - Referral-authorization.
       authorized PASARR time      notification absent.                         inconsistent with pre-certified-
       period. Contact First                                                    authorized services.
       Health Services at 1-800-
       639-6514.

1592   Service requires PASARR 197 - Precertification-authorization-            N54 - Claim information is         48 - Referral-authorization.
       authorization for           notification absent.                         inconsistent with pre-certified-
       admission to a Medicaid                                                  authorized services.
       certified Nursing Facility.
       Contact First Health
       Services at 1-800-639-6514.


1593   Service denied. Exceeds       119 - Benefit maximum for this time    M86 - Service denied because      258 - Days-units for procedure-
       the maximum units             period or occurrence has been reached. payment already made for same- revenue code.
       allowed per month                                                    similar procedure within set time  259 - Frequency of service
                                                                            frame.                    N362 -
                                                                            The number of Days or Units of
                                                                            Service exceeds our acceptable
                                                                            maximum




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                                                     EOB Code Crosswalk to HIPAA Standard Codes

1595   Nutritional services limited 119 - Benefit maximum for this time   M86 - Service denied because      259 - Frequency of service.
       to one per date of service. period or occurrence has been reached. payment already made for same-
                                                                          similar procedure within set time                          612 -
                                                                          frame.                            Per Day Limit Amount
                                                                          N357 - Time frame requirements
                                                                          between this service-procedure-
                                                                          supply and a related service-
                                                                          procedure-supply have not been
                                                                          met

1596   Recipient not eligible for   177 - Patient has not met the required    N30 - Patient ineligible for this   90 - Entity not eligible for medical
       CAP services.                eligibility requirements.                 service.                            benefits for submitted dates of
                                                                                                                  service.
1597   Provider not enrolled to    125 - Submission-billing error(s).         N30 - Patient ineligible for this   91 - Entity not eligible-not
       perform services in                                                    service.                            approved for dates of service.
       recipients benefit package.                                                  N95 - This provider type-
                                                                              provider specialty may not bill
                                                                              this service.
                                                                              N152 - Missing-incomplete-
                                                                              invalid replacement claim
                                                                              information.
1598   At-Risk Case Management      B15 - This service-procedure requires     N20 - Service not payable with      259 - Frequency of service.
       service recouped. This       that a qualifying service-procedure be    other service rendered on the
       service not allowed when     received and covered. The qualifying      same date.
       recipient is receiving       other service-procedure has not been
       related case management      received-adjudicated.
       services.

1599   CAP Respite Care services 169 - Payment adjusted because an            N20 - Service not payable with      259 - Frequency of service.
       recouped. This service       alternate benefit has been provided       other service rendered on the
       not allowed when                                                       same date.
       recipient is receiving Adult
       Care Homes, PCS or
       Therapeutic Leave.


1601   Detail previously paid and   B13 - Previously paid. Payment for this   No Mapping Required                 65 - Claim-line has been paid
       was not reprocessed          claim-service may have been provided
                                    in a previous payment

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                                                    EOB Code Crosswalk to HIPAA Standard Codes




1602   Detail previously denied    18 - Duplicate claim-service             No Mapping Required                 585 - Denied Charge or Non-
       and was not reprocessed                                                                                  covered Charge

1603   Payment is included in the 97 - The benefit for this service is      M80 - Not covered when            258 - Days-units for procedure-
       allowance for another      included in the payment-allowance for     performed during the same         revenue code
       service or procedure.      another service-procedure that has        session-date as a previously
                                  already been adjudicated.                 processed service for the patient

1604   Synagis Max 25-day QTY      119 - Benefit maximum for this time    N59 - Alert- Please refer to          216 - Drug information.
       rules exceeded. Synagis     period or occurrence has been reached. your provider manual for                   259 - Frequency of service.
       rules allow no more than                                           additional program and                                   483 -
       one 50mg vial and no                                               provider information                  Maximum coverage amount met
       more than 250mg total in                                                                                 or exceeded for benefit period
       any 25-day period.

1605   Service denied, recipient   177 - Patient has not met the required   N30 - Patient ineligible for this   90 - Entity not eligible for medical
       eligible for only           eligibility requirements.                service.                            benefits for submitted dates of
       emergency services.                                                                                      service.

1606   Service denied. Recipient 177 - Patient has not met the required     N30 - Patient ineligible for this   90 - Entity not eligible for medical
       eligible for only         eligibility requirements.                  service.                            benefits for submitted dates of
       emergency services.                                                        N95 - This provider type-     service.
       Please resubmit as an                                                provider specialty may not bill          294 - Supporting
       adjustment with                                                      this service.                       documentation.
       supporting documentation                                             N152 - Missing-incomplete-
       if an emergency situation                                            invalid replacement claim
       existed.                                                             information.


1607   Service denied.          177 - Patient has not met the required      N30 - Patient ineligible for this   90 - Entity not eligible for medical
       Supporting documentation eligibility requirements.                   service.                            benefits for submitted dates of
       does not indicate an                                                                                     service.
       emergency situation.                                                                                          294 - Supporting
                                                                                                                documentation.




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                                                      EOB Code Crosswalk to HIPAA Standard Codes

1608   Recipient eligible for        177 - Patient has not met the required    N30 - Patient ineligible for this   294 - Supporting documentation.
       emergency services only. eligibility requirements.                      service.
       Please resubmit as an Adj.
       placing non-emerg.
       charges (i.e., steri) in non-
       covered column & note
       change in Remarks field.

1609   Claim includes family         11 - The diagnosis is inconsistent with   M76 - Missing-incomplete-invalid 21 - Missing or invalid information.
       planning diagnosis(es)        the procedure.                            diagnosis or condition.          453 - Procedure Code Modifier(s)
       and no family planning                                                                                   for Service(s) Rendered.
       procedure. Please                                                                                         488 - Diagnosis code(s) for the
       resubmit with family                                                                                     services rendered
       planning procedure-
       modifier or correct the
       diagnosis.

