Denial of Paternity Form for the State of Texas

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Denial of Paternity Form for the State of Texas Powered By Docstoc
					                                                            EOB Code Crosswalk to HIPAA Standard Codes

              MEDICAID EOB                HIPAA ADJUSTMENT REASON CODE                     HIPAA REMARK CODE                  HIPAA CLAIM STATUS CODE
F8989          DESCRIPTION                              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
                                          legislated fee arrangement. (Use             payment information related to        amount met or exceeded for
                                          Group Codes PR or CO depending               these charges.                        benefit period
                                          upon liability).
2       Pre-admission not obtained.       197 - Precertification-authorization-        N54 - Claim information is            435 - Notice of Admission
                                          notification absent.                         inconsistent with pre-certified-
                                                                                       authorized services.


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



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



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 Correct 11 digit                                                invalid-deactivated-withdrawn         218 - NDC number.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

9        Service not covered by the 96 - Non-covered charge(s).                     N59 - Alert- Please refer to your 21 - Missing or invalid information.
         Medicaid program;                                                          provider manual for additional    454 - Procedure code for services
         Pharmacy, see non-covered                                                  program and provider information rendered.
         items under scope of
         services in manual.

10       Diagnosis or service invalid 125 - Submission-billing error(s).            M76 - Missing-incomplete-invalid     21 - Missing or invalid information.
         for recipient age, Verify MID,                                             diagnosis or condition.              475 - Procedure code not valid for
         diagnosis, procedure code or                                               MA66 - Missing-incomplete-           patient age.
         procedure code- modifier                                                   invalid principal procedure code.    488 - Diagnosis code(s) for the
         combination for errors.                                                                                         services rendered.
         Correct and submit as a new
         claim.
11       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 invalid   125 - Submission-billing error(s).          M76 - Missing-incomplete-invalid 86 - Diagnosis and patient gender
         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-       None                                 91 - Entity not eligible-not approved
         eligible on service date       eligible to be paid for this procedure-                                          for dates of service. 562 - Entitys
                                        service on this date of service.                                                 National Provider Identifier (NPI)



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14       Service denied per medical     45 - Charge exceeds fee schedule-           N10 - Claim-service adjusted       421 - Medical review attachment-
         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 Health     97 - The benefit for this service is        M80 - Not covered when             454 - Procedure code for services
         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 denied      29 - The time limit for filing has expired. N1 - Alert- You may appeal this       294 - Supporting documentation.
         as beyond time limit.                                                      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
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 following
         submitted to the EDS                                                       the instructions included in your
         Provider Service unit.                                                     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.                                187 - Date(s) of service.
         and submit as a new claim.




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20       Claim being processed due        45 - Charge exceeds fee schedule-          MA67 - Correction to a prior           101 - Claim was processed as
         to incorrect denial for eob      maximum allowable or contracted-           claim.                                 adjustment to previous claim.
         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, procedure- 125 - Submission-billing error(s).               l                                      21 - Missing or invalid information.
         modifier combination or                                                                                            228 - Type of bill for UB claim.
         revenue code is missing ,                                                                                          453 - Procedure code modifier(s)
         invalid or invalid for this bill                                                                                   for service(s) rendered.
         type. Correct and rebill
         denied detail as a new claim.


25       Procedure denied for patient     6 - The procedure-revenue code is          None                                   475 - Procedure code not valid for
         over 21 years old.               inconsistent with the patients age.                                               patient age.
26       Ventilator care not payable to   170 - Payment is denied when               N95 - This provider type -             25 - Entity not approved.
         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 the    date(s) of service reported.               diagnosis or condition.                255 - Diagnosis code.
         correct diagnosis code and                                                                                         477 - Diagnosis code pointer is
         submit as a new claim.                                                                                             missing or invalid.

28       Payment included in dialysis 97 - The benefit for this service is           M80 - Not covered when             454 - Procedure code for services
         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.



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29       Medicare voucher does not       148 - Information from another provider N4 - Missing-incomplete-invalid         285 - Vouchers-explanation of
         match dates-charges on          was not provided or was insufficient-   prior insurance carrier EOB.            benefits (EOB).
         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        591 - Medicare Paid at 100%
                                                                                   these charges                         Amount
31       Partially cutback for other     23 - The impact of prior payer(s)         None                                  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)      None                                     107 - Processed according to
         insurance amount.               adjudication including payments and-or                                          contract-plan provisions.
                                         adjustments.
33       CAP service not allowed on      96 - Non-covered charge(s).            MA66 - Missing-incomplete-               454 - Procedure code for services
         or after January 31, 1992.                                             invalid principal procedure code         rendered.
                                                                                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 286 - Other payers Explanation of
         locator 54 and resubmit as a incomplete.                                  identity of or payment information Benefits-payment information.
         new claim.                                                                from the primary payer. The
                                                                                   information was either not
                                                                                   reported or was illegible

35       Claim-procedure denied,         115 - Procedure postponed-canceled-or None                                      585 - Denied Charge or Non-
         services not rendered.          delayed.                                                                        covered Charge
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                                               M77 - Missing-incomplete-invalid          455 - Revenue code for services
         missing-invalid for this                                              place of service(s).                      rendered.
         procedure. Correct bill type                                          MA30 - Missing-incomplete-
         or POS and resubmit as a                                              invalid type of bill.
         new claim.



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37       Detail line not adjusted.       45 - Charge exceeds fee schedule-            None                                 247 - Line information.
                                         maximum allowable or contracted-                                                  530 - Claim Adjustment Indicator
                                         legislated fee arrangement. (Use
                                         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 DESI                                                   charge                           rendered.
         equivalent.
39       Medicare denied, no          A1 - Claim-Service denied. At least one         N8 - Crossover claim denied by       107 - Processed according to
         coinsurance or deductible or Remark Code must be provided (may               previous payer and complete          contract-plan provisions.
         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)                                    to provide adequate data for
                                                                                      adjudication
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.             187 - Date(s) of service.
         Verify and enter correct DOS                                                 N173 - No qualifying hospital stay   189 - Facility admission date
         and submit as a new claim.                                                   dates were provided for this
                                                                                      episode of care.


41       Attach sterilization consent    16 - Claim-service lacks information         N3 - Missing consent form.           48 - Referral-authorization.
         forms to claim.                 which is needed for adjudication.
42       Sterilization -abortion         B5 - Coverage-program guidelines were        None                                 21 - Missing or invalid information.
         guidelines not met.             not met or were exceeded.
43       Acquisition of organs for       109 - Claim not covered by this payer-       None                                 84 - Service not authorized.
         transplant must be billed to    contractor. You must send the claim to
         the transplant hospital.        the correct payer-contractor.
44       Claim processed for eligible    141 - Claim spans eligible and ineligible    None                               20 - Accepted for processing.
         dates only.                     periods of coverage.                                                            456 - Covered Day(s).
45       Procedure included in fee for   97 - The benefit for this service is         M80 - Not covered when             453 - Procedure Code Modifier(s)
         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 code for services
                                         already been adjudicated.                    processed service for the patient. 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.



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


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.
50       Eligibility problem- resubmit   177 - Patient has not met the required     MA04 - Secondary payment             56 - Awaiting eligibility
         claim and EOMB to EDSF.         eligibility requirements.                  cannot be considered without the     determination.
                                                                                    identity of or payment information
                                                                                    from the primary payer. The
                                                                                    information was either not
                                                                                    reported or was illegible.

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 includes 97 - The benefit for this service is      M80 - Not covered when             454 - Procedure code for services
         payment 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.




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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-         612 - Per Day Limit Amount
                                                                               similar procedure within set time
                                                                               frame.
55       Service is included in the fee 97 - The benefit for this service is   M80 - Not covered when                 454 - Procedure code for services
         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 for 97 - The benefit for this service is      M80 - Not covered when             454 - Procedure code for services
         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 allowed not met.                                      payment already made for same-
         once in 2 yrs for ages 00-20.                                              similar procedure within set time
                                                                                    frame.
58       Service dates prior to       125 - Submission-billing error(s).            MA31 - Missing-incomplete-        187 - Date(s) of service.
         admission date. Verify admit                                               invalid beginning and ending      189 - Facility admission date
         date and DOS. Correct and                                                  dates of the period billed.
         rebill as a new claim.



59       Adjustments equal to or less 45 - Charge exceeds fee schedule-     MA22 - Payment of less than               104 - Processed according to plan
         than one dollar denied.      maximum allowable or contracted-      $1.00 suppressed.                         provisions.
                                      legislated fee arrangement. (Use
                                      Group Codes PR or CO depending
                                      upon liability).
60       Not in accordance with       B5 - Coverage-program guidelines were None                                      21 - Missing or invalid information.
         Medical Policy guidelines.   not met or were exceeded.



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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 Equipment    108 - Rent-purchase guidelines were       None                                21 - Missing or invalid information.
         guidelines not met.          not met.

63       Correct assistant surgeons  125 - Submission-billing error(s).         MA130 - Your claim contains         276 - UB04-HCFA-1450-1500
         claim using TOS 08 in field                                            incomplete and-or invalid           claim form.
         24C of the HCFA-1500 claim                                             information, and no appeal rights   481 - Claim submission format is
         form and resubmit as a new                                             are afforded because the claim is   invalid.
         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 may B20 - Procedure-service was partially or N32 - Claim must be submitted by     84 - Service not authorized.
         bill.                          fully furnished by another provider.   the provider who rendered the
                                                                               service.
66       Duplicate payment to other     18 - Duplicate claim-service.          M86 - Service denied because         54 - Duplicate of a previously
         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 list                                         before we can consider payment.
         mailed to your office. Be sure
         to use the appropriate claim
         form to bill Medicare.




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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 treatments 119 - Benefit maximum for this time       None                               259 - Frequency of service.
         allowed in a 7 day period.    period or occurrence has been reached.

72       Similar item previously rented B15 - This service-procedure requires    N20 - Service not payable with     107 - Processed according to
         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 as
                                        other service-procedure has not been                                        adjustment to previous claim.
                                        received-adjudicated.

73       Claim paid copayment           3 - Co-payment Amount.                   None                               65 - Claim-line has been paid.
         deducted.
74       Rebill for services on a paper 125 - Submission-billing error(s).       N34 - Incorrect claim form-format 59 - Non-electronic request for
         claim.                                                                  for this service.                 information.
                                                                                                                   277 - Paper claim.




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75       Rebill with attached medical   16 - Claim-service lacks information    N29 - Missing documentation-             298 - Operative report.
         records, operative notes,      which is needed for adjudication.       orders-notes-summary-report-             421 - Medical review attachment-
         federal statements.                                                    chart.                                   information for service(s).
                                                                                N163 - Medical Record does not
                                                                                support code billed per the code
                                                                                definition.
76       Services not payable in      110 - Billing date predates service date. N301 - Missing-incomplete-invalid        510 - Future date
         advance.                                                               procedure date(s).
77       Rebill newborn care on a     125 - Submission-billing error(s).        N56 - Procedure code billed is not       454 - Procedure code for services
         separate claim and submit as                                           correct-valid for the service billed     rendered.
         a new claim.                                                           or the date of service billed.




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




79       This service is not payable to 170 - Payment is denied when                 N95 - This provider type -           25 - Entity not approved.
         your provider type or          performed-billed by this type of provider.   provider specialty may not bill this
         specialty in accordance with                                                service.
         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: If                                                N345 - Date range not valid with
         dates are not consecutive list                                              units submitted.
         each date of service on a
         separate line. Correct and
         resubmit.
81       Procedure allowed once in a 149 - Lifetime benefit maximum has              N117 - This service is paid only    259 - Frequency of service.
         lifetime.                   been reached for this service-benefit           once in a patients lifetime.
                                     category.



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82       Service is not consistent with- 125 - Submission-billing error(s).        M76 - Missing-incomplete-invalid 488 - Diagnosis code(s) for the
         or not covered for this                                                   diagnosis or condition.          services rendered.
         diagnosis-or description does
         not match diagnosis.



83       Exceeds legislative limits.    119 - Benefit maximum for this time    N130 - Alert- Consult plan benefit 259 - Frequency of service.
                                        period or occurrence has been reached. documents for information about
                                                                               restrictions for this service

84       Recipient is partially ineligible 141 - Claim spans eligible and ineligible None                           187 - Date(s) of service.
         for service dates. Resubmit a periods of coverage.                                                         456 - Covered Day(s).
         new claim billing only eligible
         dates of service.

85       Attending provider ID is       A1 - Claim-Service denied. At least one N253 - Missing-incomplete-invalid 21 - Missing or invalid information.
         missing, invalid, or           Remark Code must be provided (may       attending provider primary        562 - Entitys National Provider
         unresolved. Verify attending   be comprised of either the Remittance identifier.                         Identifier (NPI)
         provider ID and resubmit as    Advice Remark Code or NCPDP Reject
         a new claim or contact EDS     Reason Code)
         Provider Services if ID is
         correct
86       Adjustment of claim system. 45 - Charge exceeds fee schedule-       None                                101 - Claim was processed as
                                      maximum allowable or contracted-                                           adjustment to previous claim.
                                      legislated fee arrangement. (Use
                                      Group Codes PR or CO depending
                                      upon liability).
87       Only 22 radiation treatments 119 - Benefit maximum for this time    M86 - Service denied because        259 - Frequency of service.
         allowed in 4 wks.            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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88       Included in fee for services.     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.
                                           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 and-   submitted authorization number is            inconsistent with pre-certified-      84 - Service not authorized.
         or add PA number and              missing, invalid, or does not apply to the   authorized services.
         submit as a new claim.            billed services or provider.
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.
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)            None                                  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 are                                            required time limits following
         correct, submit claim to DMA,                                            receipt of this notice by following
         Claims Analysis Unit, see                                                the instructions included in your
         billing guidelines.                                                      contract or plan benefit
                                                                                  documents
94       Indicate private insurance        22 - This care may be covered by       MA04 - Secondary payment                    116 - Claim submitted to incorrect
         payment or attach denial and      another payer per coordination of      cannot be considered without the            payer.
         submit as a new claim, (UB        benefits.                              identity of or payment information          285 - Vouchers-explanation of
         form users may use                                                       from the primary payer. The                 benefits (EOB).
         insurance denial occurrence                                              information was either not
         codes). Attach Medicare                                                  reported or was illegible.
         vouchers if applicable.

95       Medicare denied. Rebill           148 - Information from another provider N82 - Provider must accept      132 - Entitys Medicaid provider id.
         EOMB with Medicaid claim.         was not provided or was insufficient-   insurance payment as payment in
                                           incomplete.                             full when a third party payer
                                                                                   contract specifies full
                                                                                   reimbursement.

     January 1, 2009                                                              Page 13
                                                          EOB Code Crosswalk to HIPAA Standard Codes


96        Patient liab-deduct applied to 142 - Monthly Medicaid patient liability   None                                98 - Charges applied to deductible.
          Medicare-Medicaid              amount.
          allowable.
97        Paid in part-full by Medicare. 23 - The impact of prior payer(s)          N360 - Alert- Coordination of       107 - Processed according to
                                         adjudication including payments and-or     benefits has not been calculated    contract-plan provisions.
                                         adjustments.                               when estimating benefits for this   286 - Other payers Explanation of
                                                                                    pre-determination. Submit           Benefits-payment information.
                                                                                    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. 483
          payable.                       maximum allowable or contracted-           agreement for restrictions-billing- - Maximum coverage amount met
                                         legislated fee arrangement. (Use           payment information related to      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 an       65 - Claim-line has been paid.
                                         since there will not be a CAS segment. 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 or agreement for restrictions-billing-     and is awaiting payment cycle.
          future.                        claim adjudication.                    payment information related to
                                                                                these charges
101       Pending normal in-house        133 - The disposition of this claim-   None                                    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-   None                                    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 None                                    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.




      January 1, 2009                                                          Page 14
                                                            EOB Code Crosswalk to HIPAA Standard Codes
105       Date of service is prior to      14 - The date of birth follows the date of None                               158 - Entitys date of birth.
          date of birth. If date of        service.                                                                      88 - Entity not eligible for benefits
          service and recipient MID are                                                                                  for submitted dates of service.
          correct, submit claim to DMA
          Claims Analysis Unit, see
          billing guidelines.
106       Recipient file problem under     31 - Claim denied as patient cannot be    N30 - Patient ineligible for this  56 - Awaiting eligibility
          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 ineligible   141 - Claim spans eligible and ineligible None                               88 - Entity not eligible for benefits
          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-invalid 65 - Claim-line has been paid. 631
          reimbursement rate adjusted maximum allowable or contracted-              room and board rate. N381 -         - Reimbursement Rate
          to rate on file.            legislated fee arrangement. (Use              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 to 45 - Charge exceeds fee schedule-              None                                 104 - Processed according to plan
          claims payment due to state maximum allowable or contracted-                                                   provisions.
          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).
113       Refund amount applied &     45 - Charge exceeds fee schedule-             None                                 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).
      January 1, 2009                                                           Page 15
                                                         EOB Code Crosswalk to HIPAA Standard Codes


114       Voided amount applied to      45 - Charge exceeds fee schedule-         None                                  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-      None                                  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 one N381 - Consult our contractual      98 - Charges applied to deductible.
                                        Remark Code must be provided (may       agreement for restrictions-billing-
                                        be comprised of either the Remittance payment information related to
                                        Advice Remark Code or NCPDP Reject these charges
                                        Reason Code)
118                                     31 - Claim denied as patient cannot be N185 - Alert- Do not resubmit this 56 - Awaiting eligibility
          Claim awaiting eligibility file
          update. Claim will be         identified as our insured.              claim-service                       determination.
          resubmitted for you.
119       Adjustment paid correctly per B13 - Previously paid. Payment for this   N381 - Consult our contractual        107 - Processed according to
          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 processed as
                                                                                  these charges                         adjustment to previous claim.
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     478 - Claim submitters identifier
          submit as a new claim.                                                  health insurance claim number.        (patient account number) is
                                                                                                                        missing.



121       Refile this claim & EOB -     A1 - Claim-Service denied. At least one   MA130 - Your claim contains       481 - Claim-submission format is
          system.                       Remark Code must be provided (may         incomplete and-or invalid         invalid.
                                        be comprised of either the Remittance     information, and no appeal rights
                                        Advice Remark Code or NCPDP Reject        are afforded because the claim is
                                        Reason Code)                              unprocessable. Please submit a
                                                                                  new claim with the complete-
                                                                                  correct information.



      January 1, 2009                                                          Page 16
                                                            EOB Code Crosswalk to HIPAA Standard Codes


122       Dates of service before prior 197 - Precertification-authorization-        N54 - Claim information is          84 - Service not authorized.
          approval date. Verify DOS     notification absent.                         inconsistent with pre-certified-    187 - Date(s) of service.
          and PA number; correct and                                                 authorized services.
          submit as a 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-    187 - Date(s) of service.
          and PA number; correct and                                                 authorized services.
          submit as a new claim.
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.
126       Rebill service using           125 - Submission-billing error(s).     N56 - Procedure code billed is not       454 - Procedure code for services
          appropriate habilitation code.                                        correct-valid for the service billed     rendered.
                                                                                or the date of service billed.




127       Not in accordance with          B5 - Coverage-program guidelines were      None                                21 - Missing or invalid information.
          Dental Policy guidelines.       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 claim   142 - Monthly Medicaid patient liability   N58 - Missing-incomplete-invalid 21 - Missing or invalid information.
          for partial month billing.      amount.                                    patient liability amount.
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.



      January 1, 2009                                                             Page 17
                                                           EOB Code Crosswalk to HIPAA Standard Codes

131       Resubmit as a new claim         16 - Claim-service lacks information      M29 - Missing operative report.    298 - Operative report.
          with operative record and-or    which is needed for adjudication.         N29 - Missing documentation-
          labor and delivery record,                                                orders-notes-summary-report-
          history and physical,                                                     chart.
          discharge summary,
          pathology report and
          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.

133       Enter correct bill type in form 125 - Submission-billing error(s).        MA30 - Missing-incomplete-         21 - Missing or invalid information.
          locator 4 and submit as a                                                 invalid type of bill.
          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 charges.                                              days or units of service.        revenue code.
                                                                                    M54 - Missing-incomplete-invalid
                                                                                    total charges.



135       Patient status missing/not in   125 - Submission-billing error(s).        MA43 - Missing-incomplete-         21 - Missing or invalid information.
          accordance with medicaid                                                  invalid patient status.            431 - Provide condition-functional
          policy/inconsistent with                                                                                     status at time of service.
          days/dates billed.                                                                                           90 - Entity not eligible for medical
                                                                                                                       benefits for submitted dates of
                                                                                                                       service.

136       Charge reduced per medical 45 - Charge exceeds fee schedule-              N10 - Claim-service adjusted       421 - Medical review attachment-
          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.


      January 1, 2009                                                            Page 18
                                                           EOB Code Crosswalk to HIPAA Standard Codes

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 - Procedure code for services
                                                                                      M79 - Missing-incomplete-invalid      rendered.
                                                                                      charge
139       Services limited presumptive   177 - Patient has not met the required       N30 - Patient ineligible for this     56 - Awaiting eligibility
          eligibility.                   eligibility requirements.                    service.                              determination.
140       Room charges reduced to        45 - Charge exceeds fee schedule-            N153 - Missing-incomplete-invalid     65 - Claim-line has been paid. 181
          semi-private or ward rate.     maximum allowable or contracted-             room and board rate. N381 -           - Hospitals room rate.
                                         legislated fee arrangement. (Use             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 services 125 - Submission-billing error(s).            N61 - Rebill services on separate     21 - Missing or invalid information.
          per claim form .                                                            claims.




142       Denied item must be            184 - The prescribing-ordering provider      N95 - This provider type -           91 - Entity not eligible-not approved
          obtained from state optical    is not eligible to prescribe-order the       provider specialty may not bill this for dates of service.
          contractor.                    service billed.                              service.
143       Medicaid ID number not on      31 - Claim denied as patient cannot be       None                                 33 - Subscriber and subscriber id
          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 approved
          for this provider number.      eligible to perform the service billed.      provider specialty may not bill this for dates of service.
                                                                                      service.
145       No Hysterectomy statement      16 - Claim-service lacks information         N3 - Missing consent form.           21 - Missing or invalid information.
          on file, attach or submit      which is needed for adjudication.                                                 421 - Medical review attachment-
          appropriate statement and                                                                                        information for service(s).
          file as a new claim,.


      January 1, 2009                                                              Page 19
                                                            EOB Code Crosswalk to HIPAA Standard Codes



146       Covered days paid at             45 - Charge exceeds fee schedule-      N153 - Missing-incomplete-invalid     65 - Claim-line has been paid.
          intermediate care rate.          maximum allowable or contracted-       room and board rate. N381 -           456 - Covered Day(s)
                                           legislated fee arrangement. (Use       Consult our contractual
                                           Group Codes PR or CO depending         agreement for restrictions-billing-
                                           upon liability).                       payment information related to
                                                                                  these charges
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 cut   B5 - Coverage-program guidelines were MA32 - Missing-incomplete-             259 - Frequency of service.
          off exceeded.                    not met or were exceeded.              invalid number of covered days        456 - Covered Day(s)
                                                                                  during the billing period.
                                                                                  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         None                               258 - Days-units for procedure-
          covered.                         adjustment.                                                                  revenue code.

151       Pending recoupment of claim      133 - The disposition of this claim-      None                                3 - Claim has been adjudicated
          - 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).



      January 1, 2009                                                             Page 20
                                                           EOB Code Crosswalk to HIPAA Standard Codes

153       Ancillary charges included in 125 - Submission-billing error(s).       M2 - Not paid separately when         21 - Missing or invalid information.
          per diem rate.                                                         the patient is an inpatient.




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.        523 - Anesthesia Unit Count
          billings. Anesthesia
          providers; one unit equals 1
          minute for general
          anesthesia TOS 07. Rebill
          corrected claim.
155       Medicare denied ambulance 96 - Non-covered charge(s).                  N381 - Consult our contractual        454 - Procedure code for services
          service. Not covered by                                                agreement for restrictions-billing-   rendered.
          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 lab                                             procedure code(s).                    rendered.
          CPT code. Enter CPT code                                                                                     455 - Revenue code for services
          and resubmit as a new claim.                                                                                 rendered.



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



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




      January 1, 2009                                                         Page 21
                                                          EOB Code Crosswalk to HIPAA Standard Codes


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.

161       Report does not justify higher 150 - Payment adjusted because the      None                                304 - Reports for service.
          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 physician                                            invalid beginning and ending       192 - Date of first service for
          and date patient was first                                              dates of the period billed.        current series-symptom-illness.
          seen for condition.



163       Handling fee requires name     125 - Submission-billing error(s).       N225 - Incomplete-invalid          21 - Missing or invalid information.
          of lab and test written on                                              documentation-orders-notes-        277 - Paper claim.
          claim. If ECS- tape bill,                                               summary-report-chart.              300 - Lab-test report-notes-results.
          resubmit on paper with
          required info.
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).               454 - Procedure code for services
          description and-or billed                                                                                rendered.
          amount. Refile corrected
          claim or attach explanation.

165       Breakdown charges using        125 - Submission-billing error(s).       N63 - Rebill services on separate 454 - Procedure code for services
          individual procedure codes.                                             claim lines.                      rendered.




166       Pending Buy-In investigation. 133 - The disposition of this claim-      None                               3 - Claim has been adjudicated
                                        service is pending further review.                                           and is awaiting payment cycle.


      January 1, 2009                                                          Page 22
                                                           EOB Code Crosswalk to HIPAA Standard Codes



167       No charge billed. Enter billed 125 - Submission-billing error(s).          M54 - Missing-incomplete-invalid 178 - Submitted charges.
          amount and submit detail as                                                total charges.
          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 non-     96 - Non-covered charge(s).                M79 - Missing-incomplete-invalid    178 - Submitted charges.
          covered charge.                                                            charge                              454 - Procedure code for services
                                                                                                                         rendered.
                                                                                                                         596 - Non-covered Charge Amount

170       Refile on EPSDT claim form. A1 - Claim-Service denied. At least one        N34 - Incorrect claim form-format 276 - UB04-HCFA-1450-1500
                                      Remark Code must be provided (may              for this service.                 claim form.
                                      be comprised of either the Remittance                                            481 - Claim submission format is
                                      Advice Remark Code or NCPDP Reject                                               invalid.
                                      Reason Code)
171       Resubmit with medical       16 - Claim-service lacks information           M127 - Missing patient medical      123 - Additional information
          information form attached.  which is needed for adjudication.              record for this service.            requested from entity.
                                                                                                                         421 - Medical review attachment-
                                                                                                                         information for service(s).
172       Less than 3 months pre-natal 125 - Submission-billing error(s).            N188 - The approved level of        345 - Treatment plan for service-
          care apparently given: Bill                                                care does not match the             diagnosis
          appropriate antepartum or                                                  procedure code submitted.           306 - Detailed description of
          E&M code depending on                                                                                          service.
          number of visits.


173       Transportation not to the       117 - Payment adjusted because             N157 - Transportation to-from this 101 - Claim was processed as
          nearest appropriate facility.   transportation is only covered to the      destination is not covered.        adjustment to previous claim.
          Please resubmit an              closest facility that can provide the                                         429 - Loaded miles and charges
          adjustment with                 necessary care.                                                               for transport to nearest facility with
          documentation to justify                                                                                      appropriate services.
          transport to this facility.                                                                                   430 - Nearest appropriate facility.




      January 1, 2009                                                             Page 23
                                                          EOB Code Crosswalk to HIPAA Standard Codes




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


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-HCFA-1450-1500
          correct bill type.                                                                                        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)      None                                21 - Missing or invalid information.
          indicated on EPSDT claim.      adjudication including payments and-or                                     107 - Processed according to
          Immunization paid to DHS.      adjustments.                                                               contract-plan provisions.

179       Service covered by HMO.        24 - Payment for charges adjusted.     None                                96 - No agreement with entity.
                                         Charges are covered under a capitation                                     585 - Denied Charge or Non-
                                         agreement-managed care plan.                                               covered Charge




      January 1, 2009                                                         Page 24
                                                           EOB Code Crosswalk to HIPAA Standard Codes




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

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




182       All claims suspended      133 - The disposition of this claim-          N187 - Alert- You may request a 46 - Internal review-audit.
          pending financial review. service is pending further review.            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 claim 125 - Submission-billing error(s).          N34 - Incorrect claim form-format 481 - Claim-submission format is
          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- 612 - Per Day Limit Amount
                                                                              similar procedure within set time
                                                                              frame.
185       Rebill service using         153 - Payment adjusted because the     M123 - Missing-incomplete-        21 - Missing or invalid information.
          appropriate code for dosage. payer deems the information submitted invalid name, strength, or dosage
                                       does not support this dosage.          of the drug furnished.




      January 1, 2009                                                          Page 25
                                                         EOB Code Crosswalk to HIPAA Standard Codes


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.




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




190       Dates of service changed for 45 - Charge exceeds fee schedule-        None                               187 - Date(s) of service.
          fiscal year end.             maximum allowable or contracted-
                                       legislated fee arrangement. (Use
                                       Group Codes PR or CO depending
                                       upon liability).
191       Medicaid ID number does not 140 - Patient-Insured health              None                               30 - Subscriber and subscriber id
          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.



      January 1, 2009                                                        Page 26
                                                         EOB Code Crosswalk to HIPAA Standard Codes

193       Allow once-2 years over age 119 - Benefit maximum for this time    M86 - Service denied because         259 - Frequency of service.
          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                  None                                 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.




199       Resubmit claim with          16 - Claim-service lacks information      N29 - Missing documentation-     21 - Missing or invalid information
          hysterectomy statement and which is needed for adjudication.           orders-notes-summary-report-     297 - Medical notes-report.
          medical records to include                                             chart.                           421 - Medical review attachment-
          history and physical,                                                                                   information for service(s).
          operative records, pathology
          and discharge summary.


      January 1, 2009                                                         Page 27
                                                            EOB Code Crosswalk to HIPAA Standard Codes




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


201       Date of service is before       B7 - This provider was not certified-        None                               48 - Referral-authorization.
          provider eligibility date. To   eligible to be paid for this procedure-                                         91 - Entity not eligible-not approved
          inquire, contact Division of    service on this date of service.                                                for dates of service.
          Medical Assistance, Provider
          Enrollment, 2506 Mail
          Service Center, Raleigh, NC
          27699-2506.
202       Revenue code must be billed     125 - Submission-billing error(s).           M20 - Missing-incomplete-invalid 21 - Missing or invalid information.
          with a DME- medical supply                                                   HCPCS.                           507 - HCPCS
          HCPC code.                                                                   M50 - Missing-incomplete-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 - Date(s) of service.
                                                                                       dates of the period billed.        188 - Statement from-through
                                                                                                                          dates



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 - Processed according to
          show EDC on the sterilization                                                                                   contract-plan provisions
          consent form,.




      January 1, 2009                                                               Page 28
                                                             EOB Code Crosswalk to HIPAA Standard Codes

205       No UPIN on claim. Refile with 125 - Submission-billing error(s).            None                                21 - Missing or invalid information.
          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 required.                                                invalid provider-supplier signature 466 - Entities original signature.




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


208        Resubmit for prior approved 197 - Precertification-authorization-          N54 - Claim information is          84 - Service not authorized.
          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 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.
          dental exam.                     other service-procedure has not been
                                           received-adjudicated.

210       Payment denied; there is no      58 - Payment adjusted because          None                                    344 - Documentation that provider
          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 facilities   or invalid place of service.
          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.

      January 1, 2009                                                              Page 29
                                                           EOB Code Crosswalk to HIPAA Standard Codes

212       Disproportionate share         119 - Benefit maximum for this time    None                                    259 - Frequency of service.
          hospital payment increase of   period or occurrence has been reached.
          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 RA which is needed for adjudication.            orders-notes-summary-report-
          to DMA, Program Integrity,                                                chart.
          Inpatient Psychiatric, 2515
          Mail Service Center, Raleigh,
          NC, 27699-2515.

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 note                                             summary-report-chart.
          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.



      January 1, 2009                                                            Page 30
                                                            EOB Code Crosswalk to HIPAA Standard Codes

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 - Number of miles patient was
          mile.                                                                                                       transported.
                                                                                                                      429 - Loaded miles and charges
                                                                                                                      for transport to nearest facility with
                                                                                                                      appropriate services

220       Resubmit claim with            16 - Claim-service lacks information        N29 - Missing documentation-            21 - Missing or invalid information.
          ambulance call reports to      which is needed for adjudication.           orders-notes-summary-report-            337 - Ambulance certification-
          justify one-way and round trip                                             chart.                                  documentation.
          transports on the same day.                                                N56 - Procedure code billed is not      431 - Provide condition-functional
                                                                                     correct-valid for the services          status at time of service
                                                                                     billed or the date of service billed.

221       A new prior approval request    197 - Precertification-authorization-      N54 - Claim information is              84 - Service not authorized.
          must be submitted for           notification absent.                       inconsistent with pre-certified-        258 - Days-units for procedure-
          additional units.                                                          authorized services.                    revenue code.
222       Recipient name that appears     16 - Claim-service lacks information       MA36 - Missing-incomplete-              31 - Subscriber and policyholder
          on the claim is not the same    which is needed for adjudication.          invalid patient name                    name mismatched
          name as on the attachment.
          Please attach a note of
          verification that this is the
          same person to claim-
          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 consults   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.
          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.


      January 1, 2009                                                             Page 31
                                                             EOB Code Crosswalk to HIPAA Standard Codes


226       The 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.                                                  421 - Medical review attachment-
          guidelines, resubmit a                                                                                        information for service(s).
          completed new '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 previously   97 - The benefit for this service is       M80 - Not covered when             454 - Procedure code for services
          paid cystourethroscopy           included in the payment-allowance for      performed during the same          rendered.
          code,.                           another service-procedure that has         session-date as a previously
                                           already been adjudicated.                  processed service for the patient.

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



      January 1, 2009                                                              Page 32
                                                             EOB Code Crosswalk to HIPAA Standard Codes
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)
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, child   received and covered. The qualifying      same date.
          emotionally disturbed,            other service-procedure has not been
          substance abuse or Willie         received-adjudicated.
          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 source.
          date on sterilization consent                                                                                 492 - Other Procedure Date.
          form has been 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.