1610   Family planning procedure 11 - The diagnosis is inconsistent with       M76 - Missing-incomplete-invalid 21 - Missing or invalid information.
       code requires family      the procedure.                                diagnosis or condition.
       planning diagnosis.                                                                          MA130 -
       Please correct and                                                      Your claim contains incomplete
       resubmit.                                                               and-or invalid information, and
                                                                               no appeal rights are afforded
                                                                               because the claim is
                                                                               unprocessable. Please submit a
                                                                               new claim with the complete-
                                                                               correct information.

1611   Service has already been      B20 - Procedure-service was partially     M86 - Service denied because      259 - Frequency of service.
       paid to another provider      or fully furnished by another provider.   payment already made for same- 585 - Denied Charge or Non-
       for same DOS                                                            similar procedure within set time covered Charge
                                                                               frame.

1612   Claim paid without TPL        23 - The impact of prior payer(s)      No Mapping Required                    182 - Allowable-paid from primary
       deduction. Original claim     adjudication including payments and-or                                        coverage
       reduced allowable using       adjustments.
       remaining available TPL




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                                                     EOB Code Crosswalk to HIPAA Standard Codes


1613   Service not allowed for a    A1 - Claim-Service denied. At least one N34 - Incorrect claim form-format 481 - Claim-submission format is
       DME or HIT provider -        Remark Code must be provided (may       for this service.                 invalid.
       Please resubmit on a         be comprised of either the Remittance
       pharmacy claim only if       Advice Remark Code or NCPDP Reject
       recipient is eligible for    Reason Code.) This change to be
       cost sharing                 effective 7-1-2010- Claim-Service
                                    denied. At least one Remark Code
                                    must be provided (may be comprised
                                    of either the NCPDP Reject Reason
                                    Code, or Remittance Advice Remark
                                    Code that is not an ALERT.)


1615   Claim denied. More than   167 - This (these) diagnosis(es) is (are) M64 - Missing-incomplete-invalid 255 - Diagnosis code.
       one diagnosis code within not covered.                              other diagnosis.                   488 - Diagnosis code(s) for the
       range 76400 - 76519                                                                                  services rendered.

1616   The procedure billed         4 - The procedure code is inconsistent   MA130 - Your claim contains         21 - Missing or invalid information.
       requires a modifier 26 to    with the modifier used or a required     incomplete and-or invalid           Note- At least one other status
       establish the professional   modifier is missing.                     information, and no appeal rights   code is required to identify the
       component was billed.                                                 are afforded because the claim is   missing or invalid information.
       Correct your claim and                                                unprocessable. Please submit a      453 - Procedure Code Modifier(s)
       resubmit                                                              new claim with the complete-        for Service(s) Rendered
                                                                             correct information.

1617   The attending provider       A1 - Claim-Service denied. At least one N253 - Missing-incomplete-         21 - Missing or invalid information.
       number cannot be used as     Remark Code must be provided (may       invalid attending provider primary
       a billing provider number.   be comprised of either the Remittance identifier.
       Add the correct billing      Advice Remark Code or NCPDP Reject
       provider number and          Reason Code.) This change to be
       resubmit as a new day        effective 7-1-2010- Claim-Service
       claim                        denied. At least one Remark Code
                                    must be provided (may be comprised
                                    of either the NCPDP Reject Reason
                                    Code, or Remittance Advice Remark
                                    Code that is not an ALERT.)




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1618   The LT or RT modifier        4 - The procedure code is inconsistent      No Mapping Required                21 - Missing or invalid information.
       must be on the same          with the modifier used or a required                                                                    453 -
       detail line as the NU        modifier is missing.                                                           Procedure Code Modifier(s) for
       modifier. Add the                                                                                           Service(s) Rendered
       appropriate modifier and
       resubmit the claim.
1619   The LT or RT modifier        4 - The procedure code is inconsistent      No Mapping Required                21 - Missing or invalid information.
       must be billed with          with the modifier used or a required                                                                   453 -
       procedure code billed.       modifier is missing.                                                           Procedure Code Modifier(s) for
       Add the appropriate                                                                                         Service(s) Rendered
       modifier and resubmit the
       claim
1620   Certified attending          15 - Payment adjusted because the           N77 - Missing-incomplete-invalid   21 - Missing or invalid information.
       provider number is           submitted authorization number is           designated provider number.
       required when billing this   missing, invalid, or does not apply to                            N253 -
       procedure code. Resubmit     the billed services or provider.            Missing-incomplete-invalid
       with appropriate attending                                               attending provider primary
       number                                                                   identifier.

1621   Invalid DRG grouping due     A1 - Claim-Service denied. At least one     207 - Missing-incomplete-invalid   256 - DRG code(s).             273 -
       to incorrect/insufficient    Remark Code must be provided (may           weight.              208 -          Weight.
       coding. Include weight of    be comprised of either the Remittance       Missing-incomplete-invalid DRG
       newborn on claim and         Advice Remark Code or NCPDP Reject          code.
       resubmit.                    Reason Code.) This change to be
                                    effective 7-1-2010- Claim-Service
                                    denied. At least one Remark Code
                                    must be provided (may be comprised
                                    of either the NCPDP Reject Reason
                                    Code, or Remittance Advice Remark
                                    Code that is not an ALERT.)




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1622   Intra-Nasal-Oral               B15 - This service-procedure requires     M51 - Missing-incomplete-invalid 454 - Procedure code for services
       Administration requires        that a qualifying service-procedure be    procedure code(s) and-or dates. rendered
       the appropriate Intra-Nasal-   received and covered. The qualifying
       Oral Immunization              other service-procedure has not been      N59 - Alert- Please refer to your
       procedure.                     received-adjudicated.                     provider manual for additional
                                                                                program and provider
                                                                                information.
                                                                                          N349 - The
                                                                                administration method and drug
                                                                                must be reported to adjudicate
                                                                                this service.

1623   First Intra-Nasal-Oral         A1 - Claim-Service denied. At least one   M86 - Service denied because      259 - Frequency of service
       Immunization                   Remark Code must be provided (may         payment already made for same-
       Administration and first       be comprised of either the Remittance     similar procedure within set time
       Injectable Immunization        Advice Remark Code or NCPDP Reject        frame
       Administration not             Reason Code.) This change to be
       allowed on the same day        effective 7-1-2010- Claim-Service
                                      denied. At least one Remark Code
                                      must be provided (may be comprised
                                      of either the NCPDP Reject Reason
                                      Code, or Remittance Advice Remark
                                      Code that is not an ALERT.)


1624   Incorrect Immunization         A1 - Claim-Service denied. At least one N56 - Procedure code billed is      259 - Frequency of service
       Administration Code            Remark Code must be provided (may       not correct-valid for the services
       combination billed. This       be comprised of either the Remittance billed or the date of service billed.
       combination cannot be          Advice Remark Code or NCPDP Reject
       billed on the same date of     Reason Code.) This change to be
       service. See billing           effective 7-1-2010- Claim-Service
       guidelines                     denied. At least one Remark Code
                                      must be provided (may be comprised
                                      of either the NCPDP Reject Reason
                                      Code, or Remittance Advice Remark
                                      Code that is not an ALERT.)




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1625   No payment for add-on       107 - The related or qualifying claim-       N19 - Procedure code incidental   454 - Procedure code for services
       (zzz) code allowed if       service was not identified on this claim.    to primary procedure.             rendered.
       'primary' code in series is                                                  N161 - This drug-service-
       not paid for the same date                                               supply is covered only when the
       of service, same                                                         associated service is covered.
       provider.

1626   No payment for add-on       107 - The related or qualifying claim-       N19 - Procedure code incidental   454 - Procedure code for services
       (zzz) code allowed if       service was not identified on this claim.    to primary procedure.             rendered.
       'primary' code in series is                                                   N161 - This drug-service-
       not paid for the same date                                               supply is covered only when the
       of service, same                                                         associated service is covered.
       provider.

1627   No payment for add-on       107 - The related or qualifying claim-       N19 - Procedure code incidental   454 - Procedure code for services
       (zzz) code allowed if       service was not identified on this claim.    to primary procedure.             rendered.
       'primary' code in series is                                                  N161 - This drug-service-
       not paid for the same date                                               supply is covered only when the
       of service, same                                                         associated service is covered.
       provider.

1628   Related lab test included     97 - The benefit for this service is       M80 - Not covered when             454 - Procedure code for services
       in acute hepatitis panel.     included in the payment-allowance for      performed during the same          rendered.
                                     another service-procedure that has         session-date as a previously
                                     already been adjudicated.                  processed service for the patient.

1629   Related test to acute         97 - The benefit for this service is       M80 - Not covered when             454 - Procedure code for services
       hepatitis panel recouped      included in the payment-allowance for      performed during the same          rendered.
       to allow reimbursement of     another service-procedure that has         session-date as a previously
       panel code.                   already been adjudicated.                  processed service for the patient.

1630   DME providers are             4 - The procedure code is inconsistent     No Mapping Required               453 - Procedure code modifier(s)
       required to bill modifiers    with the modifier or a required modifier                                     for service(s) rendered.
       to establish that the         is missing.
       procedure billed is new,
       used or rental. Correct
       claim and resubmit.



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                                                      EOB Code Crosswalk to HIPAA Standard Codes



1631   Gastric Restrictive           35 - Lifetime benefit maximum has         MA35 - Missing-incomplete-         259 - Frequency of service.
       Procedures limited to one     been reached.                             invalid number of lifetime reserve
       per lifetime.                                                           days.
                                                                               N362 - The number of Days or
                                                                               Units of Service exceeds our
                                                                               acceptable maximum.
1632   Physical therapy re-          B15 - This service-procedure requires     N20 - Service not payable with     258 - Days-units for procedure-
       evaluation not allowed        that a qualifying service-procedure be    other service rendered on the      revenue code.
       same date of service as       received and covered. The qualifying      same date.
       Physical therapy              other service-procedure has not been
       evaluation.                   received-adjudicated.

1633   Physical therapy              B15 - This service-procedure requires     N20 - Service not payable with    258 - Days-units for procedure-
       evaluation not allowed        that a qualifying service-procedure be    other service rendered on the     revenue code.
       same date of service as       received and covered. The qualifying      same date.
       Physical therapy re-          other service-procedure has not been
       evaluation.                   received-adjudicated.

1634   Component (either          B13 - Previously paid. Payment for this      M15 - Separately billed services- 454 -Procedure code for services
       technical or professional) claim-service may have been provided         tests have been bundled as they rendered.
       denied. Complete           in a previous payment                        are considered components of
       procedure has been                                                      the same procedure. Separate
       reimbursed within 2 years.                                              payment is not allowed.

1635   Professional component     B13 - Previously paid. Payment for this      M15 - Separately billed services- 454 -Procedure code for services
       has already been           claim-service may have been provided         tests have been bundled as they rendered.
       reimbursed within 2 years. in a previous payment.                       are considered components of
        Re-bill for technical                                                  the same procedure. Separate
       component only.                                                         payment is not allowed.


1636   Technical component has       B13 - Previously paid. Payment for this   M15 - Separately billed services- 454 -Procedure code for services
       already been reimbursed       claim-service may have been provided      tests have been bundled as they rendered.
       within 2 years. Re-bill for   in a previous payment.                    are considered components of
       professional component                                                  the same procedure. Separate
       only.                                                                   payment is not allowed.