      January 1, 2009                                                              Page 33
                                                             EOB Code Crosswalk to HIPAA Standard Codes

238       Claim adjusted to reflect         76 - Disproportionate Share Adjustment. None                                  104 - Processed according to plan
          disproportionate share rate.                                                                                    provisions.

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

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 and                                                incomplete and-or invalid         133 - Entitys UPIN
          refile claim with correct                                                   information, and no appeal rights
          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 approved
          DME enrolled providers.           is not eligible to prescribe-order the    provider specialty may not bill this for dates of service.
                                            service billed.                           service.
243       Ultra Sound previously paid       18 - Duplicate claim-service.             M86 - Service denied because         259 - Frequency of service.
          in HX for this DOS. If this is                                              payment already made for same-
          a second Ultra Sound,                                                       similar procedure within set time
          submit as adjustment with                                                   frame.
          documentation.

244       Resubmit claim with medical 16 - Claim-service lacks information            N29 - Missing documentation-        297 - Medical notes-report.
          records attached,.          which is needed for adjudication.               orders-notes-summary-report-
                                                                                      chart.
                                                                                      N163 - Medical Record does not
                                                                                      support code billed per the code
                                                                                      definition
245       Sterilization form missing-       16 - Claim-service lacks information      N3 - Missing consent form.          21 - Missing or invalid information.
          incomplete.                       which is needed for adjudication.

      January 1, 2009                                                              Page 34
                                                           EOB Code Crosswalk to HIPAA Standard Codes

246       Stamped witness signatures 125 - Submission-billing error(s).             N3 - Missing consent form.           21 - Missing or invalid information.
          are not acceptable on the                                                                                      107 - Processed according to
          sterilization consent form.                                                                                    contract plan provisions
          Have witness sign and
          resubmit.


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 services
          please recode and resubmit.                                               definition                           rendered




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 being                                               N29 - Missing documentation-
          performed same date of                                                    orders- notes- summary- report-
          service.                                                                  chart.
249       Instruct recipient to contact   22 - This care may be covered by          N185 - Alert- Do not resubmit this   116 - Claim submitted to incorrect
          Social Security to file Medi-   another payer per coordination of         claim-service                        payer.
          care benefits under renal       benefits.
          provisions. Process may take
          6 mos. do not resubmit
          Medicaid claim. EDS will
          submit your claim.
250       Over 6 hours of critical care   16 - Claim-service lacks information      N29 - Missing documentation-         294 - Supporting documentation.
          billed for the same date of     which is needed for adjudication.         orders-notes-summary-report-
          service. Please resubmit                                                  chart.
          claim with documentation of
          time (i.e.; ICU record;
          physician progress notes).
251       Please resubmit with            16 - Claim-service lacks information      N29 - Missing documentation-         262 - Type of surgery-service for
          anesthesia records,.            which is needed for adjudication          orders-notes-summary-report-         which anesthesia was
                                                                                    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 sterilization   which is needed for adjudication.         documentation-orders-notes-          107 - Processed according to
          guidelines not met.                                                       summary-report-chart.                contract-plan provisions.
                                                                                                                         666 - Surgical Procedure Code


      January 1, 2009                                                            Page 35
                                                             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 previous Remark Code must be provided (may            result of the appeal you filed.     adjustment to previous claim.
          adjustment of this claim.      be comprised of either the Remittance
                                         Advice Remark Code or NCPDP Reject
                                         Reason Code)
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 the 23 - The impact of prior payer(s)           MA34 - Missing-incomplete-         21 - Missing or invalid information.
          number of co-ins or lifetime adjudication including payments and-or        invalid number of coinsurance      458 - Coinsurance Day(s).
          reserve days billed to         adjustments.                                days during the billing period.    459 - Lifetime Reserve Day(s)
          correspond with monies on                                                  MA35 - Missing-incomplete-
          the voucher, and resubmit as                                               invalid number of lifetime reserve
          a new claim.                                                               days.

256       Claim cannot be processed.       A1 - Claim-Service denied. At least one   MA130 - Your claim contains         1 - For more detailed information,
          Explanation to follow.           Remark Code must be provided (may         incomplete and-or invalid           see remittance advice.
                                           be comprised of either the Remittance     information, and no appeal rights   104 - Processed according to plan
                                           Advice Remark Code or NCPDP Reject        are afforded because the claim is   provisions.
                                           Reason Code)                              unprocessable. Please submit a
                                                                                     new claim with the complete-
                                                                                     correct information.

257       Refile claim with itemized       16 - Claim-service lacks information      N26 - Missing itemized bill        110 - Claim requires pricing
          statement attached.              which is needed for adjudication.                                            information.
                                                                                                                        279 - Itemized claim
258       Adjustment referred to DMA       133 - The disposition of this claim-      N10 - Claim-service adjusted       258 - Days-units for procedure-
          for eligibility determination.   service is pending further review.        based on the findings of a review revenue code.
          Do not resubmit.                                                           organization-professional consult-
                                                                                     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- 612 - Per Day Limit Amount
                                                                                  similar procedure within set time
                                                                                  frame.                     N362 -
                                                                                  The number of Days or Units of
                                                                                  Service exceeds our acceptable
                                                                                  maximum
      January 1, 2009                                                             Page 36
                                                         EOB Code Crosswalk to HIPAA Standard Codes

260       Non-ionic contrast media not B15 - This service-procedure requires    N20 - Service not payable with       258 - Days-units for procedure-
          allowed same DOS as x-ray that a qualifying service-procedure be      other service rendered on the        revenue code.
          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 in   included in the payment-allowance for   performed during the same          rendered.
          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 being N381 - Consult our contractual      101 - Claim was processed as
          paid correctly.               maintained. This claim was processed agreement for restrictions-billing-     adjustment to previous claim.
                                        properly the first time                  payment information related to      107 - Processed according to
                                                                                 these charges                       contract-plan provisions.
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)
265       Adjustment must be filed on   125 - Submission-billing error(s).       N34 - Incorrect claim form-format   21 - Missing or invalid information.
          EDS adjustment request                                                 for this service.
          form.




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


      January 1, 2009                                                        Page 37
                                                           EOB Code Crosswalk to HIPAA Standard Codes



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
268       Refile adjustment with DMA- 16 - Claim-service lacks information          N1 - Alert- You may appeal this       21 - Missing or invalid information.
          5016 form and all related   which is needed for adjudication.             decision in writing within the
          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
          information along with a copy                                                                                   requested from entity.
          of the original claims RA.                                                                                      421 - Medical review attachment-
                                                                                                                          information for service(s).
270       Billing provider is not         38 - Services not provided or authorized N52 - Patient not enrolled in the      93 - Entity is not selected primary
          recipient's Carolina Access     by designated (network-primary care)     billing providers managed care         care provider.
          PCP. Authorization is           providers                                plan on the date of service.           252 - Authorization-certification
          missing or unresolved.                                                                                          number
          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 vouchers.      was not provided or was insufficient-   orders- notes- summary- report-         adjustment to previous claim.
          Resubmit with necessary         incomplete.                             chart.                                  123 - Additional information
          information along with a copy                                                                                   requested from entity.
          of original claims RA.                                                                                          285 - Vouchers-explanation of
                                                                                                                          benefits (EOB).



      January 1, 2009                                                            Page 38
                                                              EOB Code Crosswalk to HIPAA Standard Codes



272       Adjustment request denied,       138 - Claim-service denied. Appeal           M51 - Missing-incomplete-invalid 101 - Claim was processed as
          adjustments are not              procedures not followed or time limits       procedure code(s).               adjustment to previous claim.
          processed for rate changes.      not met.

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 as 45 - Charge exceeds fee schedule-                MA67 - Correction to a prior       101 - Claim was processed 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 has 45 - Charge exceeds fee schedule-                  MA67 - Correction to a prior       101 - Claim was processed as
          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 file. 142 - Monthly Medicaid patient liability   N58 - Missing-incomplete-invalid   21 - Missing or invalid information.
                                             amount.                                    patient liability amount.



      January 1, 2009                                                               Page 39
                                                         EOB Code Crosswalk to HIPAA Standard Codes

280       Full recoupment per Medical 45 - Charge exceeds fee schedule-         MA67 - Correction to a prior        101 - Claim was processed as
          or Policy review.           maximum allowable or contracted-          claim.                              adjustment to previous claim.
                                      legislated fee arrangement. (Use
                                      Group Codes PR or CO depending
                                      upon liability).
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 were None                               107 - Processed according to
          NDC number was placed on not met or were exceeded.                                                        contract-plan provisions.
          market by manufacturer.
285       Adjustment denied- change 125 - Submission-billing error(s).           N58 - Missing-incomplete-invalid   21 - Missing or invalid information.
          in patient liability should have                                       patient liability amount.
          been on claim before
          submission.



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


      January 1, 2009                                                        Page 40
                                                          EOB Code Crosswalk to HIPAA Standard Codes




287       Adjustment denied, reference 125 - Submission-billing error(s).          N1 - Alert- You may appeal this     101 - Claim was processed as
          only one claim per form.                                                 decision in writing within the      adjustment to previous claim.
          Refile adjustments                                                       required time limits following
          separately.                                                              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 not   197 - Precertification-authorization-      N54 - Claim information is         25 - Entity not approved.
          valid for Carolina Access     notification absent.                       inconsistent with pre-certified-   48 - Referral-authorization.
          recipient.                                                               authorized services.
290       RC code does not match        197 - Precertification-authorization-      N54 - Claim information is         21 - Missing or invalid information.
          DME prior approval number.    notification absent.                       inconsistent with pre-certified-
                                                                                   authorized services.
291       Resubmit claim stating which 16 - Claim-service lacks information        N29 - Missing documentation-       297 - Medical notes-report.
          tube-ovary was removed. If which is needed for adjudication.             orders-notes-summary-report-       298 - Operative report.
          bilateral, send records to                                               chart.                             421 - Medical review attachment-
          substantiate medical                                                     N163 - Medical Record does not     information for service(s).
          necessity.                                                               support code billed per the code
                                                                                   definition




      January 1, 2009                                                           Page 41
                                                           EOB Code Crosswalk to HIPAA Standard Codes


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 be benefits.                                         identity of or payment information    116 - Claim submitted to incorrect
          indicated, either as Medicare                                              from the primary payer. The           payer.
          crossover for DOS prior to 10-                                             information was either not            655 - Total Medicare Paid Amount
          1-02 or Third Party if 10-1-02                                             reported or was illegible.
          or after.                                                                  N192 - Patient is a Medicaid-
                                                                                     Qualified Medicare Beneficiary.
                                                                                     N381 - Consult our contractual
                                                                                     agreement for restrictions-billing-
                                                                                     payment information related to
                                                                                     these charges


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 point                                               number of miles traveled.        transported.
          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 be payment upon completion of services or   been separated to expedite
          resubmitted for you as            claim adjudication.                      handling. You will receive a
          multiple claims. Please watch                                              separate notice for the other
          for these claims on future R-                                              services reported.
          A‟s.                                                                       N185 - Alert- Do not resubmit this
                                                                                     claim-service


      January 1, 2009                                                            Page 42
                                                          EOB Code Crosswalk to HIPAA Standard Codes


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

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         476 - Missing or invalid units of
          records. Time-units reduced does not support this length of service     information, and no appeal rights service
          to match time documented (                                              are afforded because the claim is
          up to 3 hours).                                                         unprocessable. Please submit a
                                                                                  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 or     received and covered. The qualifying     same date.                            294 - Supporting documentation.
          member of same group.          other service-procedure has not been
          Resubmit as an adjustment      received-adjudicated.
          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



      January 1, 2009                                                         Page 43
                                                             EOB Code Crosswalk to HIPAA Standard Codes


303       Initial reline or adjustment of   119 - Benefit maximum for this time    M86 - Service denied because      259 - Frequency of service.
          complete upper dentures not       period or occurrence has been reached. payment already made for same-
          allowed until 6 months after                                             similar procedure within set time
          receipt of dentures per state                                            frame.
          limit.
304       Initial reline or adjustment of   119 - Benefit maximum for this time    M86 - Service denied because      259 - Frequency of service.
          partial upper dentures not        period or occurrence has been reached. payment already made for same-
          allowed until 6 months after                                             similar procedure within set time
          receipt of dentures per state                                            frame.
          limit.
305       Panorex not allowed in            B15 - This service-procedure requires    M86 - Service denied because      258 - Days-units for procedure-
          conjunction with full mouth       that a qualifying service-procedure be   payment already made for same- revenue code.
          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 retention,     B15 - This service-procedure requires    N20 - Service not payable with    258 - Days-units for procedure-
          and composite or amalgam          that a qualifying service-procedure be   other service rendered on the     revenue code.
          buildup not allowed on the        received and covered. The qualifying     same date.
          same date of service.             other service-procedure has not been
                                            received-adjudicated.

307       Initial reline or adjustment of   119 - Benefit maximum for this time    M86 - Service denied because      259 - Frequency of service.
          complete lower dentures not       period or occurrence has been reached. payment already made for same-
          allowed until 6 months after                                             similar procedure within set time
          receipt of dentures per state                                            frame.
          limit.
308       Related Service on same day       B15 - This service-procedure requires    M76 - Missing-incomplete-invalid 258 - Days-units for procedure-
          as Health Check screen not        that a qualifying service-procedure be   diagnosis or condition.          revenue code.
          supported by diagnosis.           received and covered. The qualifying
                                            other service-procedure has not been
                                            received-adjudicated.

309       Service is included in CORE. 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.
                                       another service-procedure that has            session-date as a previously
                                       already been adjudicated.                     processed service for the patient.



      January 1, 2009                                                            Page 44
                                                            EOB Code Crosswalk to HIPAA Standard Codes


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

311       Initial reline or adjustment of   119 - Benefit maximum for this time    M86 - Service denied because      259 - Frequency of service.
          partial lower dentures not        period or occurrence has been reached. payment already made for same-
          allowed until 6 months after                                             similar procedure within set time
          receipt of dentures per state                                            frame.
          limit.
312       Surgery fee includes charges      97 - The benefit for this service is    M80 - Not covered when             454 - Procedure code for services
          for casting- bracing.             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.

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 this                                             care does not match the           453 - Procedure Code modifier(s)
          procedure-modifier                                                        procedure code submitted.         for service(s) rendered.
          combination are not                                                       N225 - Incomplete-invalid
          substantiated on the claim-                                               documentation-orders-notes-
          records.                                                                  summary-report-chart



      January 1, 2009                                                           Page 45
                                                              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 for   included in the payment-allowance for   performed during the same           rendered.
          service. Resubmit as 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

319       Point of origin code           125 - Submission-billing error(s).          MA42 - Missing-incomplete-          21 - Missing or invalid information.
          submitted is missing or is not                                             invalid admission source.           229 - Hospital admission source.
          in accordance with medicaid
          policy. Rebill with correct
          source of admission code.
          Refer to UB manual.

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

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


      January 1, 2009                                                             Page 46
                                                            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 or    included in the payment-allowance for   performed during the same          rendered.
          consultations included in total   another service-procedure that has      session-date as a previously
          ob package will be recouped.      already been adjudicated.               processed service for the patient.

323       Hospital-office visits not   B15 - This service-procedure requires        M2 - Not paid separately when       258 - Days-units for procedure-
          allowed same date of service that a qualifying service-procedure be       the patient is an inpatient.        revenue code.
          .                            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 service that a qualifying service-procedure be       the patient is an inpatient.        revenue code.
          .                            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 rate                                              invalid principal procedure code. rendered.
          not covered for this date of                                              N188 - The approved level of
          service .                                                                 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 code                                                 incomplete and-or invalid           461 - NUBC occurrence code(s)
          24. Correct and resubmit as                                               information, and no appeal rights   and date(s).
          a new claim.                                                              are afforded because the claim is   462 - NUBC Occurrence Span
                                                                                    unprocessable. Please submit a      Code(s) and Date(s).
                                                                                    new claim with the complete-
                                                                                    correct information.

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.



      January 1, 2009                                                           Page 47
                                                              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 day.       period or occurrence has been reached. payment already made for same-      442 - Modalities of service.
                                                                                    similar procedure within set time   612 - Per Day Limit Amount
                                                                                    frame.
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 medicine       that a qualifying service-procedure be   other service rendered on the     revenue code.
          treatment is not allowed with      received and covered. The qualifying     same date.                        442 - Modalities of service.
          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 recording. another service-procedure that has           session-date as a previously
                                         already been adjudicated.                    processed service for the patient.

333       Machine charge denied,             108 - Rent-purchase guidelines were      None                              21 - Missing or invalid information.
          hospital owned equip.              not met.
334       Initial-established office visit   97 - The benefit for this service is     M80 - Not covered when             454 - Procedure code for services
          included in 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.

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



      January 1, 2009                                                             Page 48
                                                           EOB Code Crosswalk to HIPAA Standard Codes



336       Physician owned equipment - 108 - Rent-purchase guidelines were          None                              21 - Missing or invalid information.
          machine charge denied.      not met.

337       Critical care and ICU follow-   B15 - This service-procedure requires    N20 - Service not payable with    258 - Days-units for procedure-
          up 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.

338       Biopsy of cervix included in    97 - The benefit for this service is     M80 - Not covered when             454 - Procedure code for services
          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 cervix,   another service-procedure that has       session-date as a previously
          circumferential cone with or    already been adjudicated.                processed service for the patient.
          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 same     received and covered. The qualifying     same date.
          or different health             other service-procedure has not been
          department.                     received-adjudicated.

342       Dacryocystography includes 97 - The benefit for this service is          M80 - Not covered when             454 - Procedure code for services
          injection of contrast medium. 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.




      January 1, 2009                                                          Page 49
                                                          EOB Code Crosswalk to HIPAA Standard Codes

343       Colposcopy-culdoscopy        97 - The benefit for this service is      M80 - Not covered when              454 - Procedure code for services
          includes biopsy. 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

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- bracing 97 - The benefit for this service is      M80 - Not covered when             454 - Procedure code for services
          is included 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.

346       Charges for cast included in   97 - The benefit for this service is    M80 - Not covered when             454 - Procedure code for services
          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 in   97 - The benefit for this service is    M80 - Not covered when             454 - Procedure code for services
          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.

348       Charges for cast included in   97 - The benefit for this service is    M80 - Not covered when             454 - Procedure code for services
          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.



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                                                          EOB Code Crosswalk to HIPAA Standard Codes


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 or     received and covered. The qualifying     N20 - Service not payable with
          member of same group.          other service-procedure has not been     other service rendered on the
          Resubmit as an adjustment      received-adjudicated.                    same date.
          with documentation
          supporting related services.

350       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.
351       Prophylaxis w-fluoride fee    97 - The benefit for this service is      M80 - Not covered when               454 - Procedure code for services
          includes prophylaxis charges. 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.

352       Chemonucleolysis and           119 - Benefit maximum for this time    M86 - Service denied because           259 - Frequency of service.
          laminectomy cannot be billed period or occurrence has been reached. payment already made for same-
          within one year of each other.                                        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.
353       Antepartum, package can be 97 - The benefit for this service is       M80 - Not covered when                  259 - Frequency of service.
          billed only once in 300 days included in the payment-allowance for performed during the same                 454 - Procedure code for services
          prior to delivery. Laboratory another service-procedure that has      session-date as a previously           rendered.
          work is included in package already been adjudicated.                 processed service for the patient.
          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


      January 1, 2009                                                         Page 51
                                                           EOB Code Crosswalk to HIPAA Standard Codes




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

356       Mapped attending provider       A1 - Claim-Service denied.        N253 - Missing-incomplete-invalid 91 - Entity not eligible-not approved
          ID is not eligible on service                                     attending provider primary         for dates of service.         562 -
          date                                                              identifier.                        Entitys National Provider Identifier
                                                                                                               (NPI)
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.                                                           similar procedure within set time
                                                                            frame
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 panel included in the payment-allowance for performed during the same           rendered.
          that includes components   another service-procedure that has     session-date as a previously
          already paid.              already been adjudicated.              processed service for the patient.

360       Carbon dioxide determination 97 - The benefit for this service is        M80 - Not covered when             454 - Procedure code for services
          included in 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.

361       Labs included in adult health 97 - The benefit for this service is       M80 - Not covered when             454 - Procedure code for services
          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.




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                                                           EOB Code Crosswalk to HIPAA Standard Codes

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 amount
          components of a full mouth                                               similar procedure within set time met or exceeded for benefit period.
          survey.                                                                  frame.
                                                                                   N59 - Alert- Please refer to your
                                                                                   provider manual for additional
                                                                                   program and provider information

363       Not in accordance with          B5 - Coverage-program guidelines were    None                              21 - Missing or invalid information.
          medical policy guidelines.      not met or were exceeded.
364       Not in accordance with          B5 - Coverage-program guidelines were    None                              21 - Missing or invalid information.
          medical policy guidelines.      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 in   included in the payment-allowance for    performed during the same          rendered.
          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 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.

367       Semen analysis included in      97 - The benefit for this service is     M80 - Not covered when             454 - Procedure code for services
          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.



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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.

371       Supplies are included in fee   97 - The benefit for this service is     M80 - Not covered when             454 - Procedure code for services
          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 date 119 - Benefit maximum for this time     M86 - Service denied because          259 - Frequency of service.
          of service.                  period or occurrence has been reached. payment already made for same-        612 - Per Day Limit Amount
                                                                              similar procedure within set time
                                                                              frame.
373       Consults and hospital visits B15 - This service-procedure requires M2 - Not paid separately when          258 - Days-units for procedure-
          not allowed same DOS,        that a qualifying service-procedure be the patient is an inpatient.          revenue code.
          same provider specialty.     received and covered. The qualifying
                                       other service-procedure has not been
                                       received-adjudicated.

374       Consults and 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.

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 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.




      January 1, 2009                                                         Page 54
                                                        EOB Code Crosswalk to HIPAA Standard Codes



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.

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

382       Operative records received   125 - Submission-billing error(s).       MA130 - Your claim contains       21 - Missing or invalid information.
          have no DOS-or conflicting                                            incomplete and-or invalid         187 - Date(s) of service.
          DOS, correct claim-records                                            information, and no appeal rights 298 - Operative report.
          and resubmit both.                                                    are afforded because the claim is
                                                                                unprocessable. Please submit a
                                                                                new claim with the complete-
                                                                                correct information.




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                                                           EOB Code Crosswalk to HIPAA Standard Codes




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

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

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 as                                            payment already made for same-       processed claim-line.
          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 root    97 - The benefit for this service is    M80 - Not covered when               454 - Procedure code for services
          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 periodontal       already been adjudicated.               processed service for the patient.
          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 an included in the payment-allowance for       performed during the same           rendered.
          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 consults     B15 - This service-procedure requires    M2 - Not paid separately when        258 - Days-units for procedure-
          not allowed same DOS,            that a qualifying service-procedure be   the patient is an inpatient.         revenue code.
          same provider specialty.         received and covered. The qualifying
                                           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 same      B15 - This service-procedure requires    M2 - Not paid separately when        258 - Days-units for procedure-
          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. Admission       other service-procedure has not been
          WAIS bender.                     received-adjudicated.

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

394       Not in accordance with           B5 - Coverage-program guidelines were    None                                 258 - Days-units for procedure-
          medical policy guidelines.       not met or were exceeded.                                                     revenue code.
395       Delivery of placenta, external   97 - The benefit for this service is     M80 - Not covered when               454 - Procedure code for services
          cephalic version , or special    included in the payment-allowance for    performed during the same            rendered.
          miscellaneous services are       another service-procedure that has       session-date as a previously
          included in the fee for          already been adjudicated.                processed service for the patient.
          delivery.

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396       Carbon dioxide determination 97 - The benefit for this service is         M80 - Not covered when             454 - Procedure code for services
          included in 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.

397       Dilation and curettage           97 - The benefit for this service is     M80 - Not covered when              454 - Procedure code for services
          included in biopsy of cervix,    included in the payment-allowance for    performed during the same           rendered.
          circumferential cone with or     another service-procedure that has       session-date as a previously
          without D&C. Resubmit as         already been adjudicated.                processed service for the patient.
          an 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 only       6 - The procedure-revenue code is        None                              91 - Entity not eligible-not approved
          in health check for recipients   inconsistent with the patients age.                                        for dates of service.
          under 21.
399       Office visits and consults 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.

400       Admission- medical visits-       B15 - This service-procedure requires    N20 - Service not payable with    258 - Days-units for procedure-
          observation unit 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.

401       Medical visits- observation   B15 - This service-procedure requires       N20 - Service not payable with    258 - Days-units for procedure-
          unit not allowed 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.



      January 1, 2009                                                            Page 58
                                                          EOB Code Crosswalk to HIPAA Standard Codes

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

403       Medical visits- admission not B15 - This service-procedure requires      N20 - Service not payable with    258 - Days-units for procedure-
          allowed same day as initial   that a qualifying service-procedure be     other service rendered on the     revenue code.
          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 Home       that a qualifying service-procedure be    other service rendered on the     revenue code.
          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.

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

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

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

      January 1, 2009                                                          Page 59
                                                            EOB Code Crosswalk to HIPAA Standard Codes



409       Epidural follow-up- medical      B15 - This service-procedure requires    N20 - Service not payable with       258 - Days-units for procedure-
          visits 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.

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 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.

413       Blood gases 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.

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 service     other service-procedure has not been
          .                                received-adjudicated.

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




      January 1, 2009                                                           Page 60
                                                           EOB Code Crosswalk to HIPAA Standard Codes

416       Routine home care- general      B15 - This service-procedure requires    N20 - Service not payable with   258 - Days-units for procedure-
          respite care- general           that a qualifying service-procedure be   other service rendered on the    revenue code.
          inpatient care cannot be        received and covered. The qualifying     same date.
          billed on same date of          other service-procedure has not been
          service as continuous home      received-adjudicated.
          care.
417       Routine home care- inpatient    B15 - This service-procedure requires    M2 - Not paid separately when    258 - Days-units for procedure-
          respite care-general            that a qualifying service-procedure be   the patient is an inpatient.     revenue code.
          inpatient care not allowed      received and covered. The qualifying
          same date of service as         other service-procedure has not been
          continuous home care.           received-adjudicated.

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

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 respite received-adjudicated.
          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-hospice- received and covered. The qualifying     same date.
          LTC not allowed same day        other service-procedure has not been
          as general inp care.            received-adjudicated.

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

422       Only one routine home care      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- 612 - Per Day Limit Amount
                                                                                 similar procedure within set time
                                                                                 frame.

      January 1, 2009                                                          Page 61
                                                          EOB Code Crosswalk to HIPAA Standard Codes




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- 612 - Per Day Limit Amount
                                                                              similar procedure within set time
                                                                              frame.
424       Date of service on claim and 125 - Submission-billing error(s).     N3 - Missing consent form.        21 - Missing or invalid information.
          consent form disagree.                                                                                187 - Date(s) of service.
          Verify date of service and
          resubmit corrected claim or
          consent with documentation.


425       The consent form is illegible. 16 - Claim-service lacks information       N3 - Missing consent form.      123 - Additional information
          Resubmit claim with readable which is needed for adjudication.            N205 - Information provided was requested from entity.
          consent form.                                                             illegible.

426       Sterilization is non- covered. 96 - Non-covered charge(s).                M79 - Missing-incomplete-invalid 21 - Missing or invalid information.
          Place steri- related charges                                              charge                           454 - Procedure code for services
          in the non- covered column;                                                                                rendered.
          note the change in “remarks”
          field and resubmit as a new
          claim.

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 signature.
          sterilization consent form and-                                           signature                         467 - Entity signature date.
          or the physicians full                                                    MA71 - Missing-incomplete-
          signature must be dated on                                                invalid provider representative
          the date of surgery or after.                                             signature date.

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




      January 1, 2009                                                            Page 62
                                                             EOB Code Crosswalk to HIPAA Standard Codes
429       Screening not allowed same       B15 - This service-procedure requires     N20 - Service not payable with     258 - Days-units for procedure-
          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 admission       other service-procedure has not been
          wais bender.                     received-adjudicated.

430       Claim referred to the division   133 - The disposition of this claim-      N185 - Alert- Do not resubmit this 421 - Medical review attachment-
          of medical assistance for        service is pending further review.        claim-service                      information for service(s)
          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 management,      received and covered. The qualifying
          medication administration or     other service-procedure has not been
          hospital visits.                 received-adjudicated.

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

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

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




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                                                          EOB Code Crosswalk to HIPAA Standard Codes
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)
437       90742 and related vaccines ( B15 - This service-procedure requires       N20 - Service not payable with       258 - Days-units for procedure-
          hibg, rig, tig, vzig ) are not that a qualifying service-procedure be    other service rendered on the        revenue code.
          allowed on the same date of received and covered. The qualifying         same date.
          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 incorrect
          this claim must be submitted benefits.                                   identity of or payment information   payer.                        461
          to primary payer.                                                        from the primary payer. The          - NUBC occurrence code(s) and
                                                                                   information was either not           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 or                                               value code(s) or amount(s).      123 - Additional information
          incomplete. Rebill with                                                                                   requested from entity.
          complete value code data.                                                                                 463 - NUBC value code(s) and-or
          Refer to UB manual.                                                                                       amount(s).


440       Suspect dupe-exact service 18 - Duplicate claim-service.                 M86 - Service denied because         54 - Duplicate of a previously
          dated 4 digit procedure, prof.                                           payment already made for same-       processed claim-line.
          sys plug.                                                                similar procedure within set time
                                                                                   frame.
441       Suspect dupe-exact service     18 - Duplicate claim-service.             M86 - Service denied because         54 - Duplicate of a previously
          date, billed amount inst sys                                             payment already made for same-       processed claim-line.
          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.
      January 1, 2009                                                           Page 64
                                                             EOB Code Crosswalk to HIPAA Standard Codes


444       Medical screening exam fee        B15 - This service-procedure requires    M2 - Not paid separately when       258 - Days-units for procedure-
          denied due to inpatient claim     that a qualifying service-procedure be   the patient is an inpatient.        revenue code.
          paid in history for the same      received and covered. The qualifying     M86 - Service denied because
          date of service.                  other service-procedure has not been     payment already made for same-
                                            received-adjudicated.                    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 proc.                                                 payment already made for same-      processed claim-line.
          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 services      alternate benefit has been provided      the patient is an inpatient.        revenue code.
          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 claim     included in the payment-allowance for    the patient is an inpatient.        rendered.
          paid with same date of            another service-procedure that has
          service. Case management          already been adjudicated.
          fee is included in the hospital
          inpatient per diem.

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 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.


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                                                          EOB Code Crosswalk to HIPAA Standard Codes


452       Nursing home claim denied.     152 - Payment adjusted because the      M2 - Not paid separately when        21 - Missing or invalid information.
          Patient was inpatient for      payer deems the information submitted the patient is an inpatient.           56 - Awaiting eligibility
          some of these date of          does not support this length of service                                      determination.
          service. Rebill for covered
          days only. 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 sys                                             similar procedure within set time
          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 day service was not identified on this claim.   to primary procedure.               rendered.
          as surgical cleaning of skin.                                           N161 - This drug-service-supply
                                                                                  is covered only when the
                                                                                  associated service is covered.


455       Biopsy of skin only allowed 107 - The related or qualifying claim-    N161 - This drug-service-supply       454 - Procedure code for services
          when billed on the same day service was not identified on this claim. is covered only when the              rendered.
          as biopsy of skin lesion.                                             associated service is covered.

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


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                                                            EOB Code Crosswalk to HIPAA Standard Codes


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

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

465       Outpt charges within 24 hrs      B15 - This service-procedure requires    M2 - Not paid separately when       454 - Procedure code for services
          of admit not paid separately.    that a qualifying service-procedure be   the patient is an inpatient.        rendered.
          Add charges to inpt claim &      received and covered. The qualifying
          resubmit replacement claim.      other service-procedure has not been
          If mult encounter, bill others   received-adjudicated.
          not 24 hrs of admit,
          separately.


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                                                           EOB Code Crosswalk to HIPAA Standard Codes




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


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




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473       Nursing home days denied or B15 - This service-procedure requires    M2 - Not paid separately when       258 - Days-units for procedure-
          recouped to pay inpatient   that a qualifying service-procedure be   the patient is an inpatient.        revenue code.
          hospital days.              received and covered. The qualifying     M86 - Service denied because
                                      other service-procedure has not been     payment already made for same-
                                      received-adjudicated.                    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 service     18 - Duplicate claim-service.         M86 - Service denied because        54 - Duplicate of a previously
          date, prof sys plug.                                                 payment already made for same-      processed claim-line.
                                                                               similar procedure within set time
                                                                               frame.
476       Suspect 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.
477       Suspect 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.
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 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.
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-outpatient 18 - Duplicate claim-service.            M86 - Service denied because        54 - Duplicate of a previously
          hour. system plug.                                                   payment already made for same-      processed claim-line.
                                                                               similar procedure within set time
                                                                               frame.


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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.
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 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.
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.

      January 1, 2009                                                    Page 70
                                                           EOB Code Crosswalk to HIPAA Standard Codes

492       Exact dupe-overlap service      18 - Duplicate claim-service.             M86 - Service denied because        54 - Duplicate of a previously
          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-service-supply
          aspiration of cyst of breast.                                             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 procedure, 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.
498       Exact dupe dental 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.
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.


      January 1, 2009                                                          Page 71
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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 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
503       Allow 1 australian antigen lab- 119 - Benefit maximum for this time    M86 - Service denied because          259 - Frequency of service.
          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 for 119 - Benefit maximum for this time       M90 - Not covered more than           259 - Frequency of service.
          crd recipients.                 period or occurrence has been reached. once in a 12 month period.

505       Unacceptable consent form      16 - Claim-service lacks information      N3 - Missing consent form.          123 - Additional information
          copy. Resubmit consent         which is needed for adjudication.                                             requested from entity.
          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 and   included in the payment-allowance for     performed during the same          rendered.
          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 conjunction    service was not identified on this claim. to primary procedure.               rendered.
          with codes 95816,95819,or                                                N161 - This drug-service-supply
          95954. EEG must be billed                                                is covered only when the
          prior to payment for code                                                associated service is covered.
          95957.