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1637   Service denied. This test    97 - The benefit for this service is      M80 - Not covered when             454 - Procedure code for services
       is included in a related     included in the payment-allowance for     performed during the same          rendered.
       panel code already paid      another service-procedure that has        session-date as a previously
       for the same date of         already been adjudicated.                 processed service for the patient.
       service.
1639   For DOS on & After 01-01-    4 - The procedure code is inconsistent    M16 - Alert- Please see our         21 - Missing or invalid information.
       2009, procedure requires a   with the modifier used or a required      web site, mailings, or bulletins    Note- At least one other status
       secondary modifier of HP,    modifier is missing.                      for more details concerning         code is required to identify the
       HN, HO, UB, U8, U7, U6 or                                              this policy-procedure-              missing or invalid information.
       U5. Refer to the February                                              decision.         N291 - Missing-                       453 -
       2009 NC Medicaid Bulletin                                              incomplete-invalid rending          Procedure Code Modifier(s) for
       for details.                                                           provider secondary identifier.      Service(s) Rendered.


1640   For DOS on & after 01-01- 4 - The procedure code is inconsistent       M16 - Alert- Please see our         21 - Missing or invalid information.
       2009, Modifiers HP, HN,   with the modifier used or a required         web site, mailings, or bulletins    Note- At least one other status
       HO, UB, U8, U7, U6, or U5 modifier is missing.                         for more details concerning         code is required to identify the
       must be billed in the                                                  this policy-procedure-              missing or invalid information.
       secondary position. Refer                                              decision.         N291 - Missing-                      453 - Procedure
       to the February 2009 NC                                                incomplete-invalid rending          Code Modifier(s) for Service(s)
       Medicaid Bulletin for                                                  provider secondary identifier.      Rendered.
       details.

1641   Unit Cutback. Exceeds        119 - Benefit maximum for this time    M86 - Service denied because      259 - Frequency of service.
       maximum units allowed        period or occurrence has been reached. payment already made for same-                                 483 -
       per month.                                                          similar procedure within set time Maximum coverage amount met
                                                                           frame.                            or exceeded for benefit period.
                                                                           N362 - The number of Days or
                                                                           Units of Service exceeds our
                                                                           acceptable maximum.

1642   Crossover percentage         170 - Payment is denied when              N95 - This provider type -          585 - Denied Charge or Non-
       payments are not allowed     performed-billed by this type of provider provider specialty may not bill     covered Charge
       for this provider type-                                                this service
       specialty combination




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1643   Service Denied. Add on       A1 - Claim-Service denied. At least   M51 - Missing-incomplete-invalid 465 - Principal Procedure Code for
       administration code must     one Remark Code must be provided      procedure code(s).               Service(s) Rendered
       be billed with an            (may be comprised of either the
       appropriate additional       Remittance Advice Remark Code or
       immunization code.           NCPDP Reject Reason Code.) This
                                    change to be effective 7-1-2010-
                                    Claim-Service denied. At least one
                                    Remark Code must be provided
                                    (may be comprised of either the
                                    NCPDP Reject Reason Code, or
                                    Remittance Advice Remark Code
                                    that is not an ALERT.)



1644   Service Denied. Federally    A1 - Claim-Service denied. At least   M51 - Missing-incomplete-invalid 465 - Principal Procedure Code for
       funded immunization          one Remark Code must be provided      procedure code(s).               Service(s) Rendered
       administration not allowed   (may be comprised of either the
       without appropriate          Remittance Advice Remark Code or
       administration code.         NCPDP Reject Reason Code.) This
                                    change to be effective 7-1-2010-
                                    Claim-Service denied. At least one
                                    Remark Code must be provided
                                    (may be comprised of either the
                                    NCPDP Reject Reason Code, or
                                    Remittance Advice Remark Code
                                    that is not an ALERT.)



1645   Total time billed for        152 - Payment adjusted because the      N225 - Incomplete-invalid      297 - Medical notes-report.
       psychological testing is     payer deems the information submitted documentation-orders- notes-
       not documented In the        does not support this length of service summary- report- chart.
       medical records. only
       documented time has
       been reimbursed.



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1646   Cap-mr-dd respite care;        B15 - This service-procedure requires    N20 - Service not payable with      258 - Days-units for procedure-
       facility & institutional not   that a qualifying service-procedure be   other service rendered on the       revenue code.
         allowed same date of         received and covered. The qualifying     same date.
       service.                       other service-procedure has not been
                                      received-adjudicated.

1648   Invalid or missing first       125 - Submission-billing error(s).       MA122 - Missing-incomplete-         21 - Missing or invalid information
       treatment date. Resubmit                                                invalid initial treatment date.
       claim with valid first
       treatment date

1649   Procedure-Modifier not      177 - Patient has not met the required      N30 - Patient ineligible for this   453 - Procedure Code Modifier(s)
       allowed when billed by      eligibility requirements.                   service.                            for Service(s) Rendered.
       Area Mental Health                                                               N216 - Patient is not      475 - Procedure code not valid for
       Provider for recipients age                                             enrolled in this portion of our     patient age
       000-003 who are not CAP-                                                benefit package
       MR-DD on the DOS billed


1650   Recoupment per medical         B5 - Coverage-program guidelines         MA67 - Correction to a prior claim 101 - Claim was processed as
       or policy review               were not met or were exceeded.                                              adjustment to previous claim

1651   Component procedure not B15 - This service-procedure requires           N20 - Service not payable with      454 - Procedure code for services
       allowed same day as      that a qualifying service-procedure be         other service rendered on the       rendered.
       comprehensive procedure. received and covered. The qualifying           same date.
                                other service-procedure has not been
                                received-adjudicated.

1652   Care plan oversight            18 - Duplicate claim-service.            M86 - Service denied because      259 - Frequency of service.
       already paid for this                                                   payment already made for same-
       calendar month.                                                         similar procedure within set time
                                                                               frame.