      January 1, 2009                                                           Page 72
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508       Bitewing x-rays allowed once 119 - Benefit maximum for this time    M90 - Not covered more than       259 - Frequency of service.
          within 12 calendar months.   period or occurrence has been reached. once in a 12 month period.        483 - Maximum coverage amount
                                                                              N59 - Alert- Please refer to your met or exceeded for benefit period.
                                                                              provider manual for additional
                                                                              program and provider information

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

512       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
513       Inpatient respite care, RC655 B15 - This service-procedure requires M53 -Missing-incomplete-invalid        258 - Days-units for procedure-
          not allowed more than 5       that a qualifying service-procedure be days or units of service.             revenue code.
          consecutive days. Split and received and covered. The qualifying     N61 - Rebill services on separate
          rebill all subsequent days of other service-procedure has not been   claims.
          hospital stay as RC651        received-adjudicated.                  N63 - Rebill services on separate
          routine home care.                                                   claim lines.




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514       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
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 rehab B5 - Coverage-program guidelines were None                                 21 - Missing or invalid information.
          guidelines.                  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.
518       Allow one bone mineral       119 - Benefit maximum for this time    M86 - Service denied because        259 - Frequency of service.
          density every six months for period or occurrence has been reached. payment already made for same-
          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 every 119 - Benefit maximum for this time     M86 - Service denied because        259 - Frequency of service.
          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

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521       Supply code denied.            96 - Non-covered charge(s).             N56 - Procedure code billed is not 258 - Days-units for procedure-
          Additional payment not                                                 correct-valid for the services        revenue code.
          allowed unless facility-based                                          billed or the date of service billed.
          procedure has been                                                     M77 - Incomplete-invalid place of
          performed in physician office.                                         service(s).

522       Individual sealant included in 97 - The benefit for this service is    M80 - Not covered when             454 - Procedure code for services
          Quadrant previously billed.    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.

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.

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

525       Exceeds legislative limits for 119 - Benefit maximum for this time      None                              259 - Frequency of service.
          provider visits for fiscal year. period or occurrence has been reached.

526       Billed procedure only allowed 107 - The related or qualifying claim-    N19 - Procedure code incidental   454 - Procedure code for services
          on same day as Y2038,         service was not identified on this claim. to primary procedure.             rendered.
          Y2027,Y2039or Y2040.                                                    N161 - This drug-service-supply
                                                                                  is covered only when the
                                                                                  associated service is covered.


527       Laboratory services included 97 - The benefit for this service is      M80 - Not covered when             454 - Procedure code for services
          in hospital reimbursement.   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




528       Combine charges and rebill      A1 - Claim-Service denied. At least one   MA51 - Missing-incomplete-        258 - Days-units for procedure-
          using major surgery code.       Remark Code must be provided (may         invalid procedure code(s). N203 - revenue code.
          Indicate total time units in    be comprised of either the Remittance     Missing-incomplete-invalid        454 - Procedure code for services
          column G. File adjustment of    Advice Remark Code or NCPDP Reject        anesthesia time-units             rendered.
          previously paid claim if        Reason Code)                                                                523 - Anesthesia Unit Count
          necessary.
529       Rebill assistant surgeon on     125 - Submission-billing error(s).        N93 - A separate claim must be 21 - Missing or invalid information.
          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 monthly     97 - The benefit for this service is      M80 - Not covered when             454 - Procedure code for services
          professional dialysis 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.

532       Only one EKG allowed in 3       119 - Benefit maximum for this time    M86 - Service denied because        259 - Frequency of service.
          months for dialysis patients.   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




533       Only one nerve velocity test 119 - Benefit maximum for this time       M86 - Service denied because        259 - Frequency of service.
          allowed in 3 mths for dialysis. 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
534       Copay previously deducted 3 - Co-payment Amount                        None                                104 - Processed according to plan
          for this date of service.                                                                                  provisions.

535       Maximum allowable facility    45 - Charge exceeds fee schedule-         N381 - Consult our contractual      483 - Maximum coverage amount
          fee has been reached.         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).
536       Total surgical time must be   152 - Payment adjusted because the        M53 - Missing-incomplete-invalid 21 - Missing or invalid information.
          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 not 453 - Procedure Code Modifier(s)
          procedure -modifier code                                                correct-valid for the service billed for Service(s) Rendered.
          combination is not covered                                              or the date of service billed.       457 - Non-Covered Day(s).
          for the date of service.                                                N301 - Missing-incomplete-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.




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539       Exceeds limit for screening   119 - Benefit maximum for this time    M86 - Service denied because          259 - Frequency of service.
          mammogram: Age 35-39          period or occurrence has been reached. payment already made for same-
          allow one; age 40 and over                                           similar procedure within set time
          allow annual exam.                                                   frame.                         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

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 dialysis 97 - The benefit for this service is      M80 - Not covered when             454 - Procedure code for services
          includes fee for other 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.

542       Routine follow up is included 97 - The benefit for this service is      M80 - Not covered when             454 - Procedure code for services
          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.




      January 1, 2009                                                         Page 78
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544       Chemotherapy administration      97 - The benefit for this service is     M80 - Not covered when             454 - Procedure code for services
          denied, ov or consult            included in the payment-allowance for    performed during the same          rendered.
          included in administration fee   another service-procedure that has       session-date as a previously
          previously paid to the same      already been adjudicated.                processed service for the patient.
          provider for this date of
          service.

545       PDN services is non-covered 96 - Non-covered charge(s).                   M2 - Not paid separately when      454 - Procedure code for services
          when recipient is receiving                                               the patient is an inpatient.       rendered.
          inpatient services.

546       Chemo admin code includes        97 - The benefit for this service is     M80 - Not covered when             454 - Procedure code for services
          surgical procedure previously    included in the payment-allowance for    performed during the same          rendered.
          paid to same provider for        another service-procedure that has       session-date as a previously
          same DOS. Refund or              already been adjudicated.                processed service for the patient.
          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       Procedure 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.
          program. Rebill using the        received and covered. The qualifying   N52 - Patient not enrolled in the
          correct procedure code or        other service-procedure has not been   billing providers managed care
          confirm the client‟s CAP         received-adjudicated.                  plan on the date of service. N56 -
          status with the CAP case                                                Procedure code billed is not
          manager.                                                                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



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                                                          EOB Code Crosswalk to HIPAA Standard Codes

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
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-         612 - Per Day Limit Amount
                                                                              similar procedure within set time
                                                                              frame.
553       Refile with documentation of 16 - Claim-service lacks information   N29 - Missing documentation-          263 - Length of time for services
          time.                        which is needed for adjudication.      orders-notes-summary-report-          rendered
                                                                              chart.                                294 - Supporting documentation
554       Chronic disease monitoring B15 - This service-procedure requires N20 - Service not payable with           258 - Days-units for procedure-
          and components( Y2006,       that a qualifying service-procedure be other service rendered on the         revenue code.
          Y2007 and Y2024) not         received and covered. The qualifying   same date.
          allowed on the same day of other service-procedure has not been
          service.                     received-adjudicated.

555       Daily and monthly ESRD         B15 - This service-procedure requires    M86 - Service denied because      258 - Days-units for procedure-
          related services not allowed   that a qualifying service-procedure be   payment already made for same- revenue code.
          within the same calendar       received and covered. The qualifying     similar procedure within set time
          month.                         other service-procedure has not been     frame.
                                         received-adjudicated.

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

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558       Other diagnosis code 3 must      146 - Diagnosis was invalid for the      M64 - Missing-incomplete-invalid 21 - Missing or invalid information.
          be further subdivided. ( the     date(s) of service reported.             other diagnosis.                 255 - Diagnosis code.
          code must have four or five
          digits).
559       Other diagnosis code 4 must      146 - Diagnosis was invalid for the      M64 - Missing-incomplete-invalid 21 - Missing or invalid information.
          be further subdivided. ( the     date(s) of service reported.             other diagnosis.                 255 - Diagnosis code.
          code must have four or five
          digits).
560       Other diagnosis code 5 must      146 - Diagnosis was invalid for the      M64 - Missing-incomplete-invalid 21 - Missing or invalid information.
          be further subdivided.           date(s) of service reported.             other diagnosis.                 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-           612 - Per Day Limit Amount
          service.                                                           similar procedure within set time
                                                                             frame.
562       Service is included in the  97 - The benefit for this service is   M80 - Not covered when                   454 - Procedure code for services
          chemotherapy administration included in the payment-allowance for performed during the same                 rendered.
          code previously paid to the another service-procedure that has     session-date as a previously
          same provider for this DOS. already been adjudicated.              processed service for the patient.


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- 612 - Per Day Limit Amount
          per day.                                                                similar procedure within set time
                                                                                  frame.                       N362 -
                                                                                  The number of Days or Units of
                                                                                  Service exceeds our acceptable
                                                                                  maximum
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- 612 - Per Day Limit Amount
          hours ( 8 units) per day.                                               similar procedure within set time
                                                                                  frame.                       N362 -
                                                                                  The number of Days or Units of
                                                                                  Service exceeds our acceptable
                                                                                  maximum




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565       Assessments limited to two     119 - Benefit maximum for this time    M86 - Service denied because          259 - Frequency of service.
          hours ( 8 units ) per day.     period or occurrence has been reached. payment already made for same- 612 - Per Day Limit Amount
                                                                                similar procedure within set time
                                                                                frame.                        N362 -
                                                                                The number of Days or Units of
                                                                                Service exceeds our acceptable
                                                                                maximum
566       Physical therapy 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- 612 - Per Day Limit Amount
          per day.                                                              similar procedure within set time
                                                                                frame.                        N362 -
                                                                                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- 612 - Per Day Limit Amount
          per day.                                                              similar procedure within set time
                                                                                frame.                        N362 -
                                                                                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 to period or occurrence has been reached. payment already made for same- 612 - Per Day Limit Amount
          one per date of service.                                              similar procedure within set time
                                                                                frame.
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 match                                           N56 - Procedure code billed is not
          the code or code- modifier                                            correct-valid for the services
          billed by the primary                                                 billed or the date of service billed.
          physician for this date.                                              N188 - The approved level of
                                                                                care does not match the
                                                                                procedure code submitted.




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570       Percutaneous transluminal    119 - Benefit maximum for this time    M86 - Service denied because         259 - Frequency of service.
          angioplasty limit to four perperiod or occurrence has been reached. payment already made for same- 612 - Per Day Limit Amount
          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
571       Limit percutaneous           119 - Benefit maximum for this time    M86 - Service denied because         259 - Frequency of service.
          transluminal atherectomy to period or occurrence has been reached. payment already made for same- 612 - Per Day Limit Amount
          four 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
572       Service denied; PA has not 197 - Precertification-authorization-    N54 - Claim information is           48 - Referral-authorization.
          been obtained by the primary notification absent.                   inconsistent with pre-certified-     84 - Service not authorized.
          physician.                                                          authorized services.
573       Maternity care coordination 119 - Benefit maximum for this time     M86 - Service denied because         259 - Frequency of service.
          home visit allowed once per period or occurrence has been reached. payment already made for same- 612 - Per Day Limit Amount
          date of service.                                                    similar procedure within set time
                                                                              frame.
574       Procedure or procedure-      96 - Non-covered charge(s).            MA66 - Missing-incomplete-           453 - Procedure Code Modifier(s)
          modifier combination is not                                         invalid principal procedure code. for Service(s) Rendered.
          covered for the date of                                             N301 - Missing-incomplete-invalid 457 - Non-Covered Day(s).
          processing.                                                         procedure date(s).

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

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



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




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.       488 - Diagnosis code(s) for the
          Monday - Friday. Resubmit                                                                                      services rendered
          new claim for med screening
          exam fee (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 rendered                                                 invalid principal diagnosis.       488 - Diagnosis code(s) for the
          5pm to 8am Monday thru                                                                                         services rendered
          Friday or 24 hrs sat-sun.
          Service may be authorized by
          PCP or bill medical screening
          exam fee (W9922).


581       Invalid ER room auth for CA      197 - Precertification-authorization-      N54 - Claim information is         252 - Authorization-certification
          recipient. Rebill with correct   notification absent.                       inconsistent with pre-certified-   number.
          authorization or for                                                        authorized services.
          assessment fee W9922.

      January 1, 2009                                                              Page 84
                                                              EOB Code Crosswalk to HIPAA Standard Codes

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

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

584       Rebill on paper with medical 50 - These are non-covered services           N29 - Missing documentation-            277 - Paper claim.
          records that document        because this is not deemed a `medical         orders-notes-summary-report-            317 - Patients medical records.
          medical justification for    necessity by the payer.                       chart.
          removal of both tubes.                                                     N163 - Medical Record does not
                                                                                     support code billed per the code
                                                                                     definition
585       Rebill ECS with 'R' or 'L'         50 - These are non-covered services     N29 - Missing documentation-            59 - Non-electronic request for
          indicator. If bilateral            because this is not deemed a `medical   orders-notes-summary-report-            information.
          procedure was performed,           necessity by the payer.                 chart.                                  411 - Medical necessity for non-
          rebill on paper with medical                                               N163 - Medical Record does not          routine service(s)
          justification for removal of                                               support code billed per the code
          both tubes.                                                                definition
586       Records- claim indicate            125 - Submission-billing error(s).      N56 - Procedure code billed is not      21 - Missing or invalid information.
          additional procedures were                                                 correct-valid for the services          454 - Procedure code for services
          performed. Please add                                                      billed or the date of service billed.   rendered.
          appropriate ICD-9 procedure
          codes and submit as a new
          claim.
587       If sterilization charges are not   125 - Submission-billing error(s).      M76 - Missing-incomplete-invalid        178 - Submitted charges.
          covered, remove the                                                        diagnosis or condition.                 454 - Procedure code for services
          sterilization diagnosis and                                                N188 - The approved level of            rendered.                   488 -
          procedure codes from the                                                   care does not match the                 Diagnosis code(s) for the services
          claim and resubmit as a new                                                procedure code submitted.               rendered.
          claim.

      January 1, 2009                                                             Page 85
                                                           EOB Code Crosswalk to HIPAA Standard Codes


588       Surgical procedure is not    125 - Submission-billing error(s).          MA66 - Missing-incomplete-          21 - Missing or invalid information.
          billed on this claim. Please                                             invalid principal procedure code.
          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 not 21 - Missing or invalid information.
          invalid.                                                                 correct-valid for the services        490 - Other procedure code for
                                                                                   billed or the date of service billed. service(s) rendered

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

591       Claims history shows           16 - Claim-service lacks information      M29 - Missing operative report.     65 - Claim-line has been paid.
          Medicaid has previously paid which is needed for adjudication.           M30 - Missing pathology report.     298 - Operative report.
          for tonsillectomies for this                                                                                 311 - Pathology notes-report.
          recipient. 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 paid which is needed for adjudication.           M30 - Missing pathology report.     298 - Operative report
          for adenoidectomies for this                                                                                 311 - Pathology notes-report
          recipient. 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 not 21 - Missing or invalid information.
          invalid.                                                                 correct-valid for the services        490 - Other procedure code for
                                                                                   billed or the date of service billed. 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 paid    another service-procedure that has       session-date as a previously
          for the same date of service.   already been adjudicated.                processed service for the patient.



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

596       Billed procedure limited to     119 - Benefit maximum for this time    M86 - Service denied because        259 - Frequency of service.
          one per date of service.        period or occurrence has been reached. payment already made for same- 612 - Per Day Limit Amount
                                                                                 similar procedure within set time
                                                                                 frame.
597       Postpartum- newborn home        119 - Benefit maximum for this time    M86 - Service denied because        259 - Frequency of service.
          visit limited to one billing    period or occurrence has been reached. payment already made for same-
          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 per   been reached for this service-benefit    once in a patients lifetime.
          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 periodontal                                                similar procedure within set time
          evaluation and diagnosis                                                 frame.                       N357 -
          every 364 days.                                                          Time frame requirements
                                                                                   between this service-procedure-
                                                                                   supply and a related service-
                                                                                   procedure-supply have not been
                                                                                   met



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601       Only four quadrants of        149 - Lifetime benefit maximum has         M86 - Service denied because       259 - Frequency of service.
          periodontal surgery allowed   been reached for this service-benefit      payment already made for same-
          per lifetime.                 category                                   similar procedure within set time
                                                                                   frame.                        N362
                                                                                   - The number of Days or Units of
                                                                                   Service exceeds our acceptable
                                                                                   maximum
602       Sterilization epidural         125 - Submission-billing error(s).        M53 - Missing-incomplete-invalid 12 - One or more originally
          anesthesia cut back to reflect                                           days or units of service.          submitted procedure codes have
          time only when billed in                                                                                    been combined.
          conjunction with delivery
          under epidural.
603       Allow one oral evaluation      119 - Benefit maximum for this time    N59 - Alert- Please refer to your 259 - Frequency of service.
          within 6 calendar months.      period or occurrence has been reached. provider manual for additional    483 - Maximum coverage amount
                                                                                program and provider information met or exceeded for benefit period.


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-      612 - Per Day Limit Amount
          description limits code to 8                                         supply and a related service-
          units per day (1unit=1hour) .                                        procedure-supply have not been
          Correct and resubmit as a                                            met.                        N362 -
          new claim.                                                           The number of Days or Units of
                                                                               Service exceeds our acceptable
                                                                               maximum
605       Allow one routine dental      119 - Benefit maximum for this time    N59 - Alert- Please refer to your    259 - Frequency of service.
          prophylaxis within 6 calendar period or occurrence has been reached. provider manual for additional       483 - Maximum coverage amount
          months.                                                              program and provider information     met or exceeded for benefit period.

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


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

608       Recommended immunization 119 - Benefit maximum for this time            M86 - Service denied because      259 - Frequency of service.
          schedule exceeded for this    period or occurrence has been reached.    payment already made for same-
          vaccine. Recipient has                                                  similar procedure within set time
          received same immunization                                              frame.
          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 guidelines                                          MA48 - Missing-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.             242 - Tooth numbers, surfaces,
          resubmit claim.                                                                                          and-or quadrants involved.

611       Submit claim for payment to    109 - Claim not covered by this payer-   None                                116 - Claim submitted to incorrect
          the Carolina alternatives      contractor. You must send the claim to                                       payer.
          agency responsible for the     the correct payer-contractor.
          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.                                                                             processed claim-line.
                                                                                  invalid principal procedure code.
          Rebill additional time using                                                                            454 - Procedure code for services
          CPT 99292.                                                                                              rendered.
613       OB echography allowed once     119 - Benefit maximum for this time    M86 - Service denied because      259 - Frequency of service.
          per day, same provider.        period or occurrence has been reached. payment already made for same- 612 - Per Day Limit Amount
                                                                                similar procedure within set time
                                                                                frame.




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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            453 - Procedure code modifier(s)
          Refile claim and verify if free                                        information, and no appeal rights    for service(s) rendered.
          or purchased and dose                                                  are afforded because the claim is
          number in series. Thank you                                            unprocessable. Please submit a
          for reporting vaccine.                                                 new claim with the complete-
                                                                                 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- 612 - Per Day Limit Amount
          capsules(norplant) is allowed                                          similar procedure within set time
          once per date of service.                                              frame.

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-         612 - Per Day Limit Amount
          (norplant)allowed once per                                           similar procedure within set time
          date of service.                                                     frame.
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              446 - Documentation from prior
          additional payment from                                              information, and no appeal rights      claim(s) related to service(s).
          Medicaid, submit through                                             are afforded because the claim is
          adjustment or replacement                                            unprocessable. Please submit a
          claim                                                                new claim with the complete-
                                                                               correct information.




      January 1, 2009                                                        Page 90
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620       Vaccine requires 2 digit           125 - Submission-billing error(s).      MA130 - Your claim contains       21 - Missing or invalid information.
          modifier in block 24d. Refile                                              incomplete and-or invalid         453 - Procedure code modifier(s)
          claim and verify if vaccine is                                             information, and no appeal rights for service(s) rendered.
          free or purchased, dose no.                                                are afforded because the claim is
          in series, or if                                                           unprocessable. Please submit a
          contraindicated. Thanks for                                                new claim with the complete-
          reporting vaccine.                                                         correct information.

621       Date of next Health Check     125 - Submission-billing error(s).           N29 - Missing documentation-    21 - Missing or invalid information.
          screening missing, invalid or                                              orders- notes- summary- report- 187 - Date(s) of service.
          not in required mm-dd-yy                                                   chart.
          format in block 15 of CMS                                                  N78 - The necessary components
          1500 claim Form.                                                           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 your 21 - Missing or invalid information.
          calculated too far in the                                                  provider manual for additional    187 - Date(s) of service.
          future for the recipient's age                                             program and provider information 259 - Frequency of service.
          at this date 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 separate        included in the payment-allowance for   performed during the same          rendered.
          claim. Payment for w8208-          another service-procedure that has      session-date as a previously
          00955 includes the epidural.       already been adjudicated.               processed service for the patient.
          62278-62279 must be
          recouped to pay w8208-
          00955. Please file
          adjustment.
624       Duplicate procedure. Paid to       18 - Duplicate claim-service.    M86 - Service denied because       259 - Frequency of service.
          your office for a different date                                    payment already made for same-
          of service.                                                         similar procedure within set time
                                                                              frame.
625       Allow full mouth survey 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

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626       Exceeds maximum allowed          119 - Benefit maximum for this time    M86 - Service denied because        259 - Frequency of service.
          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 film 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- 612 - Per Day Limit Amount
                                                                                  similar procedure within set time
                                                                                  frame.
628       Allow one hyperbaric oxygen 119 - Benefit maximum for this time         M86 - Service denied because        259 - Frequency of service.
          therapy per 30 days.             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
629       Allow 1 service-day for div of 119 - Benefit maximum for this time      M86 - Service denied because        259 - Frequency of service.
          serv for blind.                  period or occurrence has been reached. payment already made for same- 612 - Per Day Limit Amount
                                                                                  similar procedure within set time
                                                                                  frame.
630       Only two visits allowed per      119 - Benefit maximum for this time    M86 - Service denied because        259 - Frequency of service.
          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 paid 18 - Duplicate claim-service.             M86 - Service denied because        259 - Frequency of service.
          for this date of service.                                               payment already made for same-
                                                                                  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.


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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 prior period or occurrence has been reached. Units of Service exceeds our
          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 allowed  period or occurrence has been reached. payment already made for same-         612 - Per Day Limit Amount
          per day.                                                            similar procedure within set time
                                                                              frame.
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-         612 - Per Day Limit Amount
                                                                              similar procedure within set time
                                                                              frame.
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-           612 - Per Day Limit Amount
                                                                              similar procedure within set time
                                                                              frame.
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-         612 - Per Day Limit Amount
                                                                              similar procedure within set time
                                                                              frame.
639       Follow-up allowed only twice 149 - Lifetime benefit maximum has     N362 - The number of Days or Units     259 - Frequency of service.
          in a life time.              been reached for this service-benefit  of Service exceeds our acceptable
                                       category                               maximum
640       Procedure allowed once in a 149 - Lifetime benefit maximum has      N117 - This service is paid only       259 - Frequency of service.
          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 follow 125 - Submission-billing error(s).      MA66 - Missing-incomplete-          21 - Missing or invalid information.
          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.



      January 1, 2009                                                         Page 93
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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-      612 - Per Day Limit Amount
                                                                                  similar procedure within set time
                                                                                  frame.
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.            263 - Length of time for services
          Speech Testing allowed per       does not support this many services.   N29 - Missing documentation-        rendered.
          day. One unit=1 hr. If billing                                          orders-notes-summary-report-        612 - Per Day Limit Amount
          more than 5 hrs submit                                                  chart.
          adjustment request with
          documentation of time.
646       Tympanostomy includes            97 - The benefit for this service is    M80 - Not covered when             454 - Procedure code for services
          myringotomy procedure paid       included in the payment-allowance for   performed during the same          rendered.
          previously. Resubmit as an       another service-procedure that has      session-date as a previously
          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 Units 259 - Frequency of service.
          lifetime without prior           been reached for this service-benefit   of Service exceeds our acceptable
          approval.                        category                                maximum
649       Ventilation assist               97 - The benefit for this service is    M80 - Not covered when             454 - Procedure code for services
          management includes cpap         included in the payment-allowance for   performed during the same          rendered.
          and-or cnp already paid.         another service-procedure that has      session-date as a previously
                                           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 paid        included in the payment-allowance for   performed during the same          rendered.
          for this date of service.        another service-procedure that has      session-date as a previously
                                           already been adjudicated.               processed service for the patient.



      January 1, 2009                                                          Page 94
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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 date   another service-procedure that has       session-date as a previously
          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 self- that a qualifying service-procedure be    other service rendered on the      revenue code.
          administered drugs. HIT       received and covered. The qualifying      same date.
          payments are being            other service-procedure has not been
          recouped.                     received-adjudicated.

654       Temporary closure of eyelids 97 - The benefit for this service is       M80 - Not covered when             454 - Procedure code for services
          by suture included in fee for included in the payment-allowance for     performed during the same          rendered.
          eye surgery same day.         another service-procedure that has        session-date as a previously
                                        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 - Per Day Limit Amount
          service, same or different     other service-procedure has not been     frame.
          provider.                      received-adjudicated.

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

657       HITself administered drugs     B15 - This service-procedure requires    N20 - Service not payable with     258 - Days-units for procedure-
          not allowed same day as IV     that a qualifying service-procedure be   other service rendered on the      revenue code.
          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 for included in the payment-allowance for    performed during the same          rendered.
          new hearing aid-aids.          another service-procedure that has       session-date as a previously
                                         already been adjudicated.                processed service for the patient.



      January 1, 2009                                                         Page 95
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659       HIT self-administered drugs     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.
          private duty nursing.           received and covered. The qualifying     same date.
                                          other service-procedure has not been
                                          received-adjudicated.

660       IV-pole not allowed same day B15 - This service-procedure requires       N20 - Service not payable with      258 - Days-units for procedure-
          as HIT self administered     that a qualifying service-procedure be      other service rendered on the       revenue code.
          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                                                       N188 - The approved level of
          Management and outpatient                                                care does not match the
          treatments.                                                              procedure code submitted

662       Influenza or pneumococcal        96 - Non-covered charge(s).             N30 - Patient ineligible for this   21 - Missing or invalid information.
          vaccine not covered for                                                  service.                            187 - Date(s) of service.
          recipients 21 years or older
          for date of service prior to 10-
          01-93 .
663       Procedure code w8211 no          96 - Non-covered charge(s).             N302 - Missing-incomplete-invalid 21 - Missing or invalid information.
          longer valid on or after 06-01-                                          other procedure date(s).          187 - Date(s) of service.
          93.                                                                                                        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 Health      that a qualifying service-procedure be   other service rendered on the       revenue code.
          Check screen or office visit.   received and covered. The qualifying     same date.
                                          other service-procedure has not been
                                          received-adjudicated.

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


      January 1, 2009                                                          Page 96
                                                            EOB Code Crosswalk to HIPAA Standard Codes


666       Previously submitted            16 - Claim-service lacks information         MA31 - Missing-incomplete-           21 - Missing or invalid information.
          sterilization claim and         which is needed for adjudication.            invalid beginning and ending         187 - Date(s) of service
          consent have been approved                                                   dates of the period billed.
          with a different DOS. Please                                                 N225 - Incomplete-invalid
          resubmit with records to                                                     documentation-orders- notes-
          verify your DOS or correct if                                                summary- report- chart.
          necessary.
667       Newborn assessment limited      149 - Lifetime benefit maximum has           N117 - This service is paid only     259 - Frequency of service.
          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.
672       Codes Y2141 and Y2151 not       B7 - This provider was not certified-        N95 - This provider type -           88 - Entity not eligible for benefits
          payable for health              eligible to be paid for this procedure-      provider specialty may not bill this for submitted dates of service.
          departments for services on     service on this date of service.             service.
          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 health 125 - Submission-billing error(s).               MA66 - Missing-incomplete-        21 - Missing or invalid information.
          departments for ages 11-99.                                                  invalid principal procedure code.
          Rebill using y2141.
675       Other procedure code 4 must 125 - Submission-billing error(s).               N56 - Procedure code billed is not 21 - Missing or invalid information.
          be further subdivided. (the                                                  correct-valid for the services        490 - Other procedure code for
          code must have 4 digits).                                                    billed or the date of service billed. service(s) rendered



      January 1, 2009                                                               Page 97
                                                          EOB Code Crosswalk to HIPAA Standard Codes

676       Other procedure code 5 must 125 - Submission-billing error(s).           N56 - Procedure code billed is not 21 - Missing or invalid information.
          be further subdivided. (the                                              correct-valid for the services        490 - Other procedure code for
          code must have 4 digits).                                                billed or the date of service billed. service(s) rendered.

677       Other procedure code 6 must 125 - Submission-billing error(s).           N56 - Procedure code billed is not 21 - Missing or invalid information.
          be further subdivided. (the                                              correct-valid for the services        490 - Other procedure code for
          code must have 4 digits).                                                billed or the date of service billed. service(s) rendered

678       Medicaid does not reimburse 119 - Benefit maximum for this time          None                                259 - Frequency of service.
          for multiple repeat         period or occurrence has been reached.
          sterilizations.
679       Correct codes w8206 or      125 - Submission-billing error(s).           M76 - Missing-incomplete-invalid    21 - Missing or invalid information.
          w8207 and rebill on paper                                                diagnosis or condition.             277 - Paper claim.
          with federal statement and                                               N59 - Alert- Please refer to your   421 - Medical review attachment-
          records.                                                                 provider manual for additional      information for service(s).
                                                                                   program and provider information

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

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 code.                                              N59 - Alert- Please refer to your
          Correct and resubmit.                                                    provider manual for additional
                                                                                   program and provider information

682       Induced abortion procedure     11 - The diagnosis is inconsistent with   M76 - Missing-incomplete-invalid    21 - Missing or invalid information.
          code must be billed with       the procedure.                            diagnosis or condition.             421 - Medical review attachment-
          appropriate diagnosis.                                                   N59 - Alert- Please refer to your   information for service(s).
          Correct and resubmit on                                                  provider manual for additional      488 - Diagnosis code(s) for the
          paper with records and                                                   program and provider information    services rendered.
          statement.
683       Rebill on paper with federal   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-     277 - Paper claim.
                                                                                   chart.                              421 - Medical review attachment-
                                                                                                                       information for service(s).


      January 1, 2009                                                           Page 98
                                                            EOB Code Crosswalk to HIPAA Standard Codes


684       Only 30 Home Health visits     119 - Benefit maximum for this time    M86 - Service denied because       259 - Frequency of service.
          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 for 6 - The procedure-revenue code is       None                               475 - Procedure code not valid for
          Medicaid recipients birth thru inconsistent with the patients age                                        patient age.
          age 20 only.
686       Prior approval is required for 197 - Precertification-authorization-  N54 - Claim information is         48 - Referral-authorization.
          more than 15 consecutive       notification absent.                   inconsistent with pre-certified-   84 - Service not authorized.
          therapeutic leave days.                                               authorized services.

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

688       Refile with Medicare: part B     23 - The impact of prior payer(s)      None                                  116 - Claim submitted to incorrect
          buy-in is now effective for      adjudication including payments and-or                                       payer.
          these dates of service.          adjustments.
689       Claim previously submitted to    23 - The impact of prior payer(s)      None                                  116 - Claim submitted to incorrect
          Medicare with an incorrect       adjudication including payments and-or                                       payer.
          hic number. Please correct       adjustments.
          the hic number and refile with
          Medicare.

690       Please re-file with Medicare: 22 - This care may be covered by            M86 - Service denied because        107 - Processed according to
          Records indicate that         another payer per coordination of           payment already made for same-      contract-plan provisions.
          someone other than            benefits.                                   similar procedure within set time   116 - Claim submitted to incorrect
          Medicaid is paying Medicare                                               frame.                              payer.
          part B premiums for this
          recipient for these dates of
          service.


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691       Medicare denied your claim 23 - The impact of prior payer(s)          None                               116 - Claim submitted to incorrect
          for correction and-or          adjudication including payments and-or                                    payer.
          additional information. Please adjustments.                                                              123 - Additional information
          refile to Medicare with the                                                                              requested from entity.
          eomb correction requested.

692       Refresher childbirth classes 119 - Benefit maximum for this time    M86 - Service denied because         259 - Frequency of service.
          limited to once - 180 dys.   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
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-       612 - Per Day Limit Amount
                                                                              similar procedure within set time
                                                                              frame.
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-       612 - Per Day Limit Amount
          Rebill using RC651.                                                 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
695       One colectomy 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-       612 - Per Day Limit Amount
                                                                              similar procedure within set time
                                                                              frame.
696       One colonoscopy 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-       612 - Per Day Limit Amount
                                                                              similar procedure within set time
                                                                              frame.
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-       612 - Per Day Limit Amount
                                                                              similar procedure within set time
                                                                              frame.

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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 - Missing or invalid units of
          billing only one unit.                                                                                     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 visit   125 - Submission-billing error(s).     M13 - Only one initial visit is      21 - Missing or invalid information.
          code.                                                                 covered per specialty per medical 454 - Procedure code for services
                                                                                group.                               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.)
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 12    97 - The benefit for this service is      M80 - Not covered when             454 - Procedure code for services
          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.




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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 similar rendered.
          Please file adjustment.         another service-procedure that has      procedure within set time frame
                                          already been adjudicated.               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 DME      119 - Benefit maximum for this time    M86 - Service denied because        259 - Frequency of service.
          guidelines.                     period or occurrence has been reached. payment already made for same-
                                                                                 similar procedure within set time
                                                                                 frame
706       Myelodysplasia clinic limited   119 - Benefit maximum for this time    M86 - Service denied because        259 - Frequency of service.
          to once per 90 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
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




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708       Admission H&P allowed once 119 - Benefit maximum for this time        M86 - Service denied because        259 - Frequency of service.
          per hospitalization. Transfers period or occurrence has been reached. payment already made for same-
          within the same facility do not                                       similar procedure within set time
          support the billing of a new                                          frame.                       N357 -
          admission. Rebill appropriate                                         Time frame requirements
          level CPT E-M code.                                                   between this service-procedure-
                                                                                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 procedure. period or occurrence has been reached. payment already made for same-
                                                                                similar procedure within set time
                                                                                frame
710       Only one corneal transplant 119 - Benefit maximum for this time       M86 - Service denied because        259 - Frequency of service.
          per day. If surgery            period or occurrence has been reached. payment already made for same- 612 - Per Day Limit Amount
          performed on both eyes,                                               similar procedure within set time
          document and submit as an                                             frame.
          adjustment.
711       Only one epidural follow-up 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- 612 - Per Day Limit Amount
                                                                                similar procedure within set time
                                                                                frame.
712       Only one epidural procedure 119 - Benefit maximum for this time       M86 - Service denied because        259 - Frequency of service.
          allowed every four days.       period or occurrence has been reached. payment already made for same-
                                                                                similar procedure within set time
                                                                                frame
713       Lupron depot limited to once 119 - Benefit maximum for this time      M86 - Service denied because        259 - Frequency of service.
          every 28 days.                 period or occurrence has been reached. payment already made for same-
                                                                                similar procedure within set time
                                                                                frame
714       Routine, annual or screening 96 - Non-covered charge(s).              M79 - Missing-incomplete-invalid 454 - Procedure code for services
          mammography non-covered.                                              charge                              rendered.

715       Original surgery fee includes 97 - The benefit for this service is      M80 - Not covered when             454 - Procedure code for services
          multiple stage retinal repair. 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

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-           612 - Per Day Limit Amount
                                                                               similar procedure within set time
                                                                               frame.
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-           612 - Per Day Limit Amount
                                                                               similar procedure within set time
                                                                               frame.
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-           612 - Per Day Limit Amount
                                                                               similar procedure within set time
                                                                               frame.
719       Exceeds CAP limitation for    B5 - Coverage-program guidelines were N362 - The number of Days or              259 - Frequency of service.
          Case Management.              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 following
          Please file an adjustment     received-adjudicated.                     the instructions included in your
          request with documentation                                              contract or plan benefit
          for exceptions.                                                         documents.
                                                                                  N20 - Service not payable with
                                                                                  other service rendered on the
                                                                                  same date.
                                                                                  N29 - Missing documentation-
                                                                                  orders- notes- summary- report-
                                                                                  chart.
721       Each additional lesion only   107 - The related or qualifying claim-    N19 - Procedure code incidental       465 - Principal Procedure Code for
          allowed when billed on the    service was not identified on this claim. to primary procedure.                 Service(s) Rendered.
          same day as excision of                                                 N161 - This drug-service-supply
          breast lesion.                                                          is covered only when the
                                                                                  associated service is covered.



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


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- 612 - Per Day Limit Amount
                                                                                 similar procedure within set time
                                                                                 frame.
724       Limit one CAP screening per 119 - Benefit maximum for this time        M86 - Service denied because        259 - Frequency of service.
          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 and that a qualifying service-procedure be other service rendered on the       revenue code.
          2-4 digits not allowed on the received and covered. The qualifying     same date.
          same date of service.           other service-procedure has not been
                                          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 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



      January 1, 2009                                                         Page 105
                                                             EOB Code Crosswalk to HIPAA Standard Codes



728       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

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 on        B15 - This service-procedure requires    N20 - Service not payable with   258 - Days-units for procedure-
          the same date of service as       that a qualifying service-procedure be   other service rendered on the    revenue code.
          limited oral evaluation           received and covered. The qualifying     same date.
          problem focused.                  other service-procedure has not been
                                            received-adjudicated.

731       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

732       Gamma globulin may be             119 - Benefit maximum for this time    M86 - Service denied because      259 - Frequency of service.
          billed only one time per date     period or occurrence has been reached. payment already made for same- 612 - Per Day Limit Amount
          of service. If billing multiple                                          similar procedure within set time
          units, rebill using the                                                  frame.
          appropriate dose specific
          HCPC code.



      January 1, 2009                                                           Page 106
                                                           EOB Code Crosswalk to HIPAA Standard Codes

733       Depo-Provera contraceptive     119 - Benefit maximum for this time     M86 - Service denied because        259 - Frequency of service.
          injection allowed once every   period or occurrence has been reached. payment already made for same-
          75 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
734       V20.2 must be primary          11 - The diagnosis is inconsistent with M76 - Missing-incomplete-invalid 254 - Primary diagnosis code.
          diagnosis for Health Check     the procedure.                          diagnosis or condition.
          screening visit.
735       Diagnosis modifier missing or 4 - The procedure code is inconsistent       None                          488 - Diagnosis code(s) for the
          invalid for diagnosis code (s). with the modifier or a required modifier                                 services rendered
          Health check visit requires     is missing.
          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 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

737       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

738       One supply item 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- 612 - Per Day Limit Amount
                                                                             similar procedure within set time
                                                                             frame.

      January 1, 2009                                                           Page 107
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739       HIV Case Management daily 119 - Benefit maximum for this time      M86 - Service denied because        259 - Frequency of service.
          limit has exceeded the      period or occurrence has been reached. payment already made for same- 612 - Per Day Limit Amount
          maximum of 96 units allowed                                        similar procedure within set time
          per day.                                                           frame.                       N362 -
                                                                             The number of Days or Units of
                                                                             Service exceeds our acceptable
                                                                             maximum
740       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

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-year- 119 - Benefit maximum for this time    M90 - Not covered more than            259 - Frequency of service.
          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 for 119 - Benefit maximum for this time    N381 - Consult our contractual          259 - Frequency of service.
          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

      January 1, 2009                                                       Page 108
                                                        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 allowable    119 - Benefit maximum for this time    M86 - Service denied because          259 - Frequency of service.
          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 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

749       Prior claim for Case         18 - Duplicate claim-service.         M86 - Service denied because       259 - Frequency of service.
          Management has been paid                                           payment already made for same-
          for this month.                                                    similar procedure within set time
                                                                             frame.
750       Therapeutic leave days have 119 - Benefit maximum for this time    M86 - Service denied because       259 - Frequency of service.
          exceeded the maximum of     period or occurrence has been reached. payment already made for same-
          60 allowed for the calendar                                        similar procedure within set time
          year.                                                              frame.                        N357
                                                                             - Time frame requirements
                                                                             between this service-procedure-
                                                                             supply and a related service-
                                                                             procedure-supply have not been
                                                                             met

      January 1, 2009                                                      Page 109
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751       Adult health assessment       119 - Benefit maximum for this time    M90 - Not covered more than           259 - Frequency of service.
          limited to once per 365 days. period or occurrence has been reached. once in a 12 month period.

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 root period or occurrence has been reached. payment already made for same-
          planning allowed every 364                                            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
755       ESRD related services for full 125 - Submission-billing error(s).     M53 - Missing-incomplete-invalid     258 - Days-units for procedure-
          month must be billed using                                            days or units of service.            revenue code.
          the last day of the month and                                         MA31 - Missing-incomplete-           259 - Frequency of service.
          one unit of service.                                                  invalid beginning and ending         476 - Missing or invalid units of
                                                                                dates of the period billed.          service.
756       Allow circumcision once per 149 - Lifetime benefit maximum has        N117 - This service is paid only     259 - Frequency of service.
          lifetime.                      been reached for this service-benefit  once in a patients lifetime.
                                         category
757       Allow therapeutic apheresis 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-       612 - Per Day Limit Amount
                                                                                similar procedure within set time
                                                                                frame.
758       Allow 1 dental sealant         119 - Benefit maximum for this time    None                                 259 - Frequency of service.
          (01351) per tooth.             period or occurrence has been reached.


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759       Colposcopy allowed once 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-             612 - Per Day Limit Amount
                                                                             similar procedure within set time
                                                                             frame.
760       Only one diagnosis modifier 125 - Submission-billing error(s).     MA130 - Your claim contains                258 - Days-units for procedure-
          allowed in block 24d per                                           incomplete and-or invalid                  revenue code.
          diagnosis code. 1N not                                             information, and no appeal rights
          allowed in conjunction with                                        are afforded because the claim is
          another diagnosis modifier                                         unprocessable. Please submit a
          such as 2E, etc.                                                   new claim with the complete-
                                                                             correct information.

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 multiple 50 - These are non-covered services    N180 - This item or service does 411 - Medical necessity for non-
          ultrasounds not 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

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




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765       Only one FP initial-complete   119 - Benefit maximum for this time    M86 - Service denied because       259 - Frequency of service.
          physical per 335 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
766       Medical necessity for multiple 50 - These are non-covered services    N180 - This item or service does 411 - Medical necessity for non-
          non stress test not 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

767       One adult health screening     119 - Benefit maximum for this time    M90 - Not covered more than         259 - Frequency of service.
          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 payment 119 - Benefit maximum for this time       M86 - Service denied because         259 - Frequency of service.
          limit per 10 week period has period or occurrence has been reached. payment already made for same-
          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 visits. period or occurrence has been reached. Units of Service exceeds our
                                                                               acceptable maximum
771       Procedure allowed once in a 149 - Lifetime benefit maximum has       N117 - This service is paid only     259 - Frequency of service.
          lifetime.                     been reached for this service-benefit  once in a patients lifetime.
                                        category
772       Allow one refraction per year 119 - Benefit maximum for this time    M90 - Not covered more than          259 - Frequency of service.
          on recipients under age       period or occurrence has been reached. once in a 12 month period.
          twenty five.


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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 two 119 - Benefit maximum for this time     M86 - Service denied because           259 - Frequency of service.
          years on recipients age 25    period or occurrence has been reached. payment already made for same-
          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-         612 - Per Day Limit Amount
          adjustment, attach time                                              similar procedure within set time
          documentation.                                                       frame.
776       Allow two 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
777       Rebill established visit code 125 - Submission-billing error(s).     M13 - Only one initial visit is        21 - Missing or invalid information.
          92012 or 92014 for dates of                                          covered per specialty per medical
          service 11-01-90 and there                                           group.
          after.
778       Zoladex allowed once in 28 119 - Benefit maximum for this time       N118 - This service is not paid if     259 - Frequency of service.
          days.                         period or occurrence has been reached. billed more than once every 28
                                                                               days


      January 1, 2009                                                       Page 113
                                                         EOB Code Crosswalk to HIPAA Standard Codes


779       Refractive code denied due 125 - Submission-billing error(s).           M13 - Only one initial visit is   21 - Missing or invalid information.
          to a medical diagnosis-                                                 covered per specialty per medical 454 - Procedure code for services
          medical office visit paid in                                            group.                            rendered.
          history with the same date of
          service. 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 interview 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
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-       612 - Per Day Limit Amount
                                                                                  similar procedure within set time
                                                                                  frame.
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 limited 149 - Lifetime benefit maximum has     N362 - The number of Days or         259 - Frequency of service.
          to 15 per recipient's lifetime. been reached for this service-benefit   Units of Service exceeds our
                                           category                               acceptable maximum


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785       Professional retraining fees  149 - Lifetime benefit maximum has     N362 - The number of Days or         259 - Frequency of service.
          limited to eighteen.          been reached for this service-benefit  Units of Service exceeds our
                                        category                               acceptable maximum
786       Only three visual field exams 119 - Benefit maximum for this time    M86 - Service denied because         259 - Frequency of service.
          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
788       Only one therapeutic abortion 119 - Benefit maximum for this time    M86 - Service denied because         259 - Frequency of service.
          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
789       Spinal orthotics allowed once 119 - Benefit maximum for this time    M86 - Service denied because         259 - Frequency of service.
          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


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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 aide      119 - Benefit maximum for this time    M86 - Service denied because          259 - Frequency of service.
          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
792       Epogen units exceeded.        119 - Benefit maximum for this time    N358 - Alert- This decision may       259 - Frequency of service.
          Please resubmit as an         period or occurrence has been reached. be reviewed if additional
          adjustment with lab results                                          documentation as described in
          and documentation to                                                 the contract or plan benefit
          support payment for                                                  documents is submitted.
          additional units.                                                    N362 - The number of Days or
                                                                               Units of Service exceeds our
                                                                               acceptable maximum
793       Reimbursement for epidural    97 - The benefit for this service is   M80 - Not covered when                454 - Procedure code for services
          is included in payment of     included in the payment-allowance for performed during the same              rendered.
          code w8208-00955.             another service-procedure that has     session-date as a previously
                                        already been adjudicated.              processed service for the patient.

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



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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 code for services
          admitting-attending                                                                                       rendered.
          physician. Rebill as a consult.

796       Pentamidine aerosol therapy 119 - Benefit maximum for this time      M86 - Service denied because        259 - Frequency of service.
          limited to once every 4       period or occurrence has been reached. payment already made for same-
          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 vaccine. 45 - Charge exceeds fee schedule-      M41 - We do not pay for this as     21 - Missing or invalid information.
          Contraindication modifier     maximum allowable or contracted-       the patient has no legal obligation 187 - Date(s) of service.
          indicates vaccine not given   legislated fee arrangement. (Use       to pay for this.
          on date of service. Please    Group Codes PR or CO depending
          report if vaccine given at    upon liability).
          future date.

798       Exceeds CAP-MR-DD-in-        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- 612 - Per Day Limit Amount
          home aide level I daily 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 once 119 - Benefit maximum for this time    M86 - Service denied because       259 - Frequency of service.
          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

      January 1, 2009                                                          Page 117
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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-        612 - Per Day Limit Amount
                                                                                similar procedure within set time
                                                                                frame.
801       Medical necessity for         50 - These are non-covered services     N157 - Transportation to-from this   428 - Reason for transport by
          ambulance transportation is   because this is not deemed a `medical destination is not covered.            ambulance
          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-        251 - Total anesthesia minutes.
                                        does not support this length of service chart.
                                                                                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.    239 - Dental information.
          CODE.
806       Units were changed to allow 119 - Benefit maximum for this time   N362 - The number of Days or             258 - Days-units for procedure-
          a maximum of 320 units per period or occurrence has been reached. Units of Service exceeds our             revenue code.
          month.                                                            acceptable maximum.                      259 - Frequency of service.
                                                                            N381 - Consult our contractual
                                                                            agreement for restrictions-billing-
                                                                            payment information related to
                                                                            these charges


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

808       Exceeds CAP-c daily service 119 - Benefit maximum for this time       M86 - Service denied because             259 - Frequency of 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 cardiovascular 119 - Benefit maximum for this time     M86 - Service denied because             259 - Frequency of service.
          ultra sound allowed per day. period or occurrence has been reached. payment already made for same-             612 - Per Day Limit Amount
                                                                                similar procedure within set time
                                                                                frame.
810       Adjustment denied;             125 - Submission-billing error(s).     N3 - Missing consent form.               21 - Missing or invalid information.
          adjustment can not be                                                                                          294 - Supporting documentation.
          processed without corrected
          information. 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.
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 processing.                                             chart.

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




      January 1, 2009                                                             Page 119
                                                          EOB Code Crosswalk to HIPAA Standard Codes


814       Office visit included in fee for 97 - The benefit for this service is    M80 - Not covered when             454 - Procedure code for services
          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.        101 - Claim was processed as
          90.                            another service-procedure that has        N381 - Consult our contractual      adjustment to previous claim
                                         already been adjudicated.                 agreement for restrictions-billing-
                                                                                   payment information related to
                                                                                   these charges


816       Exceeds maximum number 119 - Benefit maximum for this time            M86 - Service denied because         259 - Frequency of service.
          of physical therapy modalities period or occurrence has been reached. payment already made for same-       442 - Modalities of service.
          (3) allowed per day.                                                  similar procedure within set time    612 - Per Day Limit Amount
                                                                                frame.
                                                                                N357 - Time frame requirements
                                                                                between this service-procedure-
                                                                                supply and a related service-
                                                                                procedure-supply have not been
                                                                                met
817       Services are not to be billed 125 - Submission-billing error(s).      M53 - Missing-incomplete-invalid     21 - Missing or invalid information.
          spanning multiple calendar                                            days or units of service.            187 - Date(s) of service.
          months. Rebill with dates of                                          MA31 - Missing-incomplete-
          service within one month                                              invalid beginning and ending
          only.                                                                 dates of the period billed.
818       Adjustment denied; Please      16 - Claim-service lacks information   N29 - Missing documentation-         21 - Missing or invalid information.
          resubmit with pharmacy of      which is needed for adjudication.      orders- notes- summary- report-
          record card.                                                          chart.
819       Both the 'from' and 'to' date 125 - Submission-billing error(s).      M53 - Missing-incomplete-invalid     21 - Missing or invalid information.
          of service must be the date                                           days or units of service.            188 - Statement from-through
          of delivery when billing total                                        MA31 - Missing-incomplete-           dates.
          ob package or delivery                                                invalid beginning and ending
          codes.                                                                dates of the period billed.
820       Please resubmit claim with     16 - Claim-service lacks information   N29 - Missing documentation-         21 - Missing or invalid information.
          legible attachments.           which is needed for adjudication.      orders-notes-summary-report-
                                                                                chart.


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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. Please which is needed for adjudication.                                                 requested from entity.
          complete the address by
          adding street, city, state, and
          zip and resubmit with claim.

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 - Medical review attachment-
          blank spaces with                                                                                            information for service(s).
          appropriate information and
          resubmit with claim and-or
          records.
824       The sterilization consent form   16 - Claim-service lacks information      N3 - Missing consent form.        465 - Principal Procedure Code for
          is completed incorrectly.        which is needed for adjudication.                                           Service(s) Rendered.
          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.

826       Only two 12 hour                 119 - Benefit maximum for this time    M86 - Service denied because       259 - Frequency of service.
          pneumograms allowed in 6         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



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827       Only one waveform monitor    119 - Benefit maximum for this time     M86 - Service denied because        259 - Frequency of service.
          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
828       Disproportionate share       76 - Disproportionate Share Adjustment. None                                104 - Processed according to plan
          hospital payment increase of                                                                             provisions.
          5% for children under age 6
          with charges greater than
          annual maximum or stays
          over 65 days.
829       All claims and R-A's related 16 - Claim-service lacks information    N1 - Alert- You may appeal this     21 - Missing or invalid information.
          to interim billings must be  which is needed for adjudication.       decision in writing within the
          attached to adjustment                                               required time limits following
          request.                                                             receipt of this notice by following
                                                                               the instructions included in your
                                                                               contract or plan benefit
                                                                               documents.
                                                                               N3 - Missing consent form.
830       Non-disproportionate share 76 - Disproportionate Share Adjustment. None                                  104 - Processed according to plan
          hospital payment increase of                                                                             provisions.
          5% for children under age 1
          with charges greater than
          annual maximum or stays
          over 65 days.

831       DME procedure allowed once 119 - Benefit maximum for this time    M86 - Service denied because       259 - Frequency of service.
          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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832       DME allowed once in three       119 - Benefit maximum for this time    None                                 187 - Date(s) of service.
          years. If prior approval was    period or occurrence has been reached.                                      259 - Frequency of service.
          obtained for this piece of
          equipment for dates of
          service prior to November 1,
          1996, please resubmit as an
          adjustment.
833       DME procedure allowed once      119 - Benefit maximum for this time     M86 - Service denied because       259 - Frequency of service.
          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
834       This previously paid claim      76 - Disproportionate Share Adjustment. None                               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 repair    59 - Charges are adjusted based on        N381 - Consult our contractual      259 - Frequency of service.
          code has been paid at the       multiple or concurrent procedure rules.   agreement for restrictions-billing- 453 - Procedure Code Modifier(s)
          secondary maximum allowed       (For example multiple surgery or          payment information related to      for Service(s) Rendered
          rate.                           diagnostic imaging, concurrent            these charges
                                          anesthesia.)
836       Fludara (fludarabine            119 - Benefit maximum for this time  M86 - Service denied because           259 - Frequency of service.
          phosphate) limited to 2                                              payment already made for same-
                                          period or occurrence has been reached.                                      612 - Per Day Limit Amount
          dosages per day (50 mg                                               similar procedure within set time
          each).                                                               frame.                        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 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-         612 - Per Day Limit Amount
                                                                               similar procedure within set time
                                                                               frame.

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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
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-       612 - Per Day Limit Amount
                                                                               similar procedure within set time
                                                                               frame.
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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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
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

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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 the 186 - Purchase and rental price of
          new purchase price.          not met.                               item is purchased, or after the     durable medical equipment.
          Medicaid has previously paid                                        total of issued rental payments
          for this equipment code.                                            equals the purchase price.
                                                                              N381 - Consult our contractual
                                                                              agreement for restrictions-billing-
                                                                              payment information related to
                                                                              these charges


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


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



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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-      612 - Per Day Limit Amount
                                                                              similar procedure within set time
                                                                              frame
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-      612 - Per Day Limit Amount
                                                                              similar procedure within set time
                                                                              frame
860       This code is non-covered for 96 - Non-covered charge(s).            M79 - Missing-incomplete-invalid    454 - Procedure code for services
          paternity testing.                                                  charge                              rendered.
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-      612 - Per Day Limit Amount
                                                                              similar procedure within set time
                                                                              frame
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-      612 - Per Day Limit Amount
                                                                              similar procedure within set time
                                                                              frame


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863       Wording of hysterectomy           16 - Claim-service lacks information      N3 - Missing consent form.          21 - Missing or invalid information.
          statement doesn‟t meet            which is needed for adjudication.         N59 - Alert- Please refer to your   421 - Medical review attachment-
          federal guidelines, resubmit                                                provider manual for additional      information for service(s).
          claim using a newly obtained                                                program and provider
          statement.                                                                  information.
864       Hysterectomy statement            16 - Claim-service lacks information      N3 - Missing consent form.          21 - Missing or invalid information.
          illegible; resubmit with a        which is needed for adjudication.         N205 - Information provider was     421 - Medical review attachment-
          readable copy.                                                              illegible.                          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- Please refer to your   421 - Medical review attachment-
          with the 'prior to' statement.                                              provider manual for additional      information for service(s).
          (see Medicaid Bulletin-April                                                program and provider
          1989).                                                                      information.
866       Date of service is incorrect-     16 - Claim-service lacks information      N3 - Missing consent form.          21 - Missing or invalid information.
          missing on the hysterectomy       which is needed for adjudication.                                             187 - Date(s) of service
          statement. Correct DOS on                                                                                       298 - Operative report
          statement and initial date
          correction. Resubmit
          statement with claim &
          operative record.

867       Verify hysterectomy               16 - Claim-service lacks information      N29 - Missing documentation-        21 - Missing or invalid information.
          procedure code, correct your      which is needed for adjudication.         orders-notes-summary-report-        298 - Operative report
          claim, and resubmit with                                                    chart.                              454 - Procedure code for services
          operative records for                                                                                           rendered.
          documentation. i.e.: one
          says abdominal hyster, the
          other says vaginal.
868       Verify date of service, correct   16 - Claim-service lacks information      N29 - Missing-incomplete-invalid    187 - Date(s) of service.
          your claim, and resubmit with     which is needed for adjudication.         documentation-orders-notes-         298 - Operative report.
          operative records for                                                       summary-report-chart
          documentation. (i.e.: Date
          on claim differs from consent
          form or statement.).




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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 - Information provided was 421 - Medical review attachment-
          hysterectomy statement.                                                    illegible.                      information for service(s).
          Please identify signature and
          resubmit with claim.
870       Personal Care Services not       B15 - This service-procedure requires     N20 - Service not payable with     258 - Days-units for procedure-
          allowed the same day as          that a qualifying service-procedure be    other service rendered on the      revenue code.
          CAP In-Home Level II and In-     received and covered. The qualifying      same date.
          Home Level III.                  other service-procedure has not been
                                           received-adjudicated.

871       CAP In-Home Level II and In-     B15 - This service-procedure requires     N20 - Service not payable with     258 - Days-units for procedure-
          Home Level III not allowed       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.
          Services.                        other service-procedure has not been
                                           received-adjudicated.

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

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


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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.

879       Physician charge denied         B15 - This service-procedure requires    N20 - Service not payable with    258 - Days-units for procedure-
          same DOS as facility billing.   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.

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

881       EMG one extremity 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-      612 - Per Day Limit Amount
                                                                                 similar procedure within set time
                                                                                 frame.
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-      612 - Per Day Limit Amount
                                                                                 similar procedure within set time
                                                                                 frame.
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-      612 - Per Day Limit Amount
                                                                                 similar procedure within set time
                                                                                 frame.




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884       Rebill adjustment with         151 - Payment adjusted because the     M53 - Missing-incomplete-invalid      21 - Missing or invalid information.
          records documenting units.     payer deems the information submitted days or units of service.
                                         does not support this many services.   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.
885       Rebill adjustment with         151 - Payment adjusted because the     M53 - Missing-incomplete-invalid      21 - Missing or invalid information.
          records documenting units. payer deems the information submitted days or units of service.
                                         does not support this many services.   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 units 119 - Benefit maximum for this time    M86 - Service denied because          259 - Frequency of service.
          per day for reflex study.      period or occurrence has been reached. payment already made for same-        612 - Per Day Limit Amount
                                                                                similar procedure within set time
                                                                                frame
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-        612 - Per Day Limit Amount
                                                                                similar procedure within set time
                                                                                frame.
888       Coverage for these new CPT 96 - Non-covered charge(s).                MA66 - Missing-incomplete-            454 - Procedure code for services
          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-explanation of
          paper claim with Medicare      incomplete.                                                                  benefits (EOB).
          EOB.                                                                                                        456 - Covered Day(s)




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890       Paid at Medicaid per diem      45 - Charge exceeds fee schedule-         N381 - Consult our contractual      65 - Claim-line has been paid. 483
          rate; paid maximum             maximum allowable or contracted-          agreement for restrictions-billing- - Maximum coverage amount met
          allowable.                     legislated fee arrangement. (Use          payment information related to      or exceeded for benefit period
                                         Group Codes PR or CO depending            these charges
                                         upon liability).
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-         612 - Per Day Limit Amount
                                                                               similar procedure within set time
                                                                               frame.
892       Units cut back. Lab results    151 - Payment adjusted because the    N362 - The number of Days or           258 - Days-units for procedure-
          do not support necessity for   payer deems the information submitted Units of Service exceeds our           revenue code.
          more than 14 units EPO per     does not support this many services.  acceptable maximum.                    259 - Frequency of service.
          day.                                                                 N381 - Consult our contractual         612 - Per Day Limit Amount
                                                                               agreement for restrictions-billing-
                                                                               payment information related to
                                                                               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 for non-
          consults on the same day.                                                                                   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 same      59 - Charges are adjusted based on        N381 - Consult our contractual      259 - Frequency of service.
          date of service paid at 50     multiple or concurrent procedure rules.   agreement for restrictions-billing- 453 - Procedure Code Modifier(s)
          percent of allowable.          (For example multiple surgery or          payment information related to      for Service(s) Rendered
                                         diagnostic imaging, concurrent            these charges
                                         anesthesia.)



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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.

898       Newborn resuscitation only        150 - Payment adjusted because the      M13 - Only one initial visit is 21 - Missing or invalid information.
          payable on date of delivery.      payer deems the information submitted covered per specialty per medical
          Rebill using appropriate level    does not support this level of service. group.
          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 - Frequency of service.
                                                                                   N381 - Consult our contractual          612 - Per Day Limit Amount
                                                                                   agreement for restrictions-billing-
                                                                                   payment information related to
                                                                                   these charges

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-        None                                  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.                    107 - Processed according to
                                            legislated fee arrangement. (Use         N381 - Consult our contractual        contract-plan provisions.
                                            Group Codes PR or CO depending           agreement for restrictions-billing-
                                            upon liability).                         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.                    107 - Processed according to
                                            legislated fee arrangement. (Use         N381 - Consult our contractual        contract-plan provisions.
                                            Group Codes PR or CO depending           agreement for restrictions-billing-
                                            upon liability).                         payment information related to
                                                                                     these charges

      January 1, 2009                                                            Page 133
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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.                         107 - Processed according to
                                         legislated fee arrangement. (Use     N381 - Consult our contractual             contract-plan provisions.
                                         Group Codes PR or CO depending       agreement for restrictions-billing-
                                         upon liability).                     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 once 119 - Benefit maximum for this time    M86 - Service denied because               259 - Frequency of service.
          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 book 125 - Submission-billing error(s).      N59 - Alert- Please refer to your          21 - Missing or invalid information.
          and rebill.                                                         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-        None                              104 - Processed according to plan
                                         eligible to be paid for this procedure-                                        provisions.
                                         service on this date of service.

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


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913       Rebill your claim using the   125 - Submission-billing error(s).           MA66 - Missing-incomplete-          21 - Missing or invalid information.
          correct consultation code(s).                                              invalid principal procedure code.   454 - Procedure 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 in      included in the payment-allowance for     performed during the same          rendered.
          the dispensing fee for a new     another service-procedure that has        session-date as a previously
          aid-aids.                        already been adjudicated.                 processed service for the patient.

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

916       Resubmit claim with the post-    16 - Claim-service lacks information      N29 - Missing documentation-      21 - Missing or invalid information.
          evaluation report and            which is needed for adjudication.         orders- notes- summary- report- 294 - Supporting documentation.
          applicable invoices.                                                       chart.
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.         N252 - Missing-incomplete-invalid
          Please correct by eliminating                                              attending provider name.
          abbreviations in the clinic-
          doctor name spaces.

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 - Entitys name, address,
          Please correct by placing the                                              N3 - Missing consent form.          phone and id number
          recipients full name in the
          “name of individual” space.

919       The recipients date of birth is 16 - Claim-service lacks information       N3 - Missing consent form.        21 - Missing or invalid information.
          different on the claim and the which is needed for adjudication.           N329 - Missing-incomplete-invalid 158 - Entitys date of birth
          consent form. Please correct                                               patient birth date.
          the DOB field on the consent
          form and resubmit.




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920       CLIA certification number is    125 - Submission-billing error(s).       MA120 - Missing-incomplete-        21 - Missing or invalid information.
          unknown to NC Medicaid.                                                  invalid CLIA certification number. 142 - Entitys license-certification
          Contact your state CLIA                                                                                     number.
          authority. NC providers                                                                                     630 - Referring CLIA Number
          contact NC DFS, CLIA, PO
          Box 29530 Raleigh, NC
          27626-0530.
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 included    another service-procedure that has       session-date as a previously
          in disp. fee for new hearing    already been adjudicated.                processed service for the patient.
          aid(s) has been paid for this
          date of service.

922       Claim suspended due to          133 - The disposition of this claim-     None                               40 - Waiting for final approval.
          court order.                    service is pending further review.
923       Consultation and emergency      B15 - This service-procedure requires    N20 - Service not payable with     258 - Days-units for procedure-
          room visit not allowed on       that a qualifying service-procedure be   other service rendered on the      revenue code.
          same DOS, same provider         received and covered. The qualifying     same date.
          specialty.                      other service-procedure has not been
                                          received-adjudicated.

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

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




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926       Services billed under routine 96 - Non-covered charge(s).                N115 - This decision was based 488 - Diagnosis code(s) for the
          diagnosis are non-covered.                                               on a local medical review policy services rendered
                                                                                   (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-        612 - Per Day Limit Amount
          allowed per day.                                                       similar procedure within set time
                                                                                 frame.
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 allergenic    already been adjudicated.              frame.
          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 using   another service-procedure that has       similar procedure within set time
          code for provision of           already been adjudicated.                frame.
          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.


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

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

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 of that a qualifying service-procedure be          other service rendered on the      revenue code.
          service as W5141 or J1055. received and covered. The qualifying             same date.
                                      other service-procedure has not been
                                      received-adjudicated.

935       Skilled nurse home visit 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.
          related procedure.             received and covered. The qualifying         same date.
                                         other service-procedure has not been
                                         received-adjudicated.

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



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

939       Maternity care-newborn 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.
          skilled nurse maternal care       received and covered. The qualifying     same date.
          home visit.                       other service-procedure has not been
                                            received-adjudicated.

940       The recipient first initial and   125 - Submission-billing error(s).       MA36 - Missing-incomplete-         21 - Missing or invalid information.
          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 date    110 - Billing date predates service date None                               88 - Entity not eligible for benefits
          of service.                                                                                                   for submitted dates of service.
944       Quantity dispensed(if IV-give     154 - Payment adjusted because the    M119 - Missing-incomplete-            21 - Missing or invalid information.
          bags) and days supply(not         payer deems the information submitted invalid-deactivated-withdrawn         221 - Drug days supply and
          dosage) req.; or total quantity   does not support this days supply.    National Drug Code (NDC).             dosage.
          mismatch on detail line 0-9                                             M123 - Missing-incomplete-
          vs. compound items                                                      invalid name, strength, or dosage
          (excludes tabs-cap-pwds.).                                              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 required in                                           total charges.
          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     216 - Drug information.
          Mfg,quantity and cost of all                                             National Drug Code (NDC).
          ingredients at bottom of form.                                           M123 - Missing-incomplete-
          On detail 0-9 put compd.                                                 invalid name, strength, or dosage
          drug name, if IV-give formula                                            of the drug furnished.
          per bag.
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      187 - Date(s) of service.
                                                                                   date(s).
948       Legible drug name,           125 - Submission-billing error(s).          M119 - Missing-incomplete-           216 - Drug information.
          NDC,MFG. Must be indicated                                               invalid-deactivated-withdrawn        217 - Drug name, strength and
          on a legible claim form and-                                             National Drug Code (NDC).            dosage form.
          or drug name-strength-NDC                                                M123 - Missing-incomplete-           218 - NDC number.
          mismatch.                                                                invalid name, strength, or dosage
                                                                                   of the drug furnished.
949       Prescriptions on form must      125 - Submission-billing error(s).       MA06 - Missing-incomplete-           21 - Missing or invalid information.
          be for same month.                                                       invalid beginning and-or ending
                                                                                   date(s).
950       Claim denied: EDS will refile- 133 - The disposition of this claim-      N10 - Claim-service adjusted         42 - Awaiting related charges.
          upon receipt of info from mfg. service is pending further review.        based on the findings of a review
                                                                                   organization-professional consult-
                                                                                   manual adjudication-medical or
                                                                                   dental advisor.
                                                                                   N185 - Alert- Do not resubmit this
                                                                                   claim-service

951       Adjustment due to a payment     B5 - Coverage-program guidelines were None                                    107 - Processed according to
          error discovered from a drug    not met or were exceeded.                                                     contract-plan provisions.
          rebate inquiry.
952       Fixation of femur fracture      97 - The benefit for this service is     M80 - Not covered when             454 - Procedure code for services
          included in hemiarthroplasty,   included in the payment-allowance for    performed during the same          rendered.
          hip partial.                    another service-procedure that has       session-date as a previously
                                          already been adjudicated.                processed service for the patient.