1653   Care plan oversight for        18 - Duplicate claim-service.            M86 - Service denied because      259 - Frequency of service.
       Home Health recipient                                                   payment already made for same-
       already paid for this                                                   similar procedure within set time
       calendar month.                                                         frame.



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1654   Care plan oversight for      18 - Duplicate claim-service.            M86 - Service denied because      259 - Frequency of service.
       hospice recipient already                                             payment already made for same-
       paid for this calendar                                                similar procedure within set time
       month.                                                                frame.

1655   Comprehensive procedure      B15 - This service-procedure requires    N20 - Service not payable with       454 - Procedure code for services
       paid. Component              that a qualifying service-procedure be   other service rendered on the        rendered.
       procedures will be           received and covered. The qualifying     same date.
       recouped.                    other service-procedure has not been
                                    received-adjudicated.

1656   Payment for care plan        97 - The benefit for this service is     M80 - Not covered when             454 - Procedure code for services
       oversight is included in     included in the payment-allowance for    performed during the same          rendered.
       dialysis composite rate      another service-procedure that has       session-date as a previously
       already paid for this        already been adjudicated.                processed service for the patient.
       month.
1657   Payment for care plan        97 - The benefit for this service is     M80 - Not covered when               454 - Procedure code for services
       oversight is included in     included in the payment-allowance for    performed during the same            rendered.                    415 -
       dialysis composite rate      another service-procedure that has       session-date as a previously         Justify services outside composite
       billed separately for same   already been adjudicated.                processed service for the patient.   rate.
       calendar month

1663   Prior claim for case         18 - Duplicate claim-service.            M86 - Service denied because      259 - Frequency of service.
       management has been                                                   payment already made for same-
       paid for this month.                                                  similar procedure within set time
                                                                             frame.

1664   Service denied. Drug         119 - Benefit maximum for this time    M86 - Service denied because      258 - Days-units for procedure-
       allows 1200 units per        period or occurrence has been reached. payment already made for same- revenue code.
       calendar month                                                      similar procedure within set time 259 - Frequency of service
                                                                           frame.                   N362 -
                                                                           The number of Days or Units of
                                                                           Service exceeds our acceptable
                                                                           maximum.




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1665   Secondary Thrombectomy 97 - The benefit for this service is           M80 Not covered when                 187 Date(s) of service.
       code must be billed with a included in the payment-allowance for      performed during the same            259 Frequency of service.
       primary procedure          another service-procedure that has         session-date as a previously         453 Procedure Code Modifier(s)
                                  already been adjudicated.                  processed service for the patient.   for Service(s) Rendered

                                                                             N19 Procedure code incidental
                                                                             to primary procedure.

1666   Dermagraft limited to 4      119 - Benefit maximum for this time    M86 - Service denied because      259 - Frequency of service.
       applications totaling        period or occurrence has been reached. payment already made for same- 612 - Per Day Limit Amount
       150.00 sq. cm. per day                                              similar procedure within set time
                                                                           frame.
                                                                           N357 - Time frame requirements
                                                                           between this service-procedure-
                                                                           supply and a related service-
                                                                           procedure-supply have not been
                                                                           met

1667   Only 8 applications or 300   119 - Benefit maximum for this time    M86 - Service denied because      259 - Frequency of service.
       sq. cm. of Dermagraft        period or occurrence has been reached. payment already made for same-
       allowed every 12 weeks                                              similar procedure within set time
                                                                           frame.
                                                                           N357 - Time frame requirements
                                                                           between this service-procedure-
                                                                           supply and a related service-
                                                                           procedure-supply have not been
                                                                           met

1668   Other diagnosis code 6 is    146 - Diagnosis was invalid for the      M76 - Missing-incomplete-invalid     255 - Diagnosis code.
       invalid.                     date(s) of service reported.             diagnosis or condition.
1669   Other diagnosis code 7 is    146 - Diagnosis was invalid for the      M76 - Missing-incomplete-invalid     255 - Diagnosis code.
       invalid.                     date(s) of service reported.             diagnosis or condition.
1670   Other diagnosis code 8 is    146 - Diagnosis was invalid for the      M76 - Missing-incomplete-invalid     255 - Diagnosis code.
       invalid.                     date(s) of service reported.             diagnosis or condition.
1671   Other diagnosis code 9 is    146 - Diagnosis was invalid for the      M76 - Missing-incomplete-invalid     255 - Diagnosis code.
       invalid.                     date(s) of service reported.             diagnosis or condition.



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                                                    EOB Code Crosswalk to HIPAA Standard Codes




1672   DME allowed once in four    119 - Benefit maximum for this time    M86 - Service denied because      259 - Frequency of service.
       years ages 21 - 115         period or occurrence has been reached. payment already made for same-
                                                                          similar procedure within set time
                                                                          frame.

1674   Diagnosis billed is not     125 - Submission-billing error(s). At   MA66- Missing-incomplete-        21 - Missing or invalid information.
       allowed as primary          least one Remark Code must be           invalid principal procedure code.Note- At least one other status
       diagnosis                   provided (may be comprised of either                                     code is required to identify the
                                   the Remittance Advice Remark Code       M76 - Missing-incomplete-invalid missing or invalid information.
                                   or NCPDP Reject Reason Code.)           diagnosis or condition.                             254 -Primary
                                                                                                            diagnosis code.        488 -
                                                                                                            Diagnosis code(s) for the services
                                                                                                            rendered.
1675   Drug is limited to 240 units 119 - Benefit maximum for this time    No Mapping Required              259 - Frequency of service
       per calendar month. Units period or occurrence has been reached
       have been cutback to
       allowable units for this
       timeframe

1676   Units cutback. Exceeds      119 - Benefit maximum for this time    M86 - Service denied because      258 - Days-units for procedure-
       the maximum units           period or occurrence has been reached. payment already made for same- revenue code.
       allowed per calendar                                               similar procedure within set time   259 - Frequency of service.
       month.                                                             frame.
                                                                          N362 - The number of Days or
                                                                          Units of Service exceeds our
                                                                          acceptable maximum.