953       Individual has restricted       109 - Claim not covered by this payer-   None                                 84 - Service not authorized
          coverage - Medicaid only        contractor. You must send the claim to
          pays the part B premium.        the correct payer-contractor.


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954       Level of Service billed is not 150 - Payment adjusted because the      N1 - Alert- You may appeal this       21 - Missing or invalid information.
          documented. Please refile as payer deems the information submitted     decision in writing within the        294 - Supporting documentation
          an adjustment with further     does not support this level of service. required time limits following
          documentation or using the                                             receipt of this notice by following
          non-emergent codes.                                                    the instructions included in your
                                                                                 contract or plan benefit
                                                                                 documents.
                                                                                 N29 - Missing documentation-
                                                                                 orders- notes- summary- report-
                                                                                 chart.
955       Documentation does not           150 - Payment adjusted because the    N157 - Transportation to-from this    3 - Claim has been adjudicated
          support level of service billed. payer deems the information submitted destination is not covered.           and is awaiting payment cycle.
          Code has been changed to does not support this level of service.       N206 - The supporting
          reflect non-emergent                                                   documentation does not match
          transport.                                                             the claim.
956       Comprehensive evaluation         B15 - This service-procedure requires N20 - Service not payable with        258 - Days-units for procedure-
          and related components not that a qualifying service-procedure be      other service rendered on the         revenue code.
          allowed on the same DOS,         received and covered. The qualifying  same date.
          same or different provider.      other service-procedure has not been
                                           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- 612 - Per Day Limit Amount
          one treatment is provided                                             similar procedure within set time
          submit an adjustment with                                             frame.
          documentation showing
          medical necessity.
958       Units cut back;only one unit   119 - Benefit maximum for this time    M86 - Service denied because      259 - Frequency of service.
          allowed per day. If multiple   period or occurrence has been reached. payment already made for same- 612 - Per Day Limit Amount
          unrelated tests were                                                  similar procedure within set time
          performed, file as an                                                 frame.
          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          612 - Per Day Limit Amount
          this date of service.                                                 same date.
960       Please specify the name of     125 - Submission-billing error(s).     M123 - Missing-incomplete-             21 - Missing or invalid information.
          the medication given in this                                          invalid name, strength, or dosage      409 - Medication logs-records
          injection.                                                            of the drug furnished.                 (including medication therapy).



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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 on       received and covered. The qualifying     same date.
          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 your included in the payment-allowance for     performed during the same          rendered.
          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 allowed that a qualifying service-procedure be     other service rendered on the     revenue code.
          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.

965       Related procedure not      B15 - This service-procedure requires         N20 - Service not payable with    258 - Days-units for procedure-
          allowed same day as Y2039. 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.

966       Only one Fetal non-stress       119 - Benefit maximum for this time     M86 - Service denied because       259 - Frequency of service.
          test allowed-day. Detail has    period or occurrence has been reached. payment already made for same-
          been cut back to allow one                                              similar procedure within set time
          unit.                                                                   frame.
967       DHS immunizations cannot        150 - Payment adjusted because the      N180 - This item or service does 454 - Procedure code for services
          be assigned a family            payer deems the information submitted not meet the criteria for the        rendered.
          planning category of service;   does not support this level of service. category under which it was billed
          no family planning cos exists
          for required financial
          treatment.

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968       Records indicate your 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. Please
          resubmit with the appropriate
          5 digit diagnosis code from
          the 635-6359 range of codes.


969       Records indicate this is not a    11 - The diagnosis is inconsistent with   M76 - Missing-incomplete-invalid 488 - Diagnosis code(s) for the
          therapeutic abortion. Please      the procedure.                            diagnosis or condition.          services rendered
          remove the therapeutic                                                                                       454 - Procedure code for services
          abortion code and resubmit                                                                                   rendered
          with a corrected diagnosis
          code.
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 this   the procedure.                            diagnosis or condition.          services rendered
          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 only       included in the payment-allowance for     performed during the same          rendered.
          as follow-up to periodontal       another service-procedure that has        session-date as a previously
          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 claim                                                  chart.                            294 - Supporting documentation
          with records.
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 trip     received and covered. The qualifying      same date.
          transportation are not            other service-procedure has not been
          allowed on the same day.          received-adjudicated.



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974       Code invalid for this DOS.    125 - Submission-billing error(s).        MA31 - Missing-incomplete-         21 - Missing or invalid information.
                                                                                  invalid beginning and ending       187 - Date(s) of service.
                                                                                  dates of the period billed.
975       Documentation does not        16 - Claim-service lacks information      M22 - Missing-incomplete-invalid   428 - Reason for transport by
          support the necessity for air which is needed for adjudication.         number of miles traveled.          ambulance
          ambulance. Change miles to                                              N206 - The supporting
          reflect ground transport. Do                                            documentation does not match
          not change your codes.                                                  the claim
          Resubmit as an adjustment.

976       Air ambulance services cut   150 - Payment adjusted because the      N381 - Consult our contractual        454 - Procedure code for services
          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 transport 115 - Procedure postponed-canceled-or None                                    104 - Processed according to plan
          of patient.                  delayed.                                                                      provisions.
978       ALS not documented, please 16 - Claim-service lacks information      N29 - Missing documentation-          123 - Additional information
          refile as an adjustment with which is needed for adjudication.       orders- notes- summary- report-       requested from entity.
          further documentation, or                                            chart.                                294 - Supporting documentation.
          refile as a BLS service.

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




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982       Payment for outpatient place 45 - Charge exceeds fee schedule-           N381 - Consult our contractual      249 - Place of service.
          of service reduced to 80% of maximum allowable or contracted-            agreement for restrictions-billing-
          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 paid     97 - The benefit for this service is     M77 - Missing-incomplete-invalid 249 - Place of service.
          only for specialized services   included in the payment-allowance for    place of service.                 454 - Procedure code for services
          that cannot be provided in      another service-procedure that has                                         rendered.
          the place of residence.         already been adjudicated.

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

987       Other procedure code 2 is       125 - Submission-billing error(s).       N56 - Procedure code billed is not 21 - Missing or invalid information.
          invalid.                                                                 correct-valid for the service billed 490 - Other procedure code for
                                                                                   or the date of service billed.       service(s) rendered

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

989       Primary procedure code          125 - Submission-billing error(s).       MA66 - Missing-incomplete-           21 - Missing or invalid information.
          must be further subdivided.                                              invalid principal procedure code.    465 - Principal Procedure Code for
          (The code must have four                                                                                      Service(s) Rendered
          digits).
990       Other procedure code 2          125 - Submission-billing error(s).       N56 - Procedure code billed is not 21 - Missing or invalid information.
          must be further subdivided.                                              correct-valid for the services        490 - Other procedure code for
          (The code must have 4                                                    billed or the date of service billed. service(s) rendered
          digits).


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991       Other procedure code 3          125 - Submission-billing error(s).           N56 - Procedure code billed is not 21 - Missing or invalid information.
          must be further subdivided                                                   correct-valid for the services        490 - Other procedure code for
          (the code must have 4                                                        billed or the date of service billed. service(s) rendered
          digits).
992       CPT 90741 may not be billed     125 - Submission-billing error(s).           N56 - Procedure code billed is not 21 - Missing or invalid information.
          for dates of service on or                                                   correct-valid for the service billed 187 - Date(s) of service.
          after 01-01-1994. Please                                                     or the date of service billed.
          rebill using the appropriate,
          dose specific HCPC code
          (J1460-J1561).
993       Exceeds limitations per 365     50 - These are non-covered services          N29 - Missing documentation-        411 - Medical necessity for non-
          days; submit adjustment or      because this is not deemed a `medical        orders-notes-summary-report-        routine service(s).
          paper claim documenting the     necessity by the payer.                      chart.
          medial necessity for
          additional lens-lenses.

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 attachment-
          administration. If more than    does not support this many services.  chart.                                     information for service(s)
          3 routes required, submit as                                          N163 - Medical Record does not
          an adjustment with medical                                            support code billed per the code
          records documenting                                                   definition
          services.
995       Service rendered by salaried    185 - The rendering provider is not          N95 - This provider type -           91 - Entity not eligible-not approved
          FQHC physicians must be         eligible to perform the service billed.      provider specialty may not bill this for dates of service.
          billed by the FQHC; payment                                                  service.
          cannot be made directly to
          the attending provider.

996       Payment has been adjusted 119 - Benefit maximum for this time       None                                         186 - Purchase and rental price of
          to equal new purchase price. period or occurrence has been reached.                                              durable medical equipment.
          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 for                                                   payment already made for same-
          some of these dates of                                                       similar procedure within set time
          service. Rebill for covered                                                  frame.
          days only. Correct and
          resubmit as a new claim.

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998       Claim does not require          125 - Submission-billing error(s).       N59 - Alert- Please refer to your 21 - Missing or invalid information.
          adjustment processing.                                                   provider manual for additional
          Resubmit claim with                                                      program and provider information
          corrections as a new day
          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 codes    that a qualifying service-procedure be   other service rendered on the       revenue code.
          not allowed on the same date    received and covered. The qualifying     same date.
          of service as HCPCS manual      other service-procedure has not been
          manipulation of the spine.      received-adjudicated.

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 apply.   eligibility requirements.                apply for other coverage which
          Service is not covered. Bill                                             may be primary
          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 limitation.                                            similar procedure within set time
                                                                                  frame
1003      Date of service is more than 177 - Patient has not met the required N30 - Patient ineligible for this     91 - Entity not eligible-not approved
          30 days prior to CAP             eligibility requirements.              service.                          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 allowed                                             N20 - Service not payable with
          during inpatient stay.                                                  other service rendered on the
                                                                                  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 inpatient alternate benefit has been provided    the patient is an inpatient.      revenue code.
          services.                                                               N20 - Service not payable with
                                                                                  other service rendered on the
                                                                                  same date.
                                                                                  N30 - Patient ineligible for this
                                                                                  service



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1006   CAP limitation of 2016 hours   119 - Benefit maximum for this time    M86 - Service denied because          259 - Frequency of service.
       per waiver year has been       period or occurrence has been reached. payment already made for same-
       exceeded for crisis                                                   similar procedure within set time
       stabilization.                                                        frame
1007   Units have been changed to     119 - Benefit maximum for this time    N362 - The number of Days or          258 - Days-units for procedure-
       allow maximum on 31 units      period or occurrence has been reached. Units of Service exceeds our          revenue code.
       per month.                                                            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

1008   Sterilization guidelines not   16 - Claim-service lacks information      N3 - Missing consent form.         21 - Missing or invalid information.
       met. Invalid 'estimated date   which is needed for adjudication.                                            492 - Other Procedure Date.
       of confinement' on consent
       form.
1009   Procedure denied: Included97 - The benefit for this service is           N20 - Service not payable with     454 - Procedure code for services
       in 52647 or 52648 already included in the payment-allowance for          other service rendered on the      rendered.
       billed.                   another service-procedure that has             same date.
                                 already been adjudicated.
1010   W5142 not allowed on same B15 - This service-procedure requires          N20 - Service not payable with     258 - Days-units for procedure-
       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 day B15 - This service-procedure requires         N20 - Service not payable with     454 - Procedure code for services
       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 to 119 - Benefit maximum for this time           N43 - Bed hold or leave days        498 - Maximum leave days
       allow maximum of 60            period or occurrence has been reached.    exceeded.                           exhausted
       therapeutic leave days for the                                           N381 - Consult our contractual
       calendar year.                                                           agreement for restrictions-billing-
                                                                                payment information related to
                                                                                these charges


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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 therapeutic   received and covered. The qualifying     same date.
       leave has been paid for the   other service-procedure has not been
       same dates of service.        received-adjudicated.

1014   Service denied or cut back. 119 - Benefit maximum for this time   N362 - The number of Days or        258 - Days-units for procedure-
       Exceeds 14 consecutive day period or occurrence has been reached. Units of Service exceeds our        revenue code.
       limit.                                                            acceptable maximum.                 259 - Frequency of service.
                                                                         N381 - Consult our contractual
                                                                         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 date                                          payment already made for same-
       of service under codes                                                 similar procedure within set time
       90720-90721.                                                           frame.
1016   DTAP immunization             18 - Duplicate claim-service.            M86 - Service denied because        259 - Frequency of service.
       previously paid for this date                                          payment already made for same-
       of service under code 90700.                                           similar procedure within set time
                                                                              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 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.
1019   Evaluation and Management     B15 - This service-procedure requires    M86 - Service denied because        258 - Days-units for procedure-
       not allowed same day as       that a qualifying service-procedure be   payment already made for same-      revenue code.
       NICU. NICU has already        received and covered. The qualifying     similar procedure within set time
       been paid for this date of    other service-procedure has not been     frame.
       service.                      received-adjudicated.




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

1022   Carolina access recipient‟s      9 - The diagnosis is inconsistent with    M76 - Missing-incomplete-invalid 21 - Missing or invalid information.
       age is not valid for the         the patients age.                         diagnosis or condition.          255 - Diagnosis code.
       approved emergency
       diagnosis.
1023   Carolina access recipient‟s      10 - The diagnosis is inconsistent with   M76 - Missing-incomplete-invalid 21 - Missing or invalid information.
       gender is not valid for the      the patients gender.                      diagnosis or condition.          157 - Entitys Gender.
       approved Emergency                                                                                          255 - Diagnosis code.
       diagnosis.
1024   Prolonged service already        B15 - This service-procedure requires     N20 - Service not payable with    258 - Days-units for procedure-
       paid for this date of service.   that a qualifying service-procedure be    other service rendered on the     revenue code.
       No additional payment            received and covered. The qualifying      same date.
       allowed for stand-by on same     other service-procedure has not been
       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 recouped      included in the payment-allowance for     other service rendered on the     rendered.
       to pay primary procedure         another service-procedure that has        same date.
       (52647 or 52648).                already been adjudicated.




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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 date   other service-procedure has not been
       (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.

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

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

1031   CAP MR-DD supported living 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 day as personal care. received and covered. The qualifying        same date.
                                  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 day that a qualifying service-procedure be     other service rendered on the    revenue code.
       as related CAP services.    received and covered. The qualifying       same date.
                                   other service-procedure has not been
                                   received-adjudicated.




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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 as that a qualifying service-procedure be         other service rendered on the      revenue code.
       supported living services.  received and covered. The qualifying           same date.
                                   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 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.
       institutional respite care.       other service-procedure has not been
                                         received-adjudicated.

1035   This EOB is for internal          45 - Charge exceeds fee schedule-        None                               19 - Entity acknowledges receipt of
       tracking of Health Check          maximum allowable or contracted-                                            claim-encounter.
       visits. To determine if claim     legislated fee arrangement. (Use                                            585 - Denied Charge or Non-
       paid or denied look in the        Group Codes PR or CO depending                                              covered Charge.
       screening section of your RA.     upon liability).

1036   Thank you for reporting           89 - Professional fees removed from      M41 - We do not pay for this as     19 - Entity acknowledges receipt of
       vaccines. This vaccine is         charges.                                 the patient has no legal obligation claim-encounter.              598
       provided at no charge                                                      to pay for this.                    - Non-payable Professional
       through the Vaccines For                                                                                       Component Billed Amount.
       Children program. No
       payment allowed.
1037   Thanks for reporting vaccine      45 - Charge exceeds fee schedule-        M41 - We do not pay for this as     15 - One or more originally
       to our database. Free             maximum allowable or contracted-         the patient has no legal obligation submitted procedure code have
       modifier (F) is on claim;         legislated fee arrangement. (Use         to pay for this.                    been modified.
       however vaccine is not            Group Codes PR or CO depending                                               19 - Entity acknowledges receipt of
       available through VFC.            upon liability).                                                             claim-encounter.
       Refile with 'P' modifier if you                                                                                598 - Non-payable Professional
       purchased vaccine.                                                                                             Component Billed Amount.

1038   Claim denied. Refile with the 125 - Submission-billing error(s).           MA43 - Missing-incomplete-         21 - Missing or invalid information.
       appropriate patient status.                                                invalid patient status.




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1039   Regularly scheduled Health     B15 - This service-procedure requires     N20 - Service not payable with   258 - Days-units for procedure-
       Check screening and            that a qualifying service-procedure be    other service rendered on the    revenue code.
       interperiodic Health Check     received and covered. The qualifying      same date.
       exam are not allowed on the    other service-procedure has not been
       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 of    that a qualifying service-procedure be    other service rendered on the    revenue code.
       service as Adult Care Home     received and covered. The qualifying      same date.
       personal care service.         other service-procedure has not been
                                      received-adjudicated.

1041   Only one high risk            119 - Benefit maximum for this time    M86 - Service denied because      259 - Frequency of service.
       intervention allowed per day. period or occurrence has been reached. payment already made for same-
                                                                            similar procedure within set time
                                                                            frame.
1042   Only one Case Management 18 - Duplicate claim-service.               M86 - Service denied because      259 - Frequency of service.
       allowed per day. Case                                                payment already made for same-
       management billed through                                            similar procedure within set time
       another program has already                                          frame.
       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.                                   476 - Missing or invalid units of
       equals one unit for this                                                                              service.
       HCPC code.
1044   Multiple billings of same or   B15 - This service-procedure requires     N20 - Service not payable with   258 - Days-units for procedure-
       similar dme supply-            that a qualifying service-procedure be    other service rendered on the    revenue code.
       equipment not allowed on the   received and covered. The qualifying      same date.
       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 by      which is needed for adjudication.         invalid patients address         126 - Entitys address.
       adding the recipient‟s                                                   N225 - Incomplete-invalid        421 - Medical review attachment-
       complete address.                                                        documentation-orders- notes-     information for service(s).
                                                                                summary- report- chart.

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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 - Date(s) of service.
       surgery' statement by adding                                               summary- report- chart.             421 - Medical review attachment-
       the complete date of surgery.                                                                                  information for service(s).

1047   The witness and-or recipient 16 - Claim-service lacks information          MA75 - Missing-incomplete-          21 - Missing or invalid information.
       signature has been omitted which is needed for adjudication.               invalid patient or authorized       421 - Medical review attachment-
       on the hysterectomy                                                        representative signature.           information for service(s).
       statement. Resubmit with a                                                 N225 - Incomplete-invalid
       new completed 'prior to my                                                 documentation-orders- notes-
       surgery' statement.                                                        summary- report- chart.

1048   The signature-witness date       16 - Claim-service lacks information      MA75 - Missing-incomplete-          21 - Missing or invalid information.
       has been omitted from the        which is needed for adjudication.         invalid patient or authorized       421 - Medical review attachment-
       hysterectomy statement.                                                    representative signature            information for service(s).
       Please resubmit with a                                                                                         492 - Other Procedure Date
       completed form and initial the
       date.
1049   The DOS on the                   16 - Claim-service lacks information      M52 - Missing-incomplete-invalid    21 - Missing or invalid information.
       hysterectomy statement is        which is needed for adjudication.         from date(s) of service.            187 - Date(s) of service.
       different than the claim.                                                  N29 - Missing documentation-        421 - Medical review attachment-
       Verify the DOS with records                                                orders-notes-summary-report-        information for service(s).
       and resubmit with corrected                                                chart.
       claim and or statement.

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 approved as an
       ECS unit to obtain copy of                                                 submitter.                          electronic submitter.
       agreement. No payment
       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 as       that a qualifying service-procedure be    other service rendered on the       revenue code.
       related Case Management          received and covered. The qualifying      same date.
       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 same    that a qualifying service-procedure be     other service rendered on the       revenue code.
       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 inpatient                                          other service rendered on the
       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-same      received and covered. The qualifying       N20 - Service not payable with
       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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1057   Valid revenue code must be 125 - Submission-billing error(s).            M20 - Missing-incomplete-invalid 21 - Missing or invalid information.
       billed with a valid HCPC                                                 HCPCS.                           455 - Revenue code for services
       code. HCPC code is missing                                               M50 - Missing-incomplete-invalid rendered.
       or invalid or HCPC code has                                              revenue code(s).
       been 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 Medicaid                                            invalid principal procedure code.
       program is a Health Check
       Screen. For more information
       about billing Health Check,
       please call 1-800-688-6696.


1059   Ambulance claim form is no 125 - Submission-billing error(s).            N34 - Incorrect claim form-format 21 - Missing or invalid information.
       longer accepted. Please                                                  for this service.                 228 - Type of bill for UB claim
       resubmit ambulance charges
       on the UB92 claim.

1060   Admit hour-time of pickup is   125 - Submission-billing error(s).        N46 - Missing-incomplete-invalid    21 - Missing or invalid information.
       missing or invalid. Please                                               admission hour.
       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 each                                             days or units of service.        revenue code.
       ambulance trip on a separate
       claim.
1062   Resubmit on paper, EDS will    16 - Claim-service lacks information      MA130 - Your claim contains       277 - Paper claim.
       hold your claim and submit     which is needed for adjudication.         incomplete and-or invalid
       after buy-in process                                                     information, and no appeal rights
       complete.                                                                are afforded because the claim is
                                                                                unprocessable. Please submit a
                                                                                new claim with the complete-
                                                                                correct information.




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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).               187 - Date(s) of service.
       state a post-abortion                                                     M64 - Missing-incomplete-invalid
       procedure was done. Correct                                               other diagnosis.
       your codes to post-abortion
       diagnosis-procedure and
       rebill.
1064   Units are not consistent with    151 - Payment adjusted because the     M53 - Missing-incomplete-invalid 258 - Days-units for procedure-
       procedure (s) billed. Verify     payer deems the information submitted days or units of service.         revenue code.
       your units, correct claim and    does not support this many services.                                    476 - Missing or invalid units of
       resubmit.                                                                                                service.
1065   Cap personal care services       B15 - This service-procedure requires N20 - Service not payable with    258 - Days-units for procedure-
       not allowed on same date of      that a qualifying service-procedure be other service rendered on the    revenue code.
       service as Adult Care Home       received and covered. The qualifying   same date.
       services.                        other service-procedure has not been
                                        received-adjudicated.

1066   Cap in-home aide service 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 Adult Care Home       received and covered. The qualifying     same date.
       services.                        other service-procedure has not been
                                        received-adjudicated.

1067   Home health aide service 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 Adult Care Home       received and covered. The qualifying     same date.
       services.                        other service-procedure has not been
                                        received-adjudicated.

1068   Component(s) of urinalysis       B15 - This service-procedure requires    N20 - Service not payable with    454 - Procedure code for services
       recouped. Urinalysis; with       that a qualifying service-procedure be   other service rendered on the     rendered.
       microscopy, which is the         received and covered. The qualifying     same date.
       complete service, has been       other service-procedure has not been
       paid for this date of service,   received-adjudicated.
       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 microscopy,      that a qualifying service-procedure be   other service rendered on the     revenue code.
       which is a complete              received and covered. The qualifying     same date.
       procedure has already been       other service-procedure has not been
       paid for this date of service,   received-adjudicated.
       this provider.
1070   Urinalysis components billed     97 - The benefit for this service is     M80 - We cannot pay for this        454 - Procedure code for services
       for the same date of service     included in the payment-allowance for    when performed during the same rendered.
       must be combined under           another service-procedure that has       session as a previously
       81000. Please submit             already been adjudicated.                processed service for the patient
       adjustment request to this                                                N1 - Alert- You may appeal this
       effect for components                                                     decision in writing within the
       already paid.                                                             required time limits following
                                                                                 receipt of this notice by following
                                                                                 the instructions included in your
                                                                                 contract or plan benefit
                                                                                 documents

1071   Urinalysis components billed     97 - The benefit for this service is     M80 - We cannot pay for this        454 - Procedure code for services
       for the same date of service     included in the payment-allowance for    when performed during the same rendered.
       must be combined under           another service-procedure that has       session as a previously
       81000. Please submit             already been adjudicated.                processed service for the patient
       adjustment request to this                                                N1 - Alert- You may appeal this
       effect for components                                                     decision in writing within the
       already paid.                                                             required time limits following
                                                                                 receipt of this notice by following
                                                                                 the instructions included in your
                                                                                 contract or plan benefit
                                                                                 documents

1072   Renin Stimulation Panel has 18 - Duplicate claim-service.                 M86 - Service denied because      259 - Frequency of service.
       been paid for this date of                                                payment already made for same-
       service.                                                                  similar procedure within set time
                                                                                 frame.
1073   A negative dollar amount was 125 - Submission-billing error(s).           M49 - Missing-incomplete-invalid 21 - Missing or invalid information.
       submitted on your claim.                                                  value code(s) or amount(s).
       Negative values are not
       permitted. Please correct and
       resubmit as a new claim.


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                                                          EOB Code Crosswalk to HIPAA Standard Codes



1074   Components of                     B15 - This service-procedure requires    N20 - Service not payable with   454 - Procedure code for services
       Comprehensive Audiometry          that a qualifying service-procedure be   other service rendered on the    rendered.
       and Speech Recognition            received and covered. The qualifying     same date.
       recouped. The complete            other service-procedure has not been
       service - Comprehensive           received-adjudicated.
       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.

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 as       received and covered. The qualifying     same date.
       92557. Please submit an           other service-procedure has not been
       adjustment request to this        received-adjudicated.
       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 as       received and covered. The qualifying     same date.
       92557. Please submit an           other service-procedure has not been
       adjustment request to this        received-adjudicated.
       effect for component 92553
       already paid.
1078   Optical claim form 372-017 is     125 - Submission-billing error(s).       N34 - Incorrect claim form-format 276 - UB04-HCFA-1450-1500
       no longer accepted. Please                                                 for this service.                 claim form
       resubmit optical supply
       charges on the CMS-1500
       claim.



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                                                        EOB Code Crosswalk to HIPAA Standard Codes

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.  M59 - Missing-incomplete-invalid   476 - Missing or invalid units of
       to” dates in form locator 6 on                                         to date(s) of service.             service.
       approved UB. Correct your
       claim dates of 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.
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 per period or occurrence has been reached. payment already made for same-
       operative episode per date of                                         similar procedure within set time
       service.                                                              frame.
1084   There is a conflict in         16 - Claim-service lacks information   M86 - Service denied because        21 - Missing or invalid information.
       procedures billed. anterior    which is needed for adjudication.      payment already made for same-      294 - Supporting documentation
       and posterior procedures                                              similar procedure within set time
       billed for same date of                                               frame.
       service. review correct and-                                          N225 - Incomplete-invalid
       or resubmit with records as a                                         documentation-orders- notes-
       new day claim.                                                        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 previously                                            similar procedure within set time
       paid for this date of service.                                        frame.

1086   Review procedures. Billed-    119 - Benefit maximum for this time      M86 - Service denied because      259 - Frequency of service.
       only one instrumentation proc period or occurrence has been reached.   payment already made for same-
       allowed per day, correct and                                           similar procedure within set time
       resubmit as a new claim.                                               frame.


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                                                      EOB Code Crosswalk to HIPAA Standard Codes


1087   Insufficient documentation in 150 - Payment adjusted because the       N29 - Missing documentation-      21 - Missing or invalid information.
       records received to support payer deems the information submitted      orders-notes-summary-report-      294 - Supporting documentation
       therapeutic abortion to save does not support this level of service.   chart.
       life of mother. Resubmit with                                          N206 - The supporting
       additional medical records as                                          documentation does not match
       new day claim.                                                         the claim

1088   CAP MR-DD adult day health    B15 - This service-procedure requires    N20 - Service not payable with    258 - Days-units for procedure-
       or developmental day care     that a qualifying service-procedure be   other service rendered on the     revenue code.
       not allowed on same day as    received and covered. The qualifying     same date.
       institutional respite.        other service-procedure has not been
                                     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 same that a qualifying service-procedure be     other service rendered on the     revenue code.
       day as institutional respite. received and covered. The qualifying     same date.
                                     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 same   that a qualifying service-procedure be   other service rendered on the     revenue code.
       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 an 125 - Submission-billing error(s).        M51 - Missing-incomplete-invalid 21 - Missing or invalid information.
       approved HCPCS code for                                                procedure code(s) and-or dates.
       vitrocert.                                                             N59 - Alert- Please refer to your
                                                                              provider manual for additional
                                                                              program and provider information


1092   This HCPCS code cannot be 125 - Submission-billing error(s).           M20 - Missing-incomplete-invalid 21 - Missing or invalid information.
       billed with RC636.                                                     HCPCS
                                                                              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



1093   Antepartum package 59425 18 - Duplicate claim-service.                    M86 - Service denied because      259 - Frequency of service.
       has already been paid for this                                            payment already made for same-
       gestation period.                                                         similar procedure within set time
                                                                                 frame.
1094   Stand-By service already       18 - Duplicate claim-service.              M86 - Service denied because      259 - Frequency of service.
       paid for this date of service.                                            payment already made for same-
       No additional payment                                                     similar procedure within set time
       allowed for prolonged service                                             frame.
       on same DOS.

1095   Observation service already 18 - Duplicate claim-service.                 M86 - Service denied because      259 - Frequency of service.
       paid for this date of service.                                            payment already made for same-
       No additional payment                                                     similar procedure within set time
       allowed for prolonged service                                             frame.
       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 additional   included in the payment-allowance for    performed during the same          rendered.
       payment allowed for              another service-procedure that has       session-date as a previously
       prolonged service same           already been adjudicated.                processed service for the patient.
       DOS.
1097   Critical care has already paid   97 - The benefit for this service is     M80 - Not covered when             454 - Procedure code for services
       for this date of service. No     included in the payment-allowance for    performed during the same          rendered.
       additional payment allowed       another service-procedure that has       session-date as a previously
       for prolonged service same       already been adjudicated.                processed service for the patient.
       DOS.

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 day        B15 - This service-procedure requires    N20 - Service not payable with    258 - Days-units for procedure-
       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.




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                                                         EOB Code Crosswalk to HIPAA Standard Codes



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 Y2043.                                               similar procedure within set time
                                                                                  frame.
1102   Initial viewing of the X-ray by   97 - The benefit for this service is     M80 - Not covered when               454 - Procedure code for services
       the ER physician is included      included in the payment-allowance for    performed during the same            rendered.
       in the ER visit and will not be   another service-procedure that has       session-date as a previously
       reimbursed separately.            already been adjudicated.                processed service for the patient.

1103    Quantity outside min-max.        119 - Benefit maximum for this time    None                                   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 were None                                    107 - Processed according to
       unbreakable pack.                 not met or were exceeded.                                                     contract-plan provisions.
1106   Exceeds limit of billings for     119 - Benefit maximum for this time    None                                   259 - Frequency of service.
       antepartum package 4-6            period or occurrence has been reached.
       visits, by different providers.

1107   POS - Pharmacy initiated          B5 - Coverage-program guidelines were    None                                 107 - Processed according to
       reversal.                         not met or were exceeded.                                                     contract-plan provisions.
1108   POS - Denial due to DUR           B5 - Coverage-program guidelines were    None                                 107 - Processed according to
       alert.                            not met or were exceeded.                                                     contract-plan provisions.
1109   HCPCS for manipulation of         B15 - This service-procedure requires    N20 - Service not payable with       258 - Days-units for procedure-
       spine Not allowed on same         that a qualifying service-procedure be   other service rendered on the        revenue code.
       date of service as CPT            received and covered. The qualifying     same date.
       chiropractic manipulative         other service-procedure has not been
       treatment codes.                  received-adjudicated.




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                                                      EOB Code Crosswalk to HIPAA Standard Codes



1110   Enhanced maternity care      B15 - This service-procedure requires     N20 - Service not payable with   258 - Days-units for procedure-
       coordination not allowed on that a qualifying service-procedure be     other service rendered on the    revenue code.
       same day as related service. received and covered. The qualifying      same date.
                                    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 on that a qualifying service-procedure be     other service rendered on the    revenue code.
       same day as related service. received and covered. The qualifying      same date.
                                    other service-procedure has not been
                                    received-adjudicated.

1112   Related services not allowed B15 - This service-procedure requires     N20 - Service not payable with   258 - Days-units for procedure-
       on same date of service      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.

1113   Enhanced maternity care      B15 - This service-procedure requires     N20 - Service not payable with   258 - Days-units for procedure-
       coordination not allowed on that a qualifying service-procedure be     other service rendered on the    revenue code.
       same day as related service. received and covered. The qualifying      same date.
                                    other service-procedure has not been
                                    received-adjudicated.

1114   Enhanced child service       B15 - This service-procedure requires     N20 - Service not payable with   258 - Days-units for procedure-
       coordination not allowed on that a qualifying service-procedure be     other service rendered on the    revenue code.
       same day as related service. received and covered. The qualifying      same date.
                                    other service-procedure has not been
                                    received-adjudicated.

1115   Related service not allowed   B15 - This service-procedure requires    N20 - Service not payable with   258 - Days-units for procedure-
       on same day as enhanced       that a qualifying service-procedure be   other service rendered on the    revenue code.
       child service coordination.   received and covered. The qualifying     same date.
                                     other service-procedure has not been
                                     received-adjudicated.




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1116   Maternal outreach visits not     B15 - This service-procedure requires    N20 - Service not payable with   258 - Days-units for procedure-
       allowed on the same day as       that a qualifying service-procedure be   other service rendered on the    revenue code.
       enhanced maternity-child         received and covered. The qualifying     same date.
       service coordination or          other service-procedure has not been
       maternity care coordination      received-adjudicated.
       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 not   other service-procedure has not been
       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 date                                            similar procedure within set time
       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.
1120   Duplicate billing of base trip   18 - Duplicate claim-service.         M86 - Service denied because        259 - Frequency of service.
       has previously been paid. If                                           payment already made for same-
       multiple trips, submit with                                            similar procedure within set time
       documentation.                                                         frame.
1121   POS - Denied due to same         B5 - Coverage-program guidelines were None                                107 - Processed according to
       week reversal.                   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 same                                            frame.
       day, submit an adjustment
       with documentation.

1123   POS - metric decimal             B5 - Coverage-program guidelines were None                                21 - Missing or invalid information.
       quantity.                        not met or were exceeded.
1124   POS - DUR alert override not     B5 - Coverage-program guidelines were None                                21 - Missing or invalid information.
       found.                           not met or were exceeded.

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                                                       EOB Code Crosswalk to HIPAA Standard Codes



1125   Multiple diagnostic nasal      B15 - This service-procedure requires    M86 - Service denied because      258 - Days-units for procedure-
       Endoscopies are not allowed    that a qualifying service-procedure be   payment already made for same- revenue code.
       in the same day. Medicaid      received and covered. The qualifying     similar procedure within set time
       will consider the most         other service-procedure has not been     frame.
       complex (according to CPT      received-adjudicated.
       description) for
       reimbursement.
1126   Diagnostic nasal endoscopy     B15 - This service-procedure requires    N20 - Service not payable with    258 - Days-units for procedure-
       is not reimbursed separately   that a qualifying service-procedure be   other service rendered on the     revenue code.
       from surgical nasal            received and covered. The qualifying     same date.
       endoscopy billed for the       other service-procedure has not been
       same date of service.          received-adjudicated.

1127   Control of nasal hemorrhage    B15 - This service-procedure requires    N20 - Service not payable with    258 - Days-units for procedure-
       is not reimbursed separately   that a qualifying service-procedure be   other service rendered on the     revenue code.
       when billed in addition to     received and covered. The qualifying     same date.
       surgical nasal endoscopy       other service-procedure has not been
       with control of epistaxis.     received-adjudicated.

1128   Surgery is included in nasal   97 - The benefit for this service is     M80 - Not covered when             454 - Procedure code for services
       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 biopsy    B15 - This service-procedure requires    N20 - Service not payable with    258 - Days-units for procedure-
       is not reimbursed separately   that a qualifying service-procedure be   other service rendered on the     revenue code.
       from other surgical nasal      received and covered. The qualifying     same date.
       endoscopy billed for the       other service-procedure has not been
       same date of service.          received-adjudicated.




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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 when        received and covered. The qualifying     same date.
       performed on the same date        other service-procedure has not been
       of service as endoscopy with      received-adjudicated.
       removal of tissue from
       sphenoid sinus.
1132   Craniotomy is not reimbursed      B15 - This service-procedure requires    N20 - Service not payable with    258 - Days-units for procedure-
       separately when performed         that a qualifying service-procedure be   other service rendered on the     revenue code.
       on the same date of service       received and covered. The qualifying     same date.
       as nasal endoscopy in             other service-procedure has not been
       sphenoid region or                received-adjudicated.
       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 when        received-adjudicated.
       billed in addition to
       endoscopy for other surgery
       in sphenoid region.

1134   This proc is included in the      97 - The benefit for this service is     M80 - Not covered when             454 - Procedure code for services
       nasal endoscopy with medial       included in the payment-allowance for    performed during the same          rendered.
       and-or inferior orbital wall      another service-procedure that has       session-date as a previously
       decompression or optcal           already been adjudicated.                processed service for the patient.
       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 medial       other service-procedure has not been     processed service for the patient.
       and inferior wall                 received-adjudicated.
       decompression for the same
       date of service.


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                                                        EOB Code Crosswalk to HIPAA Standard Codes




1136   This surgical endoscopy         B15 - This service-procedure requires    N20 - Service not payable with   258 - Days-units for procedure-
       procedure is not reimbursed     that a qualifying service-procedure be   other service rendered on the    revenue code.
       as a separate procedure         received and covered. The qualifying     same date.
       when billed in addition to      other service-procedure has not been
       endoscopy with optic nerve      received-adjudicated.
       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 when      that a qualifying service-procedure be   other service rendered on the    revenue code.
       billed for the same date of     received and covered. The qualifying     same date.
       service as more complex         other service-procedure has not been
       nasal endoscopy (i.e with       received-adjudicated.
       repair CSF leak, orbital wall
       decompression).

1138   POS - processor control         B5 - Coverage-program guidelines were    None                             21 - Missing or invalid information.
       number not found.               not met or were exceeded.
1139   POS - VAN identification not    B5 - Coverage-program guidelines were    None                             21 - Missing or invalid information.
       on file.                        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 already      other service-procedure has not been
       been reimbursed as a            received-adjudicated.
       complete procedure for this
       date of service.
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 procedure     received and covered. The qualifying     same date.
       code has already been           other service-procedure has not been     N200 - The professional
       reimbursed for this date.       received-adjudicated.                    component must be billed
       Rebill for professional                                                  separately.
       component only.




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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 procedure      received and covered. The qualifying     same date.
       code has already been            other service-procedure has not been     N195 - The technical component
       reimbursed for this date.        received-adjudicated.                    must be billed separately.
       Rebill for technical
       component only.
1143   POS - production claim           B5 - Coverage-program guidelines were    None                              107 - Processed according to
       submitted in test.               not met or were exceeded.                                                  contract-plan provisions.
1144   POS - test claim submitted in    B5 - Coverage-program guidelines were    None                              107 - Processed according to
       production.                      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 service     that a qualifying service-procedure be   other service rendered on the     revenue code.
       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 payment of that a qualifying service-procedure be       other service rendered on the     rendered.
       lab panel.                   received and covered. The qualifying         same date.
                                    other service-procedure has not been
                                    received-adjudicated.

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     N20 - Service not payable with
       resection. Resubmit as an        other service-procedure has not been     other service rendered on the
       adjustment with                  received-adjudicated.                    same date.
       documentation supporting
       second cystourethroscopy on
       same day.
1148   Cystourethroscopy with           18 - Duplicate claim-service.            M86 - Service denied because      259 - Frequency of service.
       resection of ureterocele paid.                                            payment already made for same-
       Cysto with meatotomy                                                      similar procedure within set time
       recouped.. Resubmit as an                                                 frame.
       adjustment with
       documentation supporting
       second cystourethroscopy on
       same day.


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1149   Claim denied, PA is required 197 - Precertification-authorization-          N54 - Claim information is        48 - Referral-authorization.
       for rental of apnea monitor. notification absent.                           inconsistent with pre-certified-  84 - Service not authorized.
                                                                                   authorized services.
1150   Banding for this recipient was 18 - Duplicate claim-service.                M86 - Service denied because      259 - Frequency of service.
       paid prior to the November 1,                                               payment already made for same-
       1997 fee revisions; therefore,                                              similar procedure within set time
       the maintenance visit was                                                   frame.
       paid according the fees in
       existence at that time.

1151   Probing of nasolacrimal duct      97 - The benefit for this service is      M80 - Not covered when             454 - Procedure code for services
       with or without irrigation is     included in the payment-allowance for     performed during the same          rendered.
       included in a more                another service-procedure that has        session-date as a previously
       comprehensive procedure           already been adjudicated.                 processed service for the patient.
       already paid.
1152   Components denied. rebill         125 - Submission-billing error(s).        N56 - Procedure code billed is not 21 - Missing or invalid information.
       using 92557 as complete                                                     correct-valid for the service billed
       procedure versus separate                                                   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 irrigation   another service-procedure that has        session-date as a previously
       paid. Separate payment for        already been adjudicated.                 processed service for the patient.
       component of
       comprehensive procedure
       recouped.
1154   Claim denied pending rate         133 - The disposition of this claim-      None                               3 - Claim has been adjudicated
       information from DMA. Call        service is pending further review.                                           and is awaiting payment cycle.
       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.




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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 - Medical necessity for service.
       Resubmit records to review                                               summary-report-chart                297 - Medical notes-report.
       for medical necessity include:
       history-physical- operative
       records-pathology report and
       discharge summary.

1157   Delivery and-or postpartum       97 - The benefit for this service is    M80 - Not covered when             454 - Procedure code for services
       care included in total ob        included in the payment-allowance for   performed during the same          rendered.
       package.                         another service-procedure that has      session-date as a previously
                                        already been adjudicated.               processed service for the patient.

1158   Antepartum package               97 - The benefit for this service is    M80 - Not covered when             454 - Procedure code for services
       recouped. Total ob package       included in the payment-allowance for   performed during the same          rendered.
       paid which includes              another service-procedure that has      session-date as a previously
       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 this   another service-procedure that has      session-date as a previously
       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 of terminated.                              “to” date(s) of service.
       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-service-supply
       chemotherapy.                                                              is covered only when the
                                                                                  associated service is covered.




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1162   Postpartum package                97 - The benefit for this service is     M80 - Not covered when             454 - Procedure code for services
       recouped. Total ob package        included in the payment-allowance for    performed during the same          rendered.
       paid, which includes              another service-procedure that has       session-date as a previously
       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 this    another service-procedure that has       session-date as a previously
       gestation period.                 already been adjudicated.                processed service for the patient.

1164   Transposition of ovaries          97 - The benefit for this service is     M80 - Not covered when             454 - Procedure code for services
       included in abdominal             included in the payment-allowance for    performed during the same          rendered.
       hysterectomy.                     another service-procedure that has       session-date as a previously
                                         already been adjudicated.                processed service for the patient.

1165   Abdominal hysterectomy            97 - The benefit for this service is     M80 - Not covered when             454 - Procedure code for services
       includes the transposition of     included in the payment-allowance for    performed during the same          rendered.
       ovaries.                          another service-procedure that has       session-date as a previously
                                         already been adjudicated.                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 not       that a qualifying service-procedure be   other service rendered on the     rendered.
       make separate payment for         received and covered. The qualifying     same date.
       procedures that are               other service-procedure has not been
       components of a more              received-adjudicated.
       comprehensive service for
       the same date of service.

1167   DME allowed once in four          119 - Benefit maximum for this time    None                                187 - Date(s) of service.
       years. If prior approval was      period or occurrence has been reached.                                     259 - Frequency of service.
       obtained for this piece of
       equipment for dates of
       service prior to Nov 1, 1996,
       please resubmit as an
       Adjustment.
1168   Arthrodesis, hip joint included   97 - The benefit for this service is     M80 - Not covered when             454 - Procedure code for services
       in fusion of hip joint.           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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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 for      received and covered. The qualifying      same date.
       procedures that are            other service-procedure has not been
       components of a more           received-adjudicated.
       comprehensive procedure.

1170   This procedure or procedure- 125 - Submission-billing error(s).          M53 - Missing-incomplete-invalid 258 - Days-units for procedure-
       modifier combination is                                                  days or units of service.        revenue code.
       edited for units, therefore                                                                               453 - Procedure code modifier(s)
       billing a span of days is not                                                                             for service(s) rendered.
       allowed. Please bill each
       date of service on a separate
       detail

1171   Please resubmit claim with     16 - Claim-service lacks information      N29 - Missing documentation-       297 - Medical notes-report.
       medical records.               which is needed for adjudication.         orders-notes-summary-report-
                                                                                chart.
                                                                                N163 - Medical Record does 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.

1173   Superficial hyperthermia 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 chemotherapy        received and covered. The qualifying      same date.
       administration.                other service-procedure has not been
                                      received-adjudicated.




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1174   Thanks for reporting vaccine 89 - Professional fees removed from        M41 - We do not pay for this as     19 - Entity acknowledges receipt of
       to our database. This vaccine charges.                                  the patient has no legal obligation claim-encounter.
       is available at no charge                                               to pay for this.                    598 - Non-payable Professional
       through the Vaccines For                                                                                    Component Billed Amount.
       Children program and
       therefore is not reimbursable
       through Medicaid.

1175   Dialysis facility: this revenue 125 - Submission-billing error(s).      M51 - Missing-incomplete-invalid 21 - Missing or invalid information.
       code must be billed with the                                            procedure code(s).               455 - Revenue code for services
       appropriate 5-digit CPT code.                                           N50 - Missing-incomplete-invalid rendered.
       correct denied detail and                                               discharge information.
       refile as 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 revenue 125 - Submission-billing error(s).      M51 - Missing-incomplete-invalid 21 - Missing or invalid information.
       code must be billed with a                                              procedure code(s).               455 - Revenue code for services
       valid 5 digit HCPCS drug                                                N50 - Missing-incomplete-invalid rendered.
       code. Correct denied detail                                             discharge information.
       and refile as a new day
       claim.
1178   Rebill first date of on-going   125 - Submission-billing error(s).      M45 - Missing-incomplete-invalid   21 - Missing or invalid information.
       dialysis TX with occurrence                                             occurrence code(s).                213- Date of first routine dialysis.
       code 51 on the approved UB                                              MA31 - Missing-incomplete-         461 - NUBC occurrence code(s)
       before DOS 06-01-03,                                                    invalid beginning and ending       and date(s).
       occurrence code 11 on and                                               dates of the period billed.
       after 06-01-03. 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 57454    another service-procedure that has       session-date as a previously
       and 57456.                     already been adjudicated.                processed service for the patient.



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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 approved
       Medicaid for dental or          eligible to perform the service billed.      provider specialty may not bill this for dates of service.
       physician providers.                                                         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 DMA maximum allowable or contracted-                  based on the findings of a review benefits for submitted dates of
       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 are   B7 - This provider was not certified-        N59 - Alert- Please refer to your 45 - Awaiting benefit determination.
       currently covered for dental    eligible to be paid for this procedure-      provider manual for additional
       providers. Claim is under       service on this date of service.             program and provider
       review by DMA. Upon their                                                    information.
       decision your claim will be                                                  N185 - Alert- Do not resubmit this
       resubmitted for you.                                                         claim-service

1184   Insertion of vitrocert is    11 - The diagnosis is inconsistent with         M76 - Missing-incomplete-invalid 255 - Diagnosis code.
       covered only for the         the procedure.                                  diagnosis or condition.
       diagnosis of cytomegalovirus                                                 N59 - Alert- Please refer to your
       retinitis(CMV).                                                              provider manual 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.



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1187   Injectable drug adm code not B15 - This service-procedure requires         N20 - Service not payable with    454 - Procedure code for services
       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 administration    received and covered. The qualifying     same date.
       code. Injectable drug             other service-procedure has not been
       administration fee recouped.      received-adjudicated.


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 the        other service-procedure has not been
       same DOS as the complete          received-adjudicated.
       procedure.
1190   Complete proc performed on        B15 - This service-procedure requires    N20 - Service not payable with    453 - Procedure Code Modifier(s)
       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     included in the payment-allowance for    performed during the same          rendered.
       in joint exploration, biopsy or   another service-procedure that has       session-date as a previously
       removal.                          already been adjudicated.                processed service for the patient.

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 the        other service-procedure has not been
       same date of service as the       received-adjudicated.
       complete procedure.




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1193   Complete procedure               B15 - This service-procedure requires    N20 - Service not payable with    453 - Procedure Code Modifier(s)
       performed on the same date       that a qualifying service-procedure be   other service rendered on the     for Service(s) Rendered
       of service as the professional   received and covered. The qualifying     same date.
       or technical component not       other service-procedure has not been
       allowed.                         received-adjudicated.

1194   Arthrotomy with excision of      97 - The benefit for this service is     M80 - Not covered when             454 - Procedure code for services
       semilunar cartilage included     included in the payment-allowance for    performed during the same          rendered.
       in knee excision semilunar       another service-procedure that has       session-date as a previously
       cartilage.                       already been adjudicated.                processed service for the patient.

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 the       other service-procedure has not been
       same date of service as the      received-adjudicated.
       complete procedure.

1196   Complete procedure               B15 - This service-procedure requires    N20 - Service not payable with    453 - Procedure Code Modifier(s)
       performed on the same date       that a qualifying service-procedure be   other service rendered on the     for Service(s) Rendered
       of service as the professional   received and covered. The qualifying     same date.
       or technical component not       other service-procedure has not been
       allowed.                         received-adjudicated.

1197   Physician service and visual 125 - Submission-billing error(s).           N61 - Rebill services on separate 276 - UB04-HCFA-1450-1500
       aids cannot be processed on                                               claims.                           claim form.
       the same claim. Resubmit                                                                                    481 - Claim-submission format is
       physician service on a                                                                                      invalid.
       separate CMS 1500 claim.




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1198   More than one entry for       B5 - Coverage-program guidelines were    MA130 - Your claim contains        259 - Frequency of service.
       same DOS. If all entries are not met or were exceeded.                 incomplete and-or invalid          476 - Missing or invalid units of
       correct, combine all units on                                          information, and no appeal rights service
       one detail line and resubmit.                                          are afforded because 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 in 97 - The benefit for this service is     M80 - Not covered when             454 - Procedure code for services
       fee for panel, same date of   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.

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 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.

1201   Patient is enrolled in a HMO 24 - Payment for charges adjusted.    None                                    96 - No agreement with entity.
       Plan. Delivery charges have Charges are covered under a capitation                                         187 - Date(s) of service.
       been made to the HMO.         agreement-managed care plan.                                                 585 - Denied Charge or Non-
       Facilities may bill fee for                                                                                covered Charge.
       service for care rendered on
       out-of-plan dates of service.

1202   Patient is enrolled in a HMO 24 - Payment for charges adjusted.    None                                    187 - Date(s) of service.
       plan. Delivery charges have Charges are covered under a capitation                                         585 - Denied Charge or Non-
       been made to the HMO.        agreement-managed care plan.                                                  covered Charge.
       Facilities may bill fee for
       service for care rendered on
       out-of-plan dates of service




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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. 142 - Entitys license-certification
       claim or you have billed a                                                                                 number.
       test-DOS outside your CLIA                                                                                 630 - Referring CLIA Number
       certification.
1205   Arthrotomy with synovectomy    97 - The benefit for this service is     M80 - Not covered when             454 - Procedure code for services
       knee included in arthrotomy    included in the payment-allowance for    performed during the same          rendered.
       knee anterior and posterior.   another service-procedure that has       session-date as a previously
                                      already been adjudicated.                processed service for the patient.

1206   V diagnosis is not allowed as 146 - Diagnosis was invalid for the       M76 - Missing-incomplete-invalid 21 - Missing or invalid information.
       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-invalid 21 - Missing or invalid information.
       billed with value code 61 with                                          value code(s) or amount(s).      463 - NUBC value code(s) and-or
       corresponding MSA code.                                                                                  amount(s).

1208   Invalid MSA code. Please       125 - Submission-billing error(s).       M49 - Missing-incomplete-invalid 21 - Missing or invalid information.
       correct and resubmit as a                                               value code(s) or amount(s).
       new day claim.
1209   Purchase of supplies related   B15 - This service-procedure requires    M86 - Service denied because      258 - Days-units for procedure-
       to suction equipment not       that a qualifying service-procedure be   payment already made for same- revenue code.
       allowed during the same        received and covered. The qualifying     similar procedure within set time
       month equipment is rented.     other service-procedure has not been     frame.
                                      received-adjudicated.




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1210   Service recouped. Supplies        97 - The benefit for this service is     N357 - Time frame requirements        259 - Frequency of service.
       related to suction equipment      included in the payment-allowance for    between this service-procedure-       453 - Procedure Code Modifier(s)
       can not be billed within the      another service-procedure that has       supply and a related service-         for Service(s) Rendered
       same calendar month.              already been adjudicated.                procedure-supply have not been
                                                                                  met.
                                                                                  N381 - Consult our contractual
                                                                                  agreement for restrictions-billing-
                                                                                  payment information related to
                                                                                  these charges
1211   Topical application of fluoride   B15 - This service-procedure requires    N20 - Service not payable with        258 - Days-units for procedure-
       not allowed to bill on the        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.
       prophylaxis application (0-20)    other service-procedure has not been
                                         received-adjudicated.

1212   Tenotomy, single tendon can B15 - This service-procedure requires          N20 - Service not payable with        258 - Days-units for procedure-
       not be billed same date of   that a qualifying service-procedure be        other service rendered on the         revenue code.
       service as multiple tendons. received and covered. The qualifying          same date.
                                    other service-procedure has not been
                                    received-adjudicated.

1213   Prophylaxis application of        B15 - This service-procedure requires    N20 - Service not payable with        258 - Days-units for procedure-
       flouride not allowed to bill on   that a qualifying service-procedure be   other service rendered on the         revenue code.
       the same date of service as       received and covered. The qualifying     same date.
       topical application (0-20).       other service-procedure has not been
                                         received-adjudicated.

1214   Hamstring single and              B15 - This service-procedure requires    N20 - Service not payable with        258 - Days-units for procedure-
       multiple tendon lengthening       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                           other service-procedure has not been
                                         received-adjudicated.

1215   Transplant, hamstring tendon      B15 - This service-procedure requires    N20 - Service not payable with        258 - Days-units for procedure-
       to patella; single tendon not     that a qualifying service-procedure be   other service rendered on the         revenue code.
       allowed on same day as            received and covered. The qualifying     same date.
       multiple tendons.                 other service-procedure has not been
                                         received-adjudicated.



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1216   Reconstruction of dislocating   B15 - This service-procedure requires    N20 - Service not payable with   258 - Days-units for procedure-
       patella not allowed same as     that a qualifying service-procedure be   other service rendered on the    revenue code.
       extensor realignment with       received and covered. The qualifying     same date.
       patellectomy and-or revision    other service-procedure has not been
       removal of knee cap.            received-adjudicated.


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 recurrent    received and covered. The qualifying     same date.
       dislocating patella.            other service-procedure has not been
                                       received-adjudicated.

1218   Only one catheter or            119 - Benefit maximum for this time    M86 - Service denied because      259 - Frequency of service.
       reservoir-pump implantation     period or occurrence has been reached. payment already made for same-
       allowed per day, same or                                               similar procedure within set time
       different provider.                                                    frame.

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 without   that a qualifying service-procedure be   other service rendered on the    revenue code.
       allograft not allowed same      received and covered. The qualifying     same date.
       day as one component.           other service-procedure has not been
                                       received-adjudicated.

1221   Tenotomy, percutaneous,         B15 - This service-procedure requires    N20 - Service not payable with   258 - Days-units for procedure-
       Achilles tendon not allowed     that a qualifying service-procedure be   other service rendered on the    revenue code.
       same day as general             received and covered. The qualifying     same date.
       anesthesia.                     other service-procedure has not been
                                       received-adjudicated.




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1222   An electronic analysis of       18 - Duplicate claim-service.            M86 - Service denied because      259 - Frequency of service.
       cardioverter-defibrillator with                                          payment already made for same-
       programming procedure                                                    similar procedure within set time
       already paid for this date of                                            frame.
       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 special 96 - Non-covered charge(s).                  N29 - Missing documentation-        21 - Missing or invalid information.
       report and operative notes                                               orders-notes-summary-report-        421 - Medical review attachment-
       and-or medical records                                                   chart.                              information for service(s).
                                                                                N225 - Incomplete-invalid
                                                                                documentation-orders-notes-
                                                                                summary-report-chart
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 as      received and covered. The qualifying     same date.
       lengthening or shortening of    other service-procedure has not been
       tendon.                         received-adjudicated.

1226   Biopsy, soft tissue of leg or B15 - This service-procedure requires      N20 - Service not payable with      258 - Days-units for procedure-
       ankle area not allowed same that a qualifying service-procedure be       other service rendered on the       revenue code.
       day as superficial.           received and covered. The qualifying       same date.
                                     other service-procedure has not been
                                     received-adjudicated.

1227   Excision, tumor, leg or ankle   B15 - This service-procedure requires    N20 - Service not payable with      258 - Days-units for procedure-
       area not allowed same day       that a qualifying service-procedure be   other service rendered on the       revenue code.
       as excision benign tumor        received and covered. The qualifying     same date.
       deep subfacial.                 other service-procedure has not been
                                       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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1229   Repair, extensor tendon,          B15 - This service-procedure requires N20 - Service not payable with        258 - Days-units for procedure-
       legs; 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. - 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 extension B15 - This service-procedure requires       N20 - Service not payable with     258 - Days-units for procedure-
       tendon not allowed same day that a qualifying service-procedure be         other service rendered on the      revenue code.
       as multiple.                   received and covered. The qualifying        same date.
                                      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 CA 125 - Submission-billing error(s).            N54 - Claim information is         21 - Missing or invalid information.
       recipient with incorrect                                                   inconsistent with pre-certified-   276 - UB04-HCFA-1450-1500
       authorization # on CMS                                                     authorized services.               claim form
       1500. If Mon-Fri between
       5PM and 8AM or Sat-Sun
       contact PCP for Authorization




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1233   Non-ER service billed for CA     15 - Payment adjusted because the          N54 - Claim information is         21 - Missing or invalid information.
       recipient without auth if mon-   submitted authorization number is          inconsistent with pre-certified-   48 - Referral-authorization.
       fri between 5PM and 8AM or       missing, invalid, or does not apply to the authorized services.               515 - Managed Care review
       Sat-Sun contact PCP for          billed services or provider.
       auth or submit claim to the
       managed care section of
       DMA for retro-review.

1234   Single tendon lengthening or B15 - This service-procedure requires          N20 - Service not payable with     258 - Days-units for procedure-
       shortening not allowed same that a qualifying service-procedure be          other service rendered on the      revenue code.
       day as multiple.             received and covered. The qualifying           same date.
                                    other service-procedure has not been
                                    received-adjudicated.

1235   Superficial and deep transfer    B15 - This service-procedure requires      N20 - Service not payable with     258 - Days-units for procedure-
       or transplant of single tendon   that a qualifying service-procedure be     other service rendered on the      revenue code.
       not allowed on the same date     received and covered. The qualifying       same date.
       of service.                      other service-procedure has not been
                                        received-adjudicated.

1236    Allow one application of        119 - Benefit maximum for this time    M86 - Service denied because      259 - Frequency of service.
       flouride within six calendar     period or occurrence has been reached. payment already made for same- 483 - Maximum coverage amount
       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 disrupted      B15 - This service-procedure requires      N20 - Service not payable with     258 - Days-units for procedure-
       ligament, ankle not allowed      that a qualifying service-procedure be     other service rendered on the      revenue code.
       same day as primary and          received and covered. The qualifying       same date.
       both collateral ligaments.       other service-procedure has not been
                                        received-adjudicated.

1238   Arthroplasty, ankle, revision    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.
       repair of ankle.                 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

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 per                                          similar procedure within set time
       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 below B15 - This service-procedure requires       N20 - Service not payable with   258 - Days-units for procedure-
       fascia not allowed same day that a qualifying service-procedure be      other service rendered on the    revenue code.
       as drainage of foot.        received and covered. The qualifying        same date.
                                   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 benign     that a qualifying service-procedure be   other service rendered on the    revenue code.
       tumor deep subfascial          received and covered. The qualifying     same date.
       intramuscular.                 other service-procedure has not been
                                      received-adjudicated.

1244   Fasciectomy, plantar facia;  B15 - This service-procedure requires      N20 - Service not payable with   258 - Days-units for procedure-
       partial not allowed same day that a qualifying service-procedure be     other service rendered on the    revenue code.
       as removal of foot fascia.   received and covered. The qualifying       same date.
                                    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.


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                                                        EOB Code Crosswalk to HIPAA Standard Codes



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 for    B15 - This service-procedure requires    N20 - Service not payable with   258 - Days-units for procedure-
       would repair; not allowed for   that a qualifying service-procedure be   other service rendered on the    revenue code.
       extractions-surgery sites.      received and covered. The qualifying     same date.
                                       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.

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 day      received and covered. The qualifying     same date.
       as autograft.                   other service-procedure has not been
                                       received-adjudicated.

1251   Osteotomy, with or without      B15 - This service-procedure requires    N20 - Service not payable with   258 - Days-units for procedure-
       lengthening, metatarsal not     that a qualifying service-procedure be   other service rendered on the    revenue code.
       allowed same day as first       received and covered. The qualifying     same date.
       metatarsal with autograft of    other service-procedure has not been
       multiple.                       received-adjudicated.




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                                                       EOB Code Crosswalk to HIPAA Standard Codes

1252   Injectable drug administration B15 - This service-procedure requires    N20 - Service not payable with   258 - Days-units for procedure-
       not allowed same date of       that a qualifying service-procedure be   other service rendered on the    revenue code.
       service as office visit.       received and covered. The qualifying     same date.
                                      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 adm.      that a qualifying service-procedure be   other service rendered on the    revenue code.
       Inj drug adm fee recouped.     received and covered. The qualifying     same date.
                                      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 anomalies   received and covered. The qualifying     same date.
       complete procedure includes    other service-procedure has not been
       components for probe           received-adjudicated.
       placement and-or image
       acquisition.

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. Complete     B15 - This service-procedure requires    N20 - Service not payable with   258 - Days-units for procedure-
       cytopathology procedure 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.
       physician‟s interpretation.    other service-procedure has not been
                                      received-adjudicated.



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                                                        EOB Code Crosswalk to HIPAA Standard Codes


1258   Osteotomy, with or without      B15 - This service-procedure requires      N20 - Service not payable with    258 - Days-units for procedure-
       lengthening, each other than    that a qualifying service-procedure be     other service rendered on the     revenue code.
       first metarsal not allowed      received and covered. The qualifying       same date.
       same day as multiple.           other service-procedure has not been
                                       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 operation service was not identified on this claim.   to primary procedure.             Service(s) Rendered.
       must bill with primary                                                     N161 - This drug-service-supply
       procedure.                                                                 is covered only when the
                                                                                  associated service is covered.


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 the      other service-procedure has not been
       same date of service as         received-adjudicated.
       complete service.
1261   Complete procedure              B15 - This service-procedure requires      N20 - Service not payable with    258 - Days-units for procedure-
       performed on the same date      that a qualifying service-procedure be     other service rendered on the     revenue code.
       of service as professional or   received and covered. The qualifying       same date.
       technical component not         other service-procedure has not been
       allowed. component              received-adjudicated.
       recouped.
1262   Related bypass procedures       B15 - This service-procedure requires      N20 - Service not payable with    258 - Days-units for procedure-
       not allowed to bill same DOS.   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.

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 the      other service-procedure has not been
       same date of service as the     received-adjudicated.
       complete procedure.



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                                                         EOB Code Crosswalk to HIPAA Standard Codes


1264   Complete procedure               B15 - This service-procedure requires    N20 - Service not payable with   258 - Days-units for procedure-
       performed on the same date       that a qualifying service-procedure be   other service rendered on the    revenue code.
       of service as the professional   received and covered. The qualifying     same date.
       or technical component not       other service-procedure has not been
       allowed.                         received-adjudicated.

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 the       other service-procedure has not been
       same date of service as the      received-adjudicated.
       complete procedure.

1267   Complete procedure               B15 - This service-procedure requires    N20 - Service not payable with   258 - Days-units for procedure-
       performed on the same date       that a qualifying service-procedure be   other service rendered on the    revenue code.
       of service as the professional   received and covered. The qualifying     same date.
       of technical component not       other service-procedure has not been
       allowed, component               received-adjudicated.
       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, nonesterified.      received and covered. The qualifying     same date.
                                        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 the       other service-procedure has not been
       same date of service as the      received-adjudicated.
       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 date       that a qualifying service-procedure be     other service rendered on the      revenue code.
       of service as the professional   received and covered. The qualifying       same date.
       or technical component not       other service-procedure has not been
       allowed. component               received-adjudicated.
       recouped.
1271   For the same tooth, payment      119 - Benefit maximum for this time    N188 - The approved level of           259 - Frequency of service.
       is limited to 1 time per         period or occurrence has been reached. care does not match the
       surface per episode of                                                  procedure code submitted.
       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 the       other service-procedure has not been
       same date of service as the      received-adjudicated.
       complete procedure.

1273   Complete procedure               B15 - This service-procedure requires      N20 - Service not payable with     258 - Days-units for procedure-
       performed on the same date       that a qualifying service-procedure be     other service rendered on the      revenue code.
       of service as the professional   received and covered. The qualifying       same date
       or technical component not       other service-procedure has not been
       allowed. component               received-adjudicated.
       recouped.
1274   For recipients with Medicare,    22 - This care may be covered by           MA04 - Secondary payment           116 - Claim submitted to incorrect
       Medicaid will only reimburse     another payer per coordination of          cannot be considered without the payer.
       for this DME item if Medicare    benefits.                                  identity of or payment information
       has allowed or paid                                                         from the primary payer. The
                                                                                   information was either not
                                                                                   reported or was illegible.

1275   Patient monthly liability not    142 - Monthly Medicaid patient liability   N58 - Missing-incomplete-invalid   21 - Missing or invalid information.
       on eligibility file. contact     amount.                                    patient liability amount.
       county dss.



   January 1, 2009                                                            Page 190
                                                          EOB Code Crosswalk to HIPAA Standard Codes

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 the        other service-procedure has not been
       same date of service as the       received-adjudicated.
       complete procedure.

1277   Complete procedure                B15 - This service-procedure requires    N20 - Service not payable with     259 - Frequency of service.
       performed on the same date        that a qualifying service-procedure be   other service rendered on the
       of service as the professional    received and covered. The qualifying     same date.
       or technical component not        other service-procedure has not been
       allowed, component                received-adjudicated.
       recouped.
1278   Combined units of RC679,          125 - Submission-billing error(s).       M52 - Missing-incomplete-invalid   12 - One or more originally
       RC599 or RC183 must equal                                                  from date(s) of service. M53 -     submitted procedure codes have
       number of days calculated                                                  Missing-incomplete-invalid days    been combined.
       from the 'from' & 'to' dates in                                            or units of service.               258 - Days-units for procedure-
       form locator 6 on approved                                                 M59 - Missing-incomplete-invalid   revenue code.
       UB. Correct claim dates &                                                  to date(s) of service.
       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 the        other service-procedure has not been
       same date of service as the       received-adjudicated.
       complete procedure.

1280   Complete procedure                B15 - This service-procedure requires    N20 - Service not payable with     258 - Days-units for procedure-
       performed on the same date        that a qualifying service-procedure be   other service rendered on the      revenue code.
       of service as the professional    received and covered. The qualifying     same date.
       or technical component not        other service-procedure has not been
       allowed. component                received-adjudicated.
       recouped.
1281   Helicobacter pylori breath        B15 - This service-procedure requires    N20 - Service not payable with     258 - Days-units for procedure-
       test analysis not allowed to      that a qualifying service-procedure be   other service rendered on the      revenue code.
       bill on same DOS as drug          received and covered. The qualifying     same date.
       administration and sample         other service-procedure has not been
       collection.                       received-adjudicated.