1677   Service Denied, Exceeds    119 - Benefit maximum for this time    M86 - Service denied because      259 - Frequency of service.
       allowed units per calendar period or occurrence has been reached. payment already made for same-
       month.                                                            similar procedure within set time
                                                                         frame.
                                                                         N362 - The number of Days or
                                                                         Units of Service exceeds our
                                                                         acceptable maximum.




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1678   Related aneurysm          B15 - This service-procedure requires        N20 - Service not payable with      258 - Days-units for procedure-
       procedures not allowed on that a qualifying service-procedure be       other service rendered on the       revenue code.
       the same date of service. received and covered. The qualifying         same date.
                                 other service-procedure has not been
                                 received-adjudicated.

1679   Medicaid payments           B5 - Coverage-program guidelines           N59 - Alert- Please refer to        585 - Denied Charge or Non-
       suspended for non-          were not met or were exceeded.             your provider manual for            covered Charge.
       compliance of false claim                                              additional program and                615 - Policy Compliance Code.
       act. Please submit                                                     provider information
       attestation letter.

1681   Related laminotomy        B15 - This service-procedure requires        N20 - Service not payable with      258 - Days-units for procedure-
       procedures not allowed on that a qualifying service-procedure be       other service rendered on the       revenue code.
       same date of service.     received and covered. The qualifying         same date.
                                 other service-procedure has not been
                                 received-adjudicated.

1682   Vaccine procedure only      149 - Lifetime benefit maximum has         N117 - This service is paid only    259 - Frequency of service.
       allowed 2 per lifetime.     been reached for this service-benefit      once in a patients lifetime.
                                   category.                                   N362 - The number of Days or
                                                                              Units of Service exceeds our
                                                                              acceptable maximum.

1683   Diabetes self management 119 - Benefit maximum for this time           M86 - Service denied because        258 - Days-units for procedure-
       training services,         period or occurrence has been reached.      payment already made for same-      revenue code.               259 -
       individual or group                                                    similar procedure within set time   Days-units for procedure-revenue
       sessions not allowed more                                              frame.                              code.
       than 20 units per calendar                                             N357 - Time frame requirements
       year.                                                                  between this service-procedure-
                                                                              supply and a related service-
                                                                              procedure-supply have not been
                                                                              met.




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1684   Unit)s) cutback. Exceeds      119 - Benefit maximum for this time    M86 - Service denied because          258 - Days-units for procedure-
       maximum units per             period or occurrence has been reached. payment already made for same-        revenue code.               259 -
       calendar year.                                                       similar procedure within set time     Days-units for procedure-revenue
                                                                            frame.                                code.
                                                                            N357 - Time frame requirements
                                                                            between this service-procedure-
                                                                            supply and a related service-
                                                                            procedure-supply have not been
                                                                            met.

1685   The procedure billed          4 - The procedure code is inconsistent   MA130 - Your claim contains         21 - Missing or invalid information.
       requires a modifier which     with the modifier used or a required     incomplete and-or invalid
       will establish the number     modifier is missing.                     information, and no appeal rights
       of patients served for this                                            are afforded because the claim is
       DOS. Please check your                                                 unprocessable. Please submit a
       procedure, correct your                                                new claim with the complete-
       claim and resubmit                                                     correct information. N180 - This
                                                                              item or service does not meet
                                                                              the criteria for the category under
                                                                              which it was billed.

1686   Diabetes self management      A1 - Claim-Service denied. At least      M80 - Not covered when             187 - Date(s) of service.
       outpatient service not        one Remark Code must be provided         performed during the same            259 - Frequency of service.
       allowed same day as           (may be comprised of either the          session-date as a previously
       physician service.            Remittance Advice Remark Code or         processed service for the patient.
                                     NCPDP Reject Reason Code.) This
                                     change to be effective 7-1-2010-         N20 - Service not payable with
                                     Claim-Service denied. At least one       other service rendered on the
                                     Remark Code must be provided             same date.
                                     (may be comprised of either the
                                     NCPDP Reject Reason Code, or
                                     Remittance Advice Remark Code
                                     that is not an ALERT.)




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1687   Physician service not       A1 - Claim-Service denied. At least      M80 - Not covered when             187 - Date(s) of service.
       allowed same day as         one Remark Code must be provided         performed during the same            259 - Frequency of service.
       diabetes self management    (may be comprised of either the          session-date as a previously
       outpatient service.         Remittance Advice Remark Code or         processed service for the patient.
                                   NCPDP Reject Reason Code.) This
                                   change to be effective 7-1-2010-         N20 - Service not payable with
                                   Claim-Service denied. At least one       other service rendered on the
                                   Remark Code must be provided             same date.
                                   (may be comprised of either the
                                   NCPDP Reject Reason Code, or
                                   Remittance Advice Remark Code
                                   that is not an ALERT.)



1689   Condition code indicating   125 - Submission-billing error(s).       M44 - Missing-incomplete-invalid 460 - NUBC Condition Code(s)
       Medicare override not                                                condition code
       allowed when Medicare
       payment is also indicated
       on claim

1690   Related MRI procedures      B15 - This service-procedure requires    M86 - Service denied because      258 - Days-units for procedure-
       not allowed by the same     that a qualifying service-procedure be   payment already made for same- revenue code.
       attending provider.         received and covered. The qualifying     similar procedure within set time
                                   other service-procedure has not been     frame.
                                   received-adjudicated.




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1691   DMA 3000 PCS PACT is          A1 - Claim-Service denied. At least   N29 - Missing documentation-        21 - Missing or invalid information.
       missing, incomplete or        one Remark Code must be provided      orders-notes-summary-report-                                294 -
       invalid. Please attach        (may be comprised of either the       chart.                              Supporting documentation
       required information and      Remittance Advice Remark Code or              N35 - Program integrity-
       submit the claim to DMA       NCPDP Reject Reason Code.) This       utilization review decision.
       program integrity home        change to be effective 7-1-2010-                                 N225 -
       care review                   Claim-Service denied. At least one    Incomplete-invalid
                                     Remark Code must be provided          documentation-orders-notes-
                                     (may be comprised of either the       summary-report-chart
                                     NCPDP Reject Reason Code, or
                                     Remittance Advice Remark Code
                                     that is not an ALERT.)



1692   Signatures are                A1 - Claim-Service denied. At least   N29 - Missing documentation-        21 - Missing or invalid information.
       missing/illegible. Check or   one Remark Code must be provided      orders-notes-summary-report-                                 294 -
       include all attachments       (may be comprised of either the       chart.                              Supporting documentation
       requiring signatures with     Remittance Advice Remark Code or            N35 - Program integrity-
       legible copies & submit to    NCPDP Reject Reason Code.) This       utilization review decision. N205 -
       DMA Program Integrity         change to be effective 7-1-2010-       Information provided was
       home care review.             Claim-Service denied. At least one    illegible.
                                     Remark Code must be provided
                                     (may be comprised of either the
                                     NCPDP Reject Reason Code, or
                                     Remittance Advice Remark Code
                                     that is not an ALERT.)




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1693   Required certificates         A1 - Claim-Service denied. At least   N29 - Missing documentation-        21 - Missing or invalid information.
       missing/invalid. Submit to    one Remark Code must be provided      orders-notes-summary-report-                                294 -
       DMA Program Integrity         (may be comprised of either the       chart.                              Supporting documentation
       home care review w/home       Remittance Advice Remark Code or            N35 - Program integrity-
       aide info., RN/PCS Cert.,     NCPDP Reject Reason Code.) This       utilization review decision. N225 -
       licenses of staff rendering   change to be effective 7-1-2010-       Incomplete-invalid
       svc. Or appropriate           Claim-Service denied. At least one    documentation-orders-notes-
       documents                     Remark Code must be provided          summary-report-chart
                                     (may be comprised of either the
                                     NCPDP Reject Reason Code, or
                                     Remittance Advice Remark Code
                                     that is not an ALERT.)



1694   Aide's time/task sheet        A1 - Claim-Service denied. At least   N205 - Information provided was 21 - Missing or invalid information.
       (work log) is missing or      one Remark Code must be provided      illegible.                                                294 -
       information is                (may be comprised of either the               N225 - Incomplete-invalid Supporting documentation
       incomplete/illegible.         Remittance Advice Remark Code or      documentation-orders-notes-
       Submit a legible copy         NCPDP Reject Reason Code.) This       summary-report-chart
       and/or completed log if it    change to be effective 7-1-2010-
       exists.                       Claim-Service denied. At least one
                                     Remark Code must be provided
                                     (may be comprised of either the
                                     NCPDP Reject Reason Code, or
                                     Remittance Advice Remark Code
                                     that is not an ALERT.)



1695   Documentation submitted B5 -Coverage-program guidelines were N35 - Program integrity-utilization 294 - Supporting documentation
       does not support medicaid not met or were exceeded.          review decision
       coverage policy
       requirements. Submit
       claim to DMA Program
       Integrity Home Care
       Review with necessary
       documentation.



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1696   Mammography screening        119 - Benefit maximum for this time   M86 - Service denied because      259 - Frequency of service.
       limited to one per 5 years   period or occurrence has been reached payment already made for same-          453 - Procedure Code
                                                                          similar procedure within set time Modifier(s) for Service(s) Rendered
                                                                          frame.
                                                                                    N362 - The number of
                                                                          Days or Units of Service exceeds
                                                                          our acceptable maximum


1697   First treatment date not     125 - Submission-billing error(s). At     MA122 - Missing-incomplete-       21 - Missing or invalid information.
       valid, please resubmit       least one Remark Code must be             invalid initial treatment date.   192 - Date of first service for
       claim with correct first     provided (may be comprised of either                                        current series-symptom-illness.
       treatment date               the Remittance Advice Remark Code
                                    or NCPDP Reject Reason Code.) This
                                    change to be effective 7-1-2010-
                                    Submission-billing error(s). At least one
                                    Remark Code must be provided (may
                                    be comprised of either the NCPDP
                                    Reject Reason Code, or Remittance
                                    Advice Remark Code that is not an
                                    ALERT.)

1698   Invalid Sterilization        125 - Submission-billing error(s). At     N228 - Incomplete-invalid         107 - Processed according to
       consent form on file.        least one Remark Code must be             consent form.                     contract provisions (Contract
       Informed consent             provided (may be comprised of either                                        refers to provisions that exist
       obtained by DSS              the Remittance Advice Remark Code                                           between the Health Plan and a
                                    or NCPDP Reject Reason Code.) This                                          Provider of Health Care Services)
                                    change to be effective 7-1-2010-                                            21 - Missing or invalid information.
                                    Submission-billing error(s). At least one                                   Note- At least one other status
                                    Remark Code must be provided (may                                           code is required to identify the
                                    be comprised of either the NCPDP                                            missing or invalid information.
                                    Reject Reason Code, or Remittance
                                    Advice Remark Code that is not an
                                    ALERT.)




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1699   Service is not consistent   125 - Submission-billing error(s). At     M76 - Missing-incomplete-invalid 488 - Diagnosis code(s) for the
       with or not covered for     least one Remark Code must be             diagnosis or condition           services rendered
       this diagnosis or           provided (may be comprised of either
       description of service      the Remittance Advice Remark Code
       does not match diagnosis    or NCPDP Reject Reason Code.) This
                                   change to be effective 7-1-2010-
                                   Submission-billing error(s). At least one
                                   Remark Code must be provided (may
                                   be comprised of either the NCPDP
                                   Reject Reason Code, or Remittance
                                   Advice Remark Code that is not an
                                   ALERT.)