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                                                         EOB Code Crosswalk to HIPAA Standard Codes



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 the       other service-procedure has not been
       same date of service as the      received-adjudicated.
       complete procedure.

1283   Completed procedure              B15 - This service-procedure requires    N20 - Service not payable with     258 - Days-units for procedure-
       performed on the same date       that a qualifying service-procedure be   other service rendered on the      revenue code.
       of service as the professional   received and covered. The qualifying     same date.
       or technical component not       other service-procedure has not been
       allowed. Component               received-adjudicated.
       recouped
1284   Outpatient drug and alcohol  52 - The referring-prescribing-rendering N95 - This provider type -               84 - Service not authorized.
       rehab services are only      provider is not eligible to refer-prescribe- provider specialty may not bill this
       contracted through the area  order-perform the service billed.            service.
       mental health program.                                                    N201 - A mental health facility is
                                                                                 responsible for payment of
                                                                                 outside providers who furnish
                                                                                 these services-supplies to
                                                                                 residents.
1285   Components of basic          B15 - This service-procedure requires N20 - Service not payable with              454 - Procedure code for services
       metabolic panel recouped to that a qualifying service-procedure be        other service rendered on the        rendered.
       allow reimbursement of panel received and covered. The qualifying         same date.
       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.




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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 the   97 - The benefit for this service is     M80 - Not covered when             54 - Duplicate of a previously
       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 and         B15 - This service-procedure requires    N20 - Service not payable with     258 - Days-units for procedure-
       molecular diagnostics not          that a qualifying service-procedure be   other service rendered on the      revenue code.
       allowed same date of service       received and covered. The qualifying     same date.
       as hiv-1 quantification.           other service-procedure has not been
                                          received-adjudicated.

1292   Related Lipo protein        B15 - This service-procedure requires           N20 - Service not payable with     258 - Days-units for procedure-
       procedures not allowed same that a qualifying service-procedure be          other service rendered on the      revenue code.
       DOS as primary procedure. received and covered. The qualifying              same date.
                                   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.




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1295   Related molecular                B15 - This service-procedure requires    N20 - Service not payable with    258 - Days-units for procedure-
       diagnostics 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 procedure.               other service-procedure has not been
                                        received-adjudicated.

1296   Case management recouped         97 - The benefit for this service is     M80 - Not covered when             259 - Frequency of service.
       to allow payment for Case        included in the payment-allowance for    performed during the same
       Management to a CAP              another service-procedure that has       session-date as a previously
       provider within the same         already been adjudicated.                processed service for the patient.
       calendar month.

1297   Related patient nucleic acid B15 - This service-procedure requires        N20 - Service not payable with    258 - Days-units for procedure-
       procedures not allowed same that a qualifying service-procedure be        other service rendered on the     revenue code.
       DOS as primary procedures. received and covered. The qualifying           same date.
                                    other service-procedure has not been
                                    received-adjudicated.

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 more   that a qualifying service-procedure be   other service rendered on the     revenue code.
       lesions not allowed same.        received and covered. The qualifying     same date.
                                        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.




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1301   Immunization update and           B15 - This service-procedure requires    N20 - Service not payable with     258 - Days-units for procedure-
       Health Check not allowed on       that a qualifying service-procedure be   other service rendered on the      revenue code.
       same date of service by           received and covered. The qualifying     same date.
       same provider before 3-1-95.      other service-procedure has not been
                                         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 same       that a qualifying service-procedure be   other service rendered on the      revenue code.
       DOS as total.                     received and covered. The qualifying     same date.
                                         other service-procedure has not been
                                         received-adjudicated.

1304   Debridement of infected skin      B15 - This service-procedure requires    N20 - Service not payable with     258 - Days-units for procedure-
       up to 10% of body surface         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.
       each additional 10%.              other service-procedure has not been
                                         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 DOS         that a qualifying service-procedure be   other service rendered on the      revenue code.
       as multiple qualitative.          received and covered. The qualifying     same date.
                                         other service-procedure has not been
                                         received-adjudicated.

1306   Injection, intralesional; up to   B15 - This service-procedure requires    N20 - Service not payable with     258 - Days-units for procedure-
       and including seven lesions       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 seven lesions.       other service-procedure has not been
                                         received-adjudicated.

1307   Provider number invalid for       125 - Submission-billing error(s).       N77 - Missing-incomplete-invalid   21 - Missing or invalid information.
       CSHS code(s) billed.                                                       designated provider number.        132 - Entitys Medicaid provider id.



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1308   Debridement of nail(s) by any   B15 - This service-procedure requires    N20 - Service not payable with     258 - Days-units for procedure-
       method(s): one to five can      that a qualifying service-procedure be   other service rendered on the      revenue code.
       not be billed same day as       received and covered. The qualifying     same date.
       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 DOS       that a qualifying service-procedure be   other service rendered on the      revenue code.
       as multiple quanitative.        received and covered. The qualifying     same date.
                                       other service-procedure has not been
                                       received-adjudicated.

1310   Only one simple repair code     119 - Benefit maximum for this time    M86 - Service denied because         259 - Frequency of service.
       for each group of anatomic      period or occurrence has been reached. payment already made for same-       612 - Per Day Limit Amount
       sites is allowed per date of                                           similar procedure within set time
       service                                                                frame.
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 closure B15 - This service-procedure requires        N20 - Service not payable with     258 - Days-units for procedure-
       not allowed same day as with that a qualifying service-procedure be      other service rendered on the      revenue code.
       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 new                                              invalid beginning and ending
       claim.                                                                   dates of the period billed.
1314   Only one intermediate repair 119 - Benefit maximum for this time         M86 - Service denied because      259 - Frequency of service.
       code allowed per DOS.        period or occurrence has been reached.      payment already made for same- 612 - Per Day Limit Amount
                                                                                similar procedure within set time
                                                                                frame.




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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 bill                                               N161 - This drug-service-supply
       with primary procedure.                                                  is covered only when the
                                                                                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.

1318   Repair complex scalp arms      B15 - This service-procedure requires    N20 - Service not payable with     258 - Days-units for procedure-
       and or legs; 1.1cm to 2.5 cm   that a qualifying service-procedure be   other service rendered on the      revenue code.
       not allowed same day as 2.6    received and covered. The qualifying     same date.
       to 7.5cm.                      other service-procedure has not been
                                      received-adjudicated.

1319   Procedure code without units 151 - Payment adjusted because the    M53 - Missing-incomplete-invalid 476 - Missing or invalid units of
       denied, correct claim and    payer deems the information submitted days or units of service.        service
       resubmit as a new claim.     does not support this many services.

1320   Complex repair 1.1 cm to 2.5 B15 - This service-procedure requires      N20 - Service not payable with     258 - Days-units for procedure-
       cm not allowed same date of that a qualifying service-procedure be      other service rendered on the      revenue code.
       service as related procedure. received and covered. The qualifying      same date.
                                     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.


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1322   OB package paid. Previously    97 - The benefit for this service is     M80 - Not covered when             454 - Procedure code for services
       paid labs, office visits,      included in the payment-allowance for    performed during the same          rendered.
       consultations or other         another service-procedure that has       session-date as a previously
       services included in ob        already been adjudicated.                processed service for the patient.
       package will be recouped.

1323   Transcatheter placement of     107 - The related or qualifying claim-    N19 - Procedure code incidental   465 - Principal Procedure Code for
       an intravascular stent, each   service was not identified on this claim. to primary procedure.             Service(s) Rendered.
       additional vessel must bill                                              N161 - This drug-service-supply
       with primary procedure.                                                  is covered only when the
                                                                                associated service is covered.


1324   Claims must be processed       109 - Claim not covered by this payer-   N59 - Alert- Please refer to your 116 - Claim submitted to incorrect
       through DEHNR. Refer to        contractor. You must send the claim to   provider manual for additional    payer.
       your manual for processing     the correct payer-contractor.            program and provider information
       instructions.
1325   Punch graft for hair           B15 - This service-procedure requires    N20 - Service not payable with     258 - Days-units for procedure-
       transplant not allowed same    that a qualifying service-procedure be   other service rendered on the      revenue code.
       day of service as grafts for   received and covered. The qualifying     same date.
       hair transplant of more than   other service-procedure has not been
       fifteen punch grafts.          received-adjudicated.

1326   Punch graft for hair           B15 - This service-procedure requires    N20 - Service not payable with     258 - Days-units for procedure-
       transplant not allowed same    that a qualifying service-procedure be   other service rendered on the      revenue code.
       day of service as grafts for   received and covered. The qualifying     same date.
       hair transplant from 1-15      other service-procedure has not been
       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.




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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 up      B15 - This service-procedure requires    N20 - Service not payable with   258 - Days-units for procedure-
       to one percent of body area     that a qualifying service-procedure be   other service rendered on the    revenue code.
       not allowed same day of         received and covered. The qualifying     same date.
       service as related procedure.   other service-procedure has not been
                                       received-adjudicated.

1330   Treatment of burn wound up      B15 - This service-procedure requires    N20 - Service not payable with   258 - Days-units for procedure-
       to nine percent of body area    that a qualifying service-procedure be   other service rendered on the    revenue code.
       not allowed same day of         received and covered. The qualifying     same date.
       service as related procedure.   other service-procedure has not been
                                       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 date      that a qualifying service-procedure be   other service rendered on the    revenue code.
       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 2.5    B15 - This service-procedure requires    N20 - Service not payable with   258 - Days-units for procedure-
       cm not allowed same date of     that a qualifying service-procedure be   other service rendered on the    revenue code.
       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 7.5 B15 - This service-procedure requires       N20 - Service not payable with   258 - Days-units for procedure-
       cm not allowed same date of that a qualifying service-procedure be       other service rendered on the    revenue code.
       service as related procedure received and covered. The qualifying        same date.
                                    other service-procedure has not been
                                    received-adjudicated.




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1334   Encounter. provider             125 - Submission-billing error(s).       MA130 - Your claim contains       132 - Entitys Medicaid provider id.
       specialty number missing or                                              incomplete and-or invalid         144 - Entitys specialty license
       invalid. refer to appendix A.                                            information, and no appeal rights number.
       Choose the appropriate                                                   are afforded because the claim is
       specialty for the provider                                               unprocessable. Please submit a
       performing the service and                                               new claim with the complete-
       resubmit.                                                                correct information.


1335   Encounter. Provider number 125 - Submission-billing error(s).            N77 - Missing-incomplete-invalid   132 - Entitys Medicaid provider id.
       is missing. Enter provider                                               designated provider number.
       number and resubmit.

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 therapeutic       received and covered. The qualifying     same date.
       leave.                          other service-procedure has not been
                                       received-adjudicated.

1337   Adult Care Homes PCS and        B15 - This service-procedure requires    N20 - Service not payable with     258 - Days-units for procedure-
       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 additional 107 - The related or qualifying claim-    N19 - Procedure code incidental      465 - Principal Procedure Code for
       resection must bill with     service was not identified on this claim. to primary procedure.                Service(s) Rendered.
       primary procedure.                                                     N161 - This drug-service-supply
                                                                              is covered only when the
                                                                              associated service is covered.




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1339   Client behavior intervention 169 - Payment adjusted because an            M86 - Service denied because       258 - Days-units for procedure-
       services not allowed within  alternate benefit has been provided          payment already made for same- revenue code.
       the same month as assertive                                               similar procedure within set time
       community treatment.                                                      frame.                      N357 -
                                                                                 Time frame requirements
                                                                                 between this service-procedure-
                                                                                 supply and a related service-
                                                                                 procedure-supply have not been
                                                                                 met
1340   Client behavior intervention 11 - The diagnosis is inconsistent with      M76 - Missing-incomplete-invalid 255 - Diagnosis code.
       services not allowed without the procedure.                               diagnosis or condition.
       a mental health or substance
       abuse diagnosis.

1341   Periodic services and-or high 169 - Payment adjusted because an           M86 - Service denied because         258 - Days-units for procedure-
       risk intervention services not alternate benefit has been provided        payment already made for same-       revenue code.
       allowed within the same                                                   similar procedure within set time
       calendar month as assertive                                               frame.                      N357 -
       community treatment team                                                  Time frame requirements
       services.                                                                 between this service-procedure-
                                                                                 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 not     alternate benefit has been provided       payment already made for same-       revenue code.
       allowed within the same                                                   similar procedure within set time
       calendar month as periodic                                                frame.                      N357 -
       services and-or high risk                                                 Time frame requirements
       intervention services.                                                    between this service-procedure-
                                                                                 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 the    alternate benefit has been provided       other service rendered on the        revenue code.
       same day as professional                                                  same date.
       treatment services in crisis
       facilities.
1344   Service not allowed without a   11 - The diagnosis is inconsistent with   M76 - Missing-incomplete-invalid 488 - Diagnosis code(s) for the
       mental disorder diagnosis.      the procedure.                            diagnosis or condition.          services rendered


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1345   Unit limitation exceeded for    119 - Benefit maximum for this time       N362 - The number of Days or        255 - Diagnosis code.
       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 primary   service was not identified on this claim. to primary procedure.               Service(s) Rendered.
       proc                                                                      N161 - This drug-service-supply
                                                                                 is covered only when the
                                                                                 associated service is covered.

1347   Hysterectomy after cesarean 107 - The related or qualifying claim-        N19 - Procedure code incidental     465 - Principal Procedure Code for
       delivery 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.

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 file. 16 - Claim-service lacks information      MA81 - Missing-incomplete-          21 - Missing or invalid information.
       Sign claim and resubmit or      which is needed for adjudication.         invalid provider-supplier signature 117 - Claim requires signature-on-
       complete 'certification for                                                                                   file indicator.
       signature on file' form located                                                                               466 - Entities original signature.
       on DMA's website under
       provider links, provider forms




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1351   Provider signature not on file. 16 - Claim-service lacks information      MA81 - Missing-incomplete-          21 - Missing or invalid information.
       Sign claim and resubmit or      which is needed for adjudication.         invalid provider-supplier signature 117 - Claim requires signature-on-
       complete 'certification for                                                                                   file indicator.
       signature on file' form located                                                                               466 - Entities original signature.
       on DMA's website under
       provider links, provider forms


1352   Laminotomy, each additional 107 - The related or qualifying claim-    N19 - Procedure code incidental         465 - Principal Procedure Code for
       interspace must bill with   service was not identified on this claim. to primary procedure.                   Service(s) Rendered.
       primary procedure.                                                    N161 - This drug-service-supply
                                                                             is covered only when the
                                                                             associated service is covered.

1353   Laminotomy, each additional 107 - The related or qualifying claim-    N19 - Procedure code incidental         465 - Principal Procedure Code for
       segment must bill with      service was not identified on this claim. to primary procedure.                   Service(s) Rendered.
       primary procedure.                                                    N161 - This drug-service-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 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.


1355   PA number or amount billed     197 - Precertification-authorization-      M62 - Missing-incomplete-invalid 48 - Referral-authorization.
       does not match the CMNPA       notification absent.                       treatment authorization code.    178 - Submitted charges.
       form. Review, correct and                                                 N54 - Claim information is
       resubmit as a new claim.                                                  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 or     received and covered. The qualifying       same date.
       multiple incision and          other service-procedure has not been
       drainage of abscess.           received-adjudicated.



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1357   Diskectomy, thoracic, single    107 - The related or qualifying claim-    N19 - Procedure code incidental   465 - Principal Procedure Code for
       interspace must bill with       service was not identified on this claim. to primary procedure.             Service(s) Rendered.
       primary procedure.                                                        N161 - This drug-service-supply
                                                                                 is covered only when the
                                                                                 associated service is covered.

1358   Medicaid considers this code    97 - The benefit for this service is     M80 - Not covered when             54 - Duplicate of a previously
       to be an integral component     included in the payment-allowance for    performed during the same          processed claim-line.
       to the total procedure.         another service-procedure that has       session-date as a previously
       Separate reimbursement is       already been adjudicated.                processed service for the patient.
       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-supply
       primary procedure.                                                        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 of that a qualifying service-procedure be       other service rendered on the      revenue code.
       service as W8014.           received and covered. The qualifying         same date.
                                   other service-procedure has not been
                                   received-adjudicated.

1361   Destruction of lesions by any   B15 - This service-procedure requires    N20 - Service not payable with     258 - Days-units for procedure-
       method second through           that a qualifying service-procedure be   other service rendered on the      revenue code.
       fourteen not allowed same       received and covered. The qualifying     same date.
       date of service as related      other service-procedure has not been
       procedure.                      received-adjudicated.

1362   Destruction of lesions by any   B15 - This service-procedure requires    N20 - Service not payable with     258 - Days-units for procedure-
       method fifteen or more not      that a qualifying service-procedure be   other service rendered on the      revenue code.
       allowed same date of service    received and covered. The qualifying     same date.
       as related procedure.           other service-procedure has not been
                                       received-adjudicated.




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                                                        EOB Code Crosswalk to HIPAA Standard Codes

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.


1364   Destruction of warts,           B15 - This service-procedure requires    N20 - Service not payable with     258 - Days-units for procedure-
       molluscum contagiosum, or       that a qualifying service-procedure be   other service rendered on the      revenue code.
       millia by any method up to 14   received and covered. The qualifying     same date.
       lesions not allowed same        other service-procedure has not been
       date of service as related      received-adjudicated.
       procedure.
1365   Destruction of warts,           B15 - This service-procedure requires    N20 - Service not payable with     258 - Days-units for procedure-
       molluscum contagiosum, or       that a qualifying service-procedure be   other service rendered on the      revenue code.
       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 service    received-adjudicated.
       as related procedure.

1366   Excision of chest wall tumor    B15 - This service-procedure requires    N20 - Service not payable with     258 - Days-units for procedure-
       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 service    other service-procedure has not been
       as related procedure.           received-adjudicated.

1367   Excision of chest will tumor    B15 - This service-procedure requires    N20 - Service not payable with     258 - Days-units for procedure-
       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 service    other service-procedure has not been
       as related procedures.          received-adjudicated.

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 bill                                              N161 - This drug-service-supply
       with primary procedure.                                                   is covered only when the
                                                                                 associated service is covered.




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                                                         EOB Code Crosswalk to HIPAA Standard Codes

1369   Injection, anesthetic agent;    107 - The related or qualifying claim-    N19 - Procedure code incidental      465 - Principal Procedure Code for
       trigeminal nerve,               service was not identified on this claim. to primary procedure.                Service(s) Rendered.
       paravertebral facet joint                                                 N161 - This drug-service-supply
       nerve, each additional level                                              is covered only when the
       must bill with primary.                                                   associated service is covered.


1370   Code W8014 is not allowed       B15 - This service-procedure requires        N20 - Service not payable with    258 - Days-units for procedure-
       on the same date of service     that a qualifying service-procedure be       other service rendered on the     revenue code.
       as 92551 or 92552               received and covered. The qualifying         same date.
                                       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 additional                                              N161 - This drug-service-supply
       level must bill with primary                                              is covered only when the
       procedure.                                                                associated service is covered.

1372   Excision of neuroma; digital    107 - The related or qualifying claim-    N19 - Procedure code incidental      465 - Principal Procedure Code for
       nerve, each additional digit    service was not identified on this claim. to primary procedure.                Service(s) Rendered.
       must bill with primary                                                    N161 - This drug-service-supply
       procedure.                                                                is covered only when the
                                                                                 associated service is covered.


1373   Excision of neuroma, hand or 107 - The related or qualifying claim-          N19 - Procedure code incidental   465 - Principal Procedure Code for
       foot, each additional nerve  service was not identified on this claim.       to primary procedure.             Service(s) Rendered.
       must bill with primary                                                       N161 - This drug-service-supply
       procedure.                                                                   is covered only when the
                                                                                    associated service is covered.


1374   Suture of digital nerve, hand 107 - The related or qualifying claim-         N19 - Procedure code incidental   465 - Principal Procedure Code for
       or foot, each additional digital service was not identified on this claim.   to primary procedure.             Service(s) Rendered.
       nerve must bill with primary                                                 N161 - This drug-service-supply
       procedure.                                                                   is covered only when the
                                                                                    associated service is covered.



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                                                      EOB Code Crosswalk to HIPAA Standard Codes




1375   Fetal nonstress included in   97 - The benefit for this service is      M80 - Not covered when             454 - Procedure code for services
       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 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.


1377   Suture of each additional    107 - The related or qualifying claim-   N19 - Procedure code incidental      465 - Principal Procedure Code for
       major peripheral nerve must service was not identified on this claim. to primary procedure.                Service(s) Rendered.
       bill with primary procedure.                                          N161 - This drug-service-supply
                                                                             is covered only when the
                                                                             associated service is covered.


1378   Related DME procedures are B15 - This service-procedure requires        N20 - Service not payable with     258 - Days-units for procedure-
       not allowed on the same date that a qualifying service-procedure be     other service rendered on the      revenue code.
       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 - Claim-submission format is
                                      be comprised of either the Remittance     information, and no appeal rights invalid.
                                      Advice Remark Code or NCPDP Reject        are afforded because the claim is
                                      Reason Code)                              unprocessable. Please submit a
                                                                                new claim with the complete-
                                                                                correct information.
                                                                                N26 - Missing-incomplete-invalid
                                                                                itemized bill

1382   Itemized bill does not support 125 - Submission-billing error(s).        M79 - Missing-incomplete-invalid 178 - Submitted charges.
       charges billed. Please review                                            charge.                           279 - Itemized claim.
       charges, correct claim, and                                              N152 - Missing-incomplete-invalid
       resubmit for processing.                                                 replacement claim information.

1383   Nerve graft, each additional 107 - The related or qualifying claim-      N19 - Procedure code incidental   465 - Principal Procedure Code for
       nerve, single strand 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.

1384   Related strabismus surgery     107 - The related or qualifying claim-    N19 - Procedure code incidental   465 - Principal Procedure Code for
       must be billed with primary.   service was not identified on this claim. to primary procedure.             Service(s) Rendered.
                                                                                N161 - This drug-service-supply
                                                                                is covered only when the
                                                                                associated service is covered.


1385   DMA-PCG recovery project,      133 - The disposition of this claim-      None                              3 - Claim has been adjudicated
       at DMAs request on claims      service is pending further review.                                          and is awaiting payment cycle.
       where other insurance was
       available to pay medical
       expenses. For questions,
       call Sue St. John, PCG, 1-
       800-372-0878.

1386   Exceeds 50 procedures per      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- 612 - Per Day Limit Amount
                                                                             similar procedure within set time
                                                                             frame

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                                                       EOB Code Crosswalk to HIPAA Standard Codes



1387   Related strabismus surgery     107 - The related or qualifying claim-    N19 - Procedure code incidental   465 - Principal Procedure Code for
       must be billed with primary.   service was not identified on this claim. to primary procedure.             Service(s) Rendered.
                                                                                N161 - This drug-service-supply
                                                                                is covered only when the
                                                                                associated service is covered.

1388   Thoracic, add‟l 2nd, 3rd and   107 - The related or qualifying claim-    N19 - Procedure code incidental   465 - Principal Procedure Code for
       beyond order must bill with    service was not identified on this claim. to primary procedure.             Service(s) Rendered.
       primary procedure.                                                       N161 - This drug-service-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
1390   Medicare payment               148 - Information from another provider N4 - Missing-incomplete-invalid     286 - Other payers explanation of
       information for this detail is was not provided or was insufficient-   prior insurance carrier EOB.        benefits-payment information.
       not listed on attached         incomplete.
       Medicare voucher.
1391   Family planning should not     125 - Submission-billing error(s).       N56 - Procedure code billed is not 21 - Missing or invalid information.
       be indicated. Please correct                                            correct-valid for the service billed 568 - Family Planning Indicator
       and resubmit as a new day                                               or the date of service billed.
       claim.
1392   Additional hour for work       107 - The related or qualifying claim-   N19 - Procedure code incidental    465 - Principal Procedure Code for
       hardening-conditional must service was not identified on this claim.    to primary procedure.              Service(s) Rendered.
       be billed with primary                                                  N161 - This drug-service-supply
       procedure.                                                              is covered only when the
                                                                               associated service is covered.




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                                                      EOB Code Crosswalk to HIPAA Standard Codes

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)                              unprocessable. Please submit a
                                                                               new claim with the complete-
                                                                               correct information.

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- 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
1395   Please correct your claim by 125 - Submission-billing error(s).     N56 - Procedure code billed is not 454 - Procedure code for services
       using a more specific                                               correct-valid for the service billed rendered.
       hysterectomy procedure                                              or the date of service billed.
       code.
1396   Observation is not routinely 16 - Claim-service lacks information   N29 - Missing documentation-          21 - Missing or invalid information.
       allowed. Submit records to which is needed for adjudication.        orders- notes- summary- report- 287 - Medical necessity for service.
       review for Medical Necessity                                        chart                                 294 - Supporting documentation.
       include: History-physical-
       operative records-pathology
       report and discharge
       summary.
1397   Routine observation room is 78 - Non-Covered days-Room charge       M79 - Missing-incomplete-invalid 258 - Days-units for procedure-
       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 more                                             similar procedure within set time
       than 10 per calendar year.                                              frame.                       N357 -
                                                                               Time frame requirements
                                                                               between this service-procedure-
                                                                               supply and a related service-
                                                                               procedure-supply have not been
                                                                               met

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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.

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 oral   B15 - This service-procedure requires    N20 - Service not payable with     258 - Days-units for procedure-
       evaluation-problem focused,   that a qualifying service-procedure be   other service rendered on the      revenue code.
       by report not allowed same    received and covered. The qualifying     same date.
       date of service as dental     other service-procedure has not been
       exam.                         received-adjudicated.

1402   Dental exam not allowed on    B15 - This service-procedure requires    N20 - Service not payable with     258 - Days-units for procedure-
       the same date of service      that a qualifying service-procedure be   other service rendered on the      revenue code.
       detailed and extensive oral   received and covered. The qualifying     same date.
       evaluation.                   other service-procedure has not been
                                     received-adjudicated.

1403   Only one reduction per arch 119 - Benefit maximum for this time    M86 - Service denied because           259 - Frequency of service.
       allowed on the same date of period or occurrence has been reached. payment already made for same-         612 - Per Day Limit Amount
       service.                                                           similar procedure within set time
                                                                          frame.
1404   Private insurance payment     22 - This care may be covered by     MA04 - Secondary payment               116 - Claim submitted to incorrect
       indicated on claim. No record another payer per coordination of    cannot be considered without the       payer.
       of TPL on file. correct claim benefits.                            identity of or payment information
       or update recipient TPL using                                      from the primary payer. The
       DMA form 2057 and resubmit                                         information was either not
       claim.                                                             reported or was 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 and alternate benefit has been provided         other service rendered on the      revenue code.
       TL.                                                                    same date.

1406   Large volume nebulizer not    B15 - This service-procedure requires    M86 - Service denied because      258 - Days-units for procedure-
       allowed same month as         that a qualifying service-procedure be   payment already made for same- revenue code.
       compressor.                   received and covered. The qualifying     similar procedure within set time
                                     other service-procedure has not been     frame.
                                     received-adjudicated.

1407   Only one continuous epidural 119 - Benefit maximum for this time    M86 - Service denied because       259 - Frequency of service.
       analgesia allowed per 270    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
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 appropriate     125 - Submission-billing error(s).       M56 - Missing-incomplete-invalid 21 - Missing or invalid information.
       with non-Medicare                                                      payer identifier                 454 - Procedure code for services
       beneficiary. Please correct                                                                             rendered.
       and resubmit.

1410   Revenue code must be billed 125 - Submission-billing error(s).         M20 - Missing-incomplete-invalid   454 - Procedure code for services
       with a skilled nursing visit                                           HCPCS.                             rendered.
       HCPC code.                                                             M50 - Missing-incomplete-invalid   455 - Revenue code for services
                                                                              revenue code(s).                   rendered.




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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 and 149 - Lifetime benefit maximum has     N362 - The number of Days or       259 - Frequency of service.
       flouride varnish applications been reached for this service-benefit  Units of Service exceeds our
       allowed per recipient's       category                               acceptable maximum
       lifetime.
1413   DMA-PCG repayment of          198 - Payment Adjusted for exceeding N45 - Payment based on               64 - Re-pricing information.
       recoupment. Claim originally precertification- authorization         authorized amount.
       recouped with EOB 1385.
       For questions, call PCG, 1-
       800-372-0878.
1414   Provider initiated repayment 45 - Charge exceeds fee schedule-       N45 - Payment based on             64 - Re-pricing information.
       of claim originally recouped maximum allowable or contracted-        authorized amount.
       with EOB 1385.                legislated fee arrangement. (Use
                                     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 as received and covered. The qualifying     same date.
       arthroplasty.                 other service-procedure has not been
                                     received-adjudicated.

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



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                                                          EOB Code Crosswalk to HIPAA Standard Codes

1417   Diagnostic arthroscopy not        B15 - This service-procedure requires    N20 - Service not payable with     258 - Days-units for procedure-
       allowed on the same date of       that a qualifying service-procedure be   other service rendered on the      revenue code.
       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 procedure        that a qualifying service-procedure be   other service rendered on the      revenue code.
       when e-m service is not paid      received and covered. The qualifying     same date.
       for the same date of service,     other service-procedure has not been
       same provider.                    received-adjudicated.

1419   Surgical arthroscopy (D7873,      B15 - This service-procedure requires    N20 - Service not payable with     258 - Days-units for procedure-
       29804) not allowed on the         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.
       TMJ.                              other service-procedure has not been
                                         received-adjudicated.

1420   Unit cutback - exceeds max      119 - Benefit maximum for this time    N362 - The number of Days or           258 - Days-units for procedure-
       units allowed.                  period or occurrence has been reached. Units of Service exceeds our           revenue code.
                                                                              acceptable maximum.                    259 - Frequency of service.       476
                                                                              N381 - Consult our contractual         - Missing or invalid units of service
                                                                              agreement for restrictions-billing-
                                                                              payment information related to
                                                                              these charges
1421   Repair of maxillofacial soft or B15 - This service-procedure requires N20 - Service not payable with          258 - Days-units for procedure-
       hard tissue defects (d7955) that a qualifying service-procedure be     other service rendered on the          revenue code.
       not allowed on the same date received and covered. The qualifying      same date.
       of service as d7610, d7620, other service-procedure has not been
       d7650, d7660, d7680, d7710, received-adjudicated.
       d7720, d7750, d7760 or
       d7780.

1422   Immunization administration       B15 - This service-procedure requires    N59 - Alert- Please refer to your 21 - Missing or invalid information.
       not allowed without billing the   that a qualifying service-procedure be   provider manual for additional    490 - Other proedure code for
       appropriate immunization          received and covered. The qualifying     program and provider information service(s) rendered.
       code. Refer to the latest         other service-procedure has not been
       Health Check Billing Guide.       received-adjudicated.



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                                                         EOB Code Crosswalk to HIPAA Standard Codes


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 of      that a qualifying service-procedure be   other service rendered on the      revenue code.
       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 allowed     119 - Benefit maximum for this time    M86 - Service denied because      259 - Frequency of service.
       once for the same joint on      period or occurrence has been reached. payment already made for same-
       the same date of service.                                              similar procedure within set time
                                                                              frame.
1426   Injectable drug administration B15 - This service-procedure requires N20 - Service not payable with      258 - Days-units for procedure-
       not allowed on same date of that a qualifying service-procedure be     other service rendered on the     revenue code.
       service as iv infusion therapy. received and covered. The qualifying   same date.
                                       other service-procedure has not been
                                       received-adjudicated.

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



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                                                          EOB Code Crosswalk to HIPAA Standard Codes


1430   Additional application of     107 - The related or qualifying claim-         N19 - Procedure code incidental   465 - Principal Procedure Code for
       xenogaft, skin 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-supply
       primary procedure.                                                           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-supply
       primary procedures.                                                         is covered only when the
                                                                                   associated service is covered.

1432   Detail billed with incorrect or   4 - The procedure code is inconsistent     None                              453 - Procedure code modifier(s)
       no modifier. Correct detail       with the modifier or a required modifier                                     for service(s) rendered.
       and resubmit as a new day         is missing.
       claim. If reimbursement
       affected request a full
       recoupment and resubmit
       claim.
1433   Exceeds 4 units per 270 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.                        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 same that a qualifying service-procedure be other service rendered on the      revenue code.
       DOS.                        received and covered. The qualifying   same date.
                                   other service-procedure has not been
                                   received-adjudicated.



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1435   Related pelvic exenteraton     B15 - This service-procedure requires      N20 - Service not payable with    258 - Days-units for procedure-
       procedures not allowed to bill that a qualifying service-procedure be     other service rendered on the     revenue code.
       with same DOS.                 received and covered. The qualifying       same date.
                                      other service-procedure has not been
                                      received-adjudicated.

1436   Related vaginectomy         B15 - This service-procedure requires         N20 - Service not payable with    258 - Days-units for procedure-
       procedures not allowed same that a qualifying service-procedure be        other service rendered on the     revenue code.
       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 be service was not identified on this claim.       to primary procedure.             rendered.
       billed same DOS as imaging                                                N161 - This drug-service-supply
       whole body.                                                               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 same service was not identified on this claim. to primary procedure.                 Service(s) Rendered.
       DOS as primary procedure.                                             N161 - This drug-service-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 not   B15 - This service-procedure requires    N20 - Service not payable with    258 - Days-units for procedure-
       allowed same DOS as total        that a qualifying service-procedure be   other service rendered on the     revenue code.
       and direct.                      received and covered. The qualifying     same date.
                                        other service-procedure has not been
                                        received-adjudicated.




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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.

1442   One unit allowed with base        119 - Benefit maximum for this time    None                               259 - Frequency of service.
       code, correct all units on your   period or occurrence has been reached.
       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 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.
       individual speech-language        other service-procedure has not been
       therapy service.                  received-adjudicated.

1445   Group speech-language             B15 - This service-procedure requires    N20 - Service not payable with   258 - Days-units for procedure-
       therapy services recouped.        that a qualifying service-procedure be   other service rendered on the    revenue code.
       Group speech-language             received and covered. The qualifying     same date.
       treatment not allowed same        other service-procedure has not been
       day as individual speech-         received-adjudicated.
       language treatment.