1706   Non-Physican Counseling     A1 - Claim-Service denied. At least one   M86 - Service denied because      259 - Frequency of service
       Immunization                Remark Code must be provided (may         payment already made for same-
       Administration procedure    be comprised of either the Remittance     similar procedure within set time
       not allowed same day as     Advice Remark Code or NCPDP Reject        frame
       Physician Counseling        Reason Code.) This change to be
       Immunization                effective 7-1-2010- Claim-Service
                                   denied. At least one Remark Code
                                   must be provided (may be comprised
                                   of either the NCPDP Reject Reason
                                   Code, or Remittance Advice Remark
                                   Code that is not an ALERT.)




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1707   Procedure recouped.           A1 - Claim-Service denied. At least   M86 - Service denied because      259 - Frequency of service
       Administration with Non-      one Remark Code must be provided      payment already made for same-
       Physician Counseling not      (may be comprised of either the       similar procedure within set time
       allowed same day as           Remittance Advice Remark Code or      frame
       Physician Counseling          NCPDP Reject Reason Code.) This
                                     change to be effective 7-1-2010-
                                     Claim-Service denied. At least one
                                     Remark Code must be provided
                                     (may be comprised of either the
                                     NCPDP Reject Reason Code, or
                                     Remittance Advice Remark Code
                                     that is not an ALERT.)



1711   Portable geseous oxygen       A1 - Claim-Service denied. At least   M80 - Not covered when             187 - Date(s) of service.
       system; Home                  one Remark Code must be provided      performed during the same            455 - Revenue code for services
       compressor including          (may be comprised of either the       session-date as a previously       rendered.
       containes not allowed         Remittance Advice Remark Code or      processed service for the patient.
       during same period as         NCPDP Reject Reason Code.) This                           M86 - Service
       other related system/units.   change to be effective 7-1-2010-      denied because payment already
                                     Claim-Service denied. At least one    made for same-similar procedure
                                     Remark Code must be provided          within set time frame.
                                     (may be comprised of either the                  N20 - Service not
                                     NCPDP Reject Reason Code, or          payable with other service
                                     Remittance Advice Remark Code         rendered on the same date.
                                     that is not an ALERT.)




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1712   Other related system/units     A1 - Claim-Service denied. At least      M80 - Not covered when             187 - Date(s) of service.
       not allowed when portable      one Remark Code must be provided         performed during the same            455 - Revenue code for services
       gaseous oxygen system;         (may be comprised of either the          session-date as a previously       rendered.
       Home compressor                Remittance Advice Remark Code or         processed service for the patient.
       including containers is        NCPDP Reject Reason Code.) This                              M86 - Service
       paid in history.               change to be effective 7-1-2010-         denied because payment already
                                      Claim-Service denied. At least one       made for same-similar procedure
                                      Remark Code must be provided             within set time frame.
                                      (may be comprised of either the                     N20 - Service not
                                      NCPDP Reject Reason Code, or             payable with other service
                                      Remittance Advice Remark Code            rendered on the same date.
                                      that is not an ALERT.)



1718   CBSA code missing,             125 - Submission-billing error(s). At    M49 - Missing-incomplete-invalid 21 - Missing or invalid information.
       invalid or does not match      least one Remark Code must be            value code(s) or amount(s).      Note- At least one other status
       zip code of the location       provided (may be comprised of either                                      code is required to identify the
       where service was              the Remittance Advice Remark Code                                         missing or invalid information.
       provided. Correct claim        or NCPDP Reject Reason Code.)                                                                463 - NUBC
       and refile or contact EDS                                                                                Value Code(s) and-or Amount(s).
       provider services 1-800-                                                                                                              500 -
       688-6696                                                                                                 Entitys Postal-Zip Code.

1719   The hospice revenue code       125 - Submission-billing error(s). At    M49 - Missing-incomplete-invalid 21 - Missing or invalid information.
       billed must be billed with a   least one Remark Code must be            value code(s) or amount(s).      Note- At least one other status
       value code of 61 and           provided (may be comprised of either                                      code is required to identify the
       corresponding CBSA code.       the Remittance Advice Remark Code                                         missing or invalid information.
                                      or NCPDP Reject Reason Code.)                                                                463 - NUBC
                                                                                                                Value Code(s) and-or Amount(s).

1720   NDC validity cannot be         125 - Submission-billing error(s)        M119 - Missing-incomplete-        218 - NDC number
       confirmed                                                               invalid-deactivated-withdrawn
                                                                               National Drug Code (NDC).
1721   Related MRI procedure not      B15 - This service-procedure requires    N20 - Service not payable with    258 - Days-units for procedure-
       allowed on same date of        that a qualifying service-procedure be   other service rendered on the     revenue code.
       service, same or different     received and covered. The qualifying     same date.
       provider.                      other service-procedure has not been
                                      received-adjudicated.


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                                                      EOB Code Crosswalk to HIPAA Standard Codes




1722   Prior authorization         197 - Precertification-authorization-      N54 - Claim information is         48 - Referral-authorization.
       required. Prescriber must notification absent.                         inconsistent with pre-certified-
       call ACS at 1-866-246-8505.                                            authorized services.

1723   Non-Preferred agent           38 - Services not provided or            No Mapping Required                1 - For more detailed information,
       prescriber must call ACS      authorized by designated (network-                                          see remittance advice.
       at 1-866-246-8505.            primary care) providers.
1724   Secondary Thrombectomy        97 - The benefit for this service is     M80 - Not covered when             187 - Date(s) of service.
       not allowed same day as       included in the payment-allowance for    performed during the same          259 - Frequency of service.