1446   Only one Case Management          B15 - This service-procedure requires    N20 - Service not payable with   454 - Procedure code for services
       allowed per month. Case           that a qualifying service-procedure be   other service rendered on the    rendered.
       management billed through         received and covered. The qualifying     same date.
       another program has already       other service-procedure has not been
       been paid this month.             received-adjudicated.

1447   Stable isotope dilution not       B15 - This service-procedure requires    N20 - Service not payable with   258 - Days-units for procedure-
       allowed to bill with multiple.    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.


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1448   Parathyroid                     107 - The related or qualifying claim-    N19 - Procedure code incidental     465 - Principal Procedure Code for
       autotransplantation must bill   service was not identified on this claim. to primary procedure.               Service(s) Rendered.
       with primary proc.                                                        N161 - This drug-service-supply
                                                                                 is covered only when the
                                                                                 associated service is covered.

1449   Related procedures and DHS B15 - This service-procedure requires           N20 - Service not payable with     258 - Days-units for procedure-
       dental clinic visit 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.

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 to that a qualifying service-procedure be        other service rendered on the      revenue code.
       bill with related procedure. received and covered. The qualifying          same date.
                                    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-supply
       billed with primary proc.                                                 is covered only when the
                                                                                 associated service is covered.

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.


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                                                        EOB Code Crosswalk to HIPAA Standard Codes



1455   Transluminal balloon            107 - The related or qualifying claim-    N19 - Procedure code incidental   465 - Principal Procedure Code for
       angioplasty, each additional    service was not identified on this claim. to primary procedure.             Service(s) Rendered.
       peripheral artery must bill                                               N161 - This drug-service-supply
       with primary procedure                                                    is covered only when the
                                                                                 associated service is covered.


1456   Transluminal artherectomy,      107 - The related or qualifying claim-    N19 - Procedure code incidental   465 - Principal Procedure Code for
       ea add‟l peripheral artery      service was not identified on this claim. to primary procedure.             Service(s) Rendered.
       must bill with primary proc.                                              N161 - This drug-service-supply
                                                                                 is covered only when the
                                                                                 associated service is covered.

1457   Transluminal artherectomy,      107 - The related or qualifying claim-    N19 - Procedure code incidental   465 - Principal Procedure Code for
       each add‟l visceral artery      service was not identified on this claim. to primary procedure.             Service(s) Rendered.
       must bill with primary                                                    N161 - This drug-service-supply
       procedure.                                                                is covered only when the
                                                                                 associated service is covered.

1458   Liver imaging procedures not B15 - This service-procedure requires       N20 - Service not payable with     258 - Days-units for procedure-
       allowed to bill with same    that a qualifying service-procedure be      other service rendered on the      revenue code.
       DOS.                         received and covered. The qualifying        same date.
                                    other service-procedure has not been
                                    received-adjudicated.

1459   Liver imaging with vascular     B15 - This service-procedure requires    N20 - Service not payable with     258 - Days-units for procedure-
       flow 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.

1460   Cardiac blood pool imaging, B15 - This service-procedure requires        N20 - Service not payable with     258 - Days-units for procedure-
       gated equilibrium not allowed that a qualifying service-procedure be     other service rendered on the      revenue code.
       to bill with multiple studies. 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

1461   Performance of the test           97 - The benefit for this service is     M80 - Not covered when             454 - Procedure code for services
       physician supervision, report     included in the payment-allowance for    performed during the same          rendered.
       and interpretation included in    another service-procedure that has       session-date as a previously
       the cardiac stress test.          already been adjudicated.                processed service for the patient.

1462   Myocardial perfusion study        107 - The related or qualifying claim-    N19 - Procedure code incidental   454 - Procedure code for services
       must bill with related            service was not identified on this claim. to primary procedure.             rendered.
       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-       612 - Per Day Limit Amount
                                                                                similar procedure within set time
                                                                                frame.
1464   Amino acids, qualitative not      B15 - This service-procedure requires N20 - Service not payable with        258 - Days-units for procedure-
       allowed to bill with multiple.    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.

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 multiple.    received and covered. The qualifying     same date.
                                         other service-procedure has not been
                                         received-adjudicated.

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 method     received and covered. The qualifying     same date.
       not allowed to bill with single   other service-procedure has not been
                                         received-adjudicated.

1467   Immunoassay for analyte           B15 - This service-procedure requires    N20 - Service not payable with     258 - Days-units for procedure-
       other than infectious agent       that a qualifying service-procedure be   other service rendered on the      revenue code.
       for single step method not        received and covered. The qualifying     same date.
       allowed with multiple step        other service-procedure has not been
       method.                           received-adjudicated.


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1468   Chromatography,                  B15 - This service-procedure requires    N20 - Service not payable with     258 - Days-units for procedure-
       quantitative, column, multiple   that a qualifying service-procedure be   other service rendered on the      revenue code.
       analytes not allowed same        received and covered. The qualifying     same date.
       DOS as single analyte.           other service-procedure has not been
                                        received-adjudicated.

1469   Infectious agent analysis not B15 - This service-procedure requires       N20 - Service not payable with     258 - Days-units for procedure-
       allowed with HIV resistance that a qualifying service-procedure be        other service rendered on the      revenue code.
       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 multiplex. 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.

1471   Components of HIV                B15 - This service-procedure requires    N20 - Service not payable with     258 - Days-units for procedure-
       resistance testing recouped.     that a qualifying service-procedure be   other service rendered on the      revenue code.
       components not allowed           received and covered. The qualifying     same date.
       same day as HIV resistance       other service-procedure has not been
       testing.                         received-adjudicated.

1472   IV infusion for therapy-      107 - The related or qualifying claim-    N19 - Procedure code incidental      454 - Procedure code for services
       diagnosis must be billed with service was not identified on this claim. to primary procedure.                rendered.
       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.




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                                                        EOB Code Crosswalk to HIPAA Standard Codes


1474   Transcatheter placement of      107 - The related or qualifying claim-    N19 - Procedure code incidental   454 - Procedure code for services
       an intracoronary stent, each    service was not identified on this claim. to primary procedure.             rendered.
       add‟l vessel must bill with                                               N161 - This drug-service-supply
       primary procedure.                                                        is covered only when the
                                                                                 associated service is covered.

1475   Percutaneous transluminal     107 - The related or qualifying claim-      N19 - Procedure code incidental   454 - Procedure code for services
       coronary balloon angioplasty; service was not identified on this claim.   to primary procedure.             rendered.
       single vessel must bill with                                              N161 - This drug-service-supply
       primary procedure.                                                        is covered only when the
                                                                                 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-supply
       procedure.                                                                is covered only when the
                                                                                 associated service is covered.


1477   Percutaneous transluminal       107 - The related or qualifying claim-    N19 - Procedure code incidental   454 - Procedure code for services
       pulmonary artery balloon        service was not identified on this claim. to primary procedure.             rendered.
       angioplasty, each add‟l                                                   N161 - This drug-service-supply
       vessel must bill with primary                                             is covered only when the
       procedure.                                                                associated service is covered.


1478   Doppler echocardiography, 107 - The related or qualifying claim-     N19 - Procedure code incidental        454 - Procedure code for services
       pulsed wave; complete must service was not identified on this claim. to primary procedure.                  rendered.
       bill with related procedure.                                         N161 - This drug-service-supply
                                                                            is covered only when the
                                                                            associated service is covered.

1479   Doppler echocardiography, 107 - The related or qualifying claim-      N19 - Procedure code incidental       454 - Procedure code for services
       pulsed wave: follow up must service was not identified on this claim. to primary procedure.                 rendered.
       bill with related procedure.                                          N161 - This drug-service-supply
                                                                             is covered only when the
                                                                             associated service is covered.



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1480   Pulmonary stress testing,       B15 - This service-procedure requires       N20 - Service not payable with    454 - Procedure code for services
       simple not allowed to bill with that a qualifying service-procedure be      other service rendered on the     rendered.
       complex.                        received and covered. The qualifying        same date.
                                       other service-procedure has not been
                                       received-adjudicated.

1481   Cardiac stress test includes   97 - The benefit for this service is         M80 - Not covered when             454 - Procedure code for services
       performance of the test,       included in the payment-allowance for        performed during the same          rendered.
       physician supervision,         another service-procedure that has           session-date as a previously
       interpretation and report.     already been adjudicated.                    processed service for the patient.

1482   Intraoperative neurophysilogy 107 - The related or qualifying claim-     N19 - Procedure code incidental      454 - Procedure code for services
       testing, per hour must be      service was not identified on this claim. to primary procedure.                rendered.
       billed with primary procedure.                                           N161 - This drug-service-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.


1484   Hepatitis a vaccine, pediatric- 107 - The related or qualifying claim-      N19 - Procedure code incidental   454 - Procedure code for services
       adolescent dosage, 2 dose       service was not identified on this claim.   to primary procedure.             rendered.
       schedule must bill with                                                     N161 - This drug-service-supply
       primary procedure.                                                          is covered only when the
                                                                                   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-supply
       procedure.                                                               is covered only when the
                                                                                associated service is covered.




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1486   Impotence drugs not covered 197 - Precertification-authorization-           N54 - Claim information is         475 - Procedure code not valid for
       for males under age 25, The notification absent.                            inconsistent with pre-certified-   patient age.
       physician (or designee) must                                                authorized services.
       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-supply
       with primary procedure.                                                   is covered only when the
                                                                                 associated service is covered.

1488   Intravascular doppler velocity 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.
       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 use service was not identified on this claim.   to primary procedure.              rendered.
       must bill with primary                                                      N161 - This drug-service-supply
       procedure.                                                                  is covered only when the
                                                                                   associated service is covered.


1490   Use of operating microscope     107 - The related or qualifying claim-    N20 - Service not payable with       454 - Procedure code for services
       not allowed with primary        service was not identified on this claim. other service rendered on the        rendered.
       procedure.                                                                same date.
1491   Prolonged physician service     107 - The related or qualifying claim-    N19 - Procedure code incidental      454 - Procedure code for services
       in the inpatient setting must   service was not identified on this claim. to primary procedure.                rendered.
       bill with primary procedure.                                              N161 - This drug-service-supply
                                                                                 is covered only when the
                                                                                 associated service is covered.

1492   Prolonged physician service     107 - The related or qualifying claim-    N19 - Procedure code incidental      454 - Procedure code for services
       in the office 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.



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1493   Critical care, evaluation and   107 - The related or qualifying claim-    N19 - Procedure code incidental      454 - Procedure code for services
       mgmt must bill with primary     service was not identified on this claim. to primary procedure.                rendered.
       procedure.                                                                N161 - This drug-service-supply
                                                                                 is covered only when the
                                                                                 associated service is covered.

1494   Payment included in multiple 97 - The benefit for this service is           M80 - Not covered when             54 - Duplicate of a previously
       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-arterial; service was not identified on this claim.   to primary procedure.              rendered.
       infusion tech, 1 to 8 hours;                                                N161 - This drug-service-supply
       each additional hour must bill                                              is covered only when the
       with primary procedure.                                                     associated service is covered.

1496   Chemotherapy                    107 - The related or qualifying claim-    N19 - Procedure code incidental      454 - Procedure code for services
       administration, intravenous,    service was not identified on this claim. to primary procedure.                rendered.
       infusion tech, up to 1 hour                                               N161 - This drug-service-supply
       must bill with primary                                                    is covered only when the
       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 must       service was not identified on this claim. to primary procedure.                rendered.
       bill with primary procedure.                                              N161 - This drug-service-supply
                                                                                 is covered only when the
                                                                                 associated service is covered.


1498   Strabismus surgery, repair of 107 - The related or qualifying claim-        N19 - Procedure code incidental    454 - Procedure code for services
       detached extraocular muscle service was not identified on this claim.       to primary procedure.              rendered.
       must bill with primary                                                      N161 - This drug-service-supply
       procedure.                                                                  is covered only when the
                                                                                   associated service is covered.




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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.

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-supply
       primary procedure.                                                        is covered only when the
                                                                                 associated service is covered.

1502   Components denied. Rebill       B15 - This service-procedure requires    N20 - Service not payable with     454 - Procedure code for services
       using 81000 as the complete     that a qualifying service-procedure be   other service rendered on the      rendered.
       procedure, versus multiple      received and covered. The qualifying     same date.
       components of urinalysis.       other service-procedure has not been
                                       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 with service was not identified on this claim. to primary procedure.             Service(s) Rendered.
       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 related service was not identified on this claim.    to primary procedure.              rendered.
       p codes must be billed same                                              N161 - This drug-service-supply
       DOS.                                                                     is covered only when the
                                                                                associated service is covered.


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1505   Tenotomy, single included in 97 - The benefit for this service is       M80 - Not covered when             454 - Procedure code for services
       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 only   service was not identified on this claim. to primary procedure.             Service(s) Rendered.
       allowed when billed in                                                   N161 - This drug-service-supply
       addition to primary surgery                                              is covered only when the
       procedure. Review claim,                                                 associated service is covered.
       correct and resubmit as a
       new claim.
1507   Multiple osteotomy of          B15 - This service-procedure requires    N20 - Service not payable with     258 - Days-units for procedure-
       metatarsals 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.

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 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.

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.




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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.
1514   Separate reimbursement not      B15 - This service-procedure requires    N20 - Service not payable with     258 - Days-units for procedure-
       allowed when other services     that a qualifying service-procedure be   other service rendered on the      revenue code.
       are paid on the same date of    received and covered. The qualifying     same date.
       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 procedure 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.

1517   Removal of vitreous included B15 - This service-procedure requires       N20 - Service not payable with     258 - Days-units for procedure-
       in extracapsular cataract    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.




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1518   Enterolysis included in           B15 - This service-procedure requires    N20 - Service not payable with    258 - Days-units for procedure-
       intestinal procedures 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.

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 because       received and covered. The qualifying     same date.
       same procedure code has           other service-procedure has not been     N184 - Rebill technical and
       already been                      received-adjudicated.                    professional components
       reimbursed as a complete                                                   separately.
       procedure for this date of
       service.
1520   Technical component of this       B15 - This service-procedure requires    N20 - Service not payable with    454 - Procedure code for services
       procedure has already been        that a qualifying service-procedure be   other service rendered on the     rendered.
       reimbursed for this date.         received and covered. The qualifying     same date.
       Rebill for professional           other service-procedure has not been     N200 - The professional
       component only.                   received-adjudicated.                    component must be billed
                                                                                  separately.
1521   Professional component of         B15 - This service-procedure requires    N20 - Service not payable with    454 - Procedure code for services
       this procedure code has           that a qualifying service-procedure be   other service rendered on the     rendered.
       already been reimbursed for       received and covered. The qualifying     same date.
       this date. Rebill for technical   other service-procedure has not been     N195 - The technical component
       component only.                   received-adjudicated.                    must be billed separately

1522   No payment for add-on (zzz) 107 - The related or qualifying claim-         N19 - Procedure code incidental   454 - Procedure code for services
       code allowed if 'primary' code service was not identified on this claim.   to primary procedure.             rendered.
       in series is not paid for the                                              N161 - This drug-service-supply
       same DOS, same provider.                                                   is covered only when the
                                                                                  associated service is covered.

1523   No payment for add-on (zzz) 107 - The related or qualifying claim-         N19 - Procedure code incidental   454 - Procedure code for services
       code allowed if 'primary' code service was not identified on this claim.   to primary procedure.             rendered.
       in series is not paid for the                                              N161 - This drug-service-supply
       same DOS, same provider.                                                   is covered only when the
                                                                                  associated service is covered.




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1524   No payment for add-on (zzz) 107 - The related or qualifying claim-         N19 - Procedure code incidental   454 - Procedure code for services
       code allowed if 'primary' code service was not identified on this claim.   to primary procedure.             rendered.
       in series is not paid for the                                              N161 - This drug-service-supply
       same DOS, same provider.                                                   is covered only when the
                                                                                  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 on 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.

1526   Related removal of venous    B15 - This service-procedure requires         N20 - Service not payable with    258 - Days-units for procedure-
       access device not allowed on 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.

1527   No payment for add-on (zzz) 107 - The related or qualifying claim-         N19 - Procedure code incidental   454 - Procedure code for services
       code allowed if 'primary' code service was not identified on this claim.   to primary procedure.             rendered.
       in series is not paid for the                                              N161 - This drug-service-supply
       same DOS, same provider.                                                   is covered only when the
                                                                                  associated service is covered.

1528   Reimbursement for monthly 97 - The benefit for this service is             M80 - Not covered when             454 - Procedure code for services
       rental of DME includes        included in the payment-allowance for        performed during the same          rendered.
       payment for related supplies. another service-procedure that has           session-date as a previously
                                     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 monthly      received and covered. The qualifying        similar procedure within set time
       rental of related DME.         other service-procedure has not been        frame.
                                      received-adjudicated.




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1530   No payment for add-on (size) 107 - The related or qualifying claim-         N19 - Procedure code incidental   454 - Procedure code for services
       code allowed if 'primary' code service was not identified on this claim.    to primary procedure.             rendered.
       in series is not paid for the                                               N161 - This drug-service-supply
       same DOS, same provider.                                                    is covered only when the
                                                                                   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 not                                             N161 - This drug-service-supply
       paid for the same DOS,                                                      is covered only when the
       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 during    that a qualifying service-procedure be       the patient is an inpatient.      revenue code.
       inpatient or nursing home      received and covered. The qualifying
       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 inpatient      received and covered. The qualifying
       or nursing home stay.             other service-procedure has not been
                                         received-adjudicated.

1537   Units were changed to allow 119 - Benefit maximum for this time        N362 - The number of Days or           258 - Days-units for procedure-
       a maximum of 14 units per    period or occurrence has been reached. Units of Service exceeds our              revenue code.
       day.                                                                   acceptable maximum.                    259 - Frequency of service.
                                                                              N381 - Consult our contractual         612 - Per Day Limit Amount
                                                                              agreement for restrictions-billing-
                                                                              payment information related to
                                                                              these charges
1538   Graft procedure denied.      107 - The related or qualifying claim-    N19 - Procedure code incidental        454 - Procedure code for services
       Graft procedure only allowed service was not identified on this claim. to primary procedure.                  rendered.
       when billed in addition to                                             N161 - This drug-service-supply
       spinal operative session,                                              is covered only when the
       same date of service.                                                  associated service is 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 fluoride   that a qualifying service-procedure be   other service rendered on the      revenue code.
       varnish. Medicaid does not        received and covered. The qualifying     same date.
       cover other topical fluorides     other service-procedure has not been
       as a separate procedure.          received-adjudicated.

1540   D1203 is limited to the         125 - Submission-billing error(s).         MA66 - Missing-incomplete-         21 - Missing or invalid information.
       application of topical fluoride                                            invalid principal procedure code
       varnish. Rebill prophy and                                                 or date.
       fluoride with correct
       combination procedure code
       (D1201 or D1205).

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 visit. 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.



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                                                      EOB Code Crosswalk to HIPAA Standard Codes


1542   Clinic visit not allowed same B15 - This service-procedure requires    N20 - Service not payable with     258 - Days-units for procedure-
       date of service as E-M visit. 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.

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         612 - Per Day Limit Amount
                                                                            acceptable maximum
1544   Recipient has reached 21st 119 - Benefit maximum for this time       N362 - The number of Days or         259 - Frequency of service.
       birthday and has exceeded 8 period or occurrence has been reached. Units of Service exceeds our
       unmanaged visits. PA from                                            acceptable maximum
       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 fee                                         similar procedure within set time
       previously paid.                                                     frame.
1546   Psychotherapy & E-M cannot 97 - The benefit for this service is      M80 - Not covered when               54 - Duplicate of a previously
       be billed as separate         included in the payment-allowance for performed during the same             processed claim-line.
       procedure. Previously billed another service-procedure that has      session-date as a previously
       E-M procedure will be         already been adjudicated.              processed service for the patient.
       recouped. Rebill the
       appropriate psychotherapy
       code that includes medical E-
       M.

1547   Service recouped. E-M billed   97 - The benefit for this service is    M80 - Not covered when             54 - Duplicate of a previously
       on same date of service as     included in the payment-allowance for   performed during the same          processed claim-line.
       psychotherapy. Rebill using    another service-procedure that has      session-date as a previously
       the appropriate                already been adjudicated.               processed service for the patient.
       psychotherapy code that
       includes medical evaluation
       and management.




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1548   Exceeds unmanaged mental 119 - Benefit maximum for this time           M86 - Service denied because         259 - Frequency of service.
       health visit limitation.        period or occurrence has been reached. payment already made for same-
                                                                              similar procedure within set time
                                                                              frame.
1549   Recipient must have             B5 - Coverage-program guidelines were N19 - Procedure code incidental       21 - Missing or invalid information.
       received EPO therapy on the not met or were exceeded.                  to primary procedure.                454 - Procedure code for services
       same date of service or                                                N161 - This drug-service-supply      rendered.
       within 3 months prior to the                                           is covered only when the
       date of service of ferrlecit or                                        associated service is covered.
       iron sucrose.

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 visits 119 - Benefit maximum for this time    M86 - Service denied because         259 - Frequency of service.
       allowed without prior           period or occurrence has been reached. payment already made for same-
       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
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 HIV 125 - Submission-billing error(s).           MA66 - Missing-incomplete-           21 - Missing or invalid information.
       viral load codes and refile.                                           invalid principal procedure code
                                                                              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 stay. received and covered. The qualifying
                                       other service-procedure has not been
                                       received-adjudicated.




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                                                      EOB Code Crosswalk to HIPAA Standard Codes

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 must   146 - Diagnosis was invalid for the      M81 - You are required to code to 255 - Diagnosis code.
       be further subdivided. (the   date(s) of service reported.             the highest level of specificity
       code must have four or five
       digits)
1557   Other diagnosis code 7 must   146 - Diagnosis was invalid for the      M81 - You are required to code to 255 - Diagnosis code.
       be further subdivided. (the   date(s) of service reported.             the highest level of specificity
       code must have four or five
       digits)
1558   Other diagnosis code 8 must   146 - Diagnosis was invalid for the      M81 - You are required to code to 255 - Diagnosis code.
       be further subdivided. (the   date(s) of service reported.             the highest level of specificity
       code must have four or five
       digits)
1559   Other diagnosis code 9 must   146 - Diagnosis was invalid for the      M81 - You are required to code to 255 - Diagnosis code.
       be further subdivided. (the   date(s) of service reported.             the highest level of specificity
       code must have four or five
       digits)
1560   Provider must split details   125 - Submission-billing error(s).       MA130 - Your claim contains       21 - Missing or invalid information.
       between UB with the revenue                                            incomplete and-or invalid         481 - Claim submission format is
       code and CMS-1500 with the                                             information, and no appeal rights invalid.
       HCPCS code.                                                            are afforded because the claim is
                                                                              unprocessable. Please submit a
                                                                              new claim with the complete-
                                                                              correct information.

1561   RES not allowed same DOS B15 - This service-procedure requires         N20 - Service not payable with     258 - Days-units for procedure-
       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 as that a qualifying service-procedure be      other service rendered on the      revenue code.
       maternity care coordination. 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



1563   Revenue Code for Skilled      125 - Submission-billing error(s).        M50 - Missing-incomplete-invalid    454 - Procedure code for services
       Nursing Visit has been billed                                           revenue code(s).                    rendered.             455 -
       with an invalid HCPCS code                                              M51 - Missing-incomplete-invalid,   Revenue code for services
                                                                               procedure code(s) and-or dates      rendered.

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.

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 stay received and covered. The qualifying      same date.
                                     other service-procedure has not been
                                     received-adjudicated.

1568   Personal Care Services and    16 - Claim-service lacks information       N34 - Incorrect claim form-format 481 - Claim-submission format is
       Private Duty Nursing are no   which is needed for adjudication.         for this service.                  invalid.
       longer billed on the UB.
       Rebill on the CMS 1500.




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                                                         EOB Code Crosswalk to HIPAA Standard Codes

1569   PCS not allowed same days        B15 - This service-procedure requires    N20 - Service not payable with          259 - Frequency of service.
       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 is B15 - This service-procedure requires           N20 - Service not payable with          259 - Frequency of service.
       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.

1571   Adj. Denied. Records do not 16 - Claim-service lacks information          N29 - Missing-incomplete-invalid        267 - Number of miles patient was
       support individual transports. which is needed for adjudication.          documentation-orders-notes-             transported
       A recoupment has been                                                     summary-report-charge.                  454 - Procedure code for services
       initiated for the individual                                              N56 - Procedure code billed is not      rendered
       transport previously paid.                                                correct-valid for the services
       Please resubmit claim for a                                               billed or the date of service billed.
       round trip trans.                                                         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 service.
                                                                               N381 - Consult our contractual
                                                                               agreement for restrictions-billing-
                                                                               payment information related to
                                                                               these charges

1573   Case Management paid to          B15 - This service-procedure requires    N20 - Service not payable with          258 - Days-units for procedure-
       DMH recouped to allow            that a qualifying service-procedure be   other service rendered on the           revenue code.
       payment for Case                 received and covered. The qualifying     same date.
       Management to CAP                other service-procedure has not been
       provider for the same date of    received-adjudicated.
       service
1574   Adjustment of immediate          119 - Benefit maximum for this time    M86 - Service denied because              258 - Days-units for procedure-
       dentures not allowed until six   period or occurrence has been reached. payment already made for same-            revenue code.
       months after receipt of                                                 similar procedure within set time         454 - Procedure code for services
       denture per State limit                                                 frame.                                    rendered.

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                                                       EOB Code Crosswalk to HIPAA Standard Codes

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   CAP Recipients are not         177 - Patient has not met the required      N30 - Patient ineligible for this    90 - Entity not eligible for medical
       eligible for at-risk case      eligibility requirements.                   service.                             benefits for submitted dates of
       management services                                                                                             service.
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 for     another service-procedure that has          session-date as a previously
       the same tooth, same date of already been adjudicated.                     processed service for the patient.
       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   Adjustment of immediate        119 - Benefit maximum for this time         M86 - Service denied because         258 - Days-units for procedure-
       dentures not allowed until six period or occurrence has been reached.      payment already made for same-       revenue code.
       months after receipt of                                                    similar procedure within set time    454 - Procedure code for services
       denture per State limit                                                    frame.                               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 number 119 - Benefit maximum for this time                 M86 - Service denied because       259 - Frequency of service.
       of physical therapy modalities period or occurrence has been reached.      payment already made for same- 442 - Modalities of service.
       (6) allowed per day for dental                                             similar procedure within set time 612 - Per Day Limit Amount
       provider.                                                                  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

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 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-        612 - Per Day Limit Amount
                                                                              similar procedure within set time
                                                                              frame.
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-        411 - Medical necessity for non-
       within a six month period,                                             similar procedure within set time     routine service(s).
       without documentation of                                               frame.                        N29 -
       necessity.                                                             Missing documentation-orders-
                                                                              notes-summary-report-chart.
                                                                              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-          612 - Per Day Limit Amount
       service.                                                             similar procedure within set time
                                                                            frame.
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-          612 - Per Day Limit Amount
       service.                                                             similar procedure within set time
                                                                            frame.
1588   Claim denied. Treatment has B20 - Procedure-service was partially or M86 - Service denied because            258 - Days-units for procedure-
       been rendered by another      fully furnished by another provider.   payment already made for same-          revenue code.
       provider for this date of                                            similar procedure within set time
       service                                                              frame.
1589   Only one incision 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-          612 - Per Day Limit Amount
                                                                            similar procedure within set time
                                                                            frame.

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                                                        EOB Code Crosswalk to HIPAA Standard Codes

1590   No PASARR number on file 197 - Precertification-authorization-            N54 - Claim information is         48 - Referral-authorization.
       at EDS. Contact First Health notification absent.                         inconsistent with pre-certified-
       Services at 1-800-639-6514.                                               authorized services.

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 Health                                              authorized services.
       Services at 1-800-639-6514.

1592   Service requires PASARR        197 - Precertification-authorization-      N54 - Claim information is         48 - Referral-authorization.
       authorization for admission to notification absent.                       inconsistent with pre-certified-
       a Medicaid certified Nursing                                              authorized services.
       Facility. Contact First Health
       Services at 1-800-639-6514.

1593   Service denied. Exceeds the 119 - Benefit maximum for this time      M86 - Service denied because            258 - Days-units for procedure-
       maximum units allowed per period or occurrence has been reached. payment already made for same-              revenue code.
       month                                                                similar procedure within set time       259 - Frequency of service
                                                                            frame.                    N362 -
                                                                            The number of Days or Units of
                                                                            Service exceeds our acceptable
                                                                            maximum
1594   Procedure code is not usually B15 - This service-procedure requires M80 - Not covered when                   454 - Procedure code for services
       performed with code in        that a qualifying service-procedure be performed during the same               rendered.
       history.                      received and covered. The qualifying   session-date as a previously
                                     other service-procedure has not been   processed service for the patient.
                                     received-adjudicated.

1595   Nutritional services limited to 119 - Benefit maximum for this time    M86 - Service denied because          259 - Frequency of service.
       one per date of service.        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
1596   Recipient not eligible for CAP 177 - Patient has not met the required N30 - Patient ineligible for this      90 - Entity not eligible for medical
       services.                       eligibility requirements.              service.                              benefits for submitted dates of
                                                                                                                    service.

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1597   Provider not enrolled to       125 - Submission-billing error(s).         N30 - Patient ineligible for this    91 - Entity not eligible-not approved
       perform services in recipients                                            service.                             for dates of service.
       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 related   other service-procedure has not been
       case management services.        received-adjudicated.

1599   CAP Respite Care services 169 - Payment adjusted because an               N20 - Service not payable with      259 - Frequency of service.
       recouped. This service not alternate benefit has been provided            other service rendered on the
       allowed when recipient is                                                 same date.
       receiving Adult Care Homes,
       PCS or Therapeutic Leave.

1601   Detail previously paid and    B13 - Previously paid. Payment for this     None                                65 - Claim-line has been paid
       was not reprocessed           claim-service may have been provided
                                     in a previous payment
1602   Detail previously denied and 18 - Duplicate claim-service                 None                                585 - Denied Charge or Non-
       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 service included in the payment-allowance for       performed during the same           revenue code
       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 your 216 - Drug information.
       rules exceeded. Synagis          period or occurrence has been reached. provider manual for additional    259 - Frequency of service.
       rules allow no more than one                                            program and provider information 483 - Maximum coverage amount
       50mg vial and no more than                                                                                met or exceeded for benefit period
       250mg total in 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 emergency      eligibility requirements.                service.                            benefits for submitted dates of
       services.                                                                                                     service.

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                                                        EOB Code Crosswalk to HIPAA Standard Codes



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 emergency  eligibility requirements.                    service.                               benefits for submitted dates of
       services. Please resubmit as                                              N95 - This provider type-provider      service.
       an adjustment with                                                        specialty may not bill this service.   294 - Supporting documentation.
       supporting documentation if                                               N152 - Missing-incomplete-invalid
       an emergency situation                                                    replacement claim information.
       existed.

1607   Service denied. Supporting      177 - Patient has not met the required    N30 - Patient ineligible for this      90 - Entity not eligible for medical
       documentation does not          eligibility requirements.                 service.                               benefits for submitted dates of
       indicate an emergency                                                                                            service.
       situation.                                                                                                       294 - Supporting documentation.
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) and      the procedure.                            diagnosis or condition.          453 - Procedure Code Modifier(s)
       no family planning procedure.                                                                              for Service(s) Rendered.
       Please resubmit with family                                                                                488 - Diagnosis code(s) for the
       planning procedure-modifier                                                                                services rendered
       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 planning the procedure.                              diagnosis or condition.
       diagnosis. Please correct                                                 MA130 - Your claim contains
       and resubmit.                                                             incomplete 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.




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1611   Service has already been         B20 - Procedure-service was partially or M86 - Service denied because          259 - Frequency of service.
       paid to another provider for     fully furnished by another provider.     payment already made for same-        585 - Denied Charge or Non-
       same DOS                                                                  similar procedure within set time     covered Charge
                                                                                 frame.
1612   Claim paid without TPL           23 - The impact of prior payer(s)        None                                  182 - Allowable-paid from primary
       deduction. Original claim        adjudication including payments and-or                                         coverage
       reduced allowable using          adjustments.
       remaining available TPL
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 cost   Reason Code)
       sharing
1617   The attending provider           A1 - Claim-Service denied. At least one N253 - Missing-incomplete-invalid 21 - Missing or invalid information.
       number cannot be used as a       Remark Code must be provided (may       attending provider primary
       billing provider number. Add     be comprised of either the Remittance identifier.
       the correct billing provider     Advice Remark Code or NCPDP Reject
       number and resubmit as a         Reason Code)
       new day claim

1618   The LT or RT modifier must 4 - The procedure code is inconsistent             None                              21 - Missing or invalid information.
       be on the same detail line as with the modifier used or a required                                              453 - Procedure Code Modifier(s)
       the NU modifier. Add the      modifier is missing.                                                              for Service(s) Rendered
       appropriate modifier and
       resubmit the claim.

1619   The LT or RT modifier must 4 - The procedure code is inconsistent             None                              21 - Missing or invalid information.
       be billed with procedure code with the modifier used or a required                                              453 - Procedure Code Modifier(s)
       billed. Add the appropriate   modifier is missing.                                                              for Service(s) Rendered
       modifier and resubmit the
       claim

1620   Certified attending provider     15 - Payment adjusted because the            N77 - Missing-incomplete-invalid 21 - Missing or invalid information.
       number is required when          submitted authorization number is            designated provider number.
       billing this procedure code.     missing, invalid, or does not apply to the   N253 - Missing-incomplete-invalid
       Resubmit with appropriate        billed services or provider.                 attending provider primary
       attending number                                                              identifier.



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                                                        EOB Code Crosswalk to HIPAA Standard Codes



1622   Intra-Nasal-Oral                B15 - This service-procedure requires      M51 - Missing-incomplete-invalid 454 - Procedure code for services
       Administration requires the     that a qualifying service-procedure be     procedure code(s) and-or dates. rendered
       appropriate Intra-Nasal-Oral    received and covered. The qualifying       N59 - Alert- Please refer to your
       Immunization procedure.         other service-procedure has not been       provider manual for additional
       Refer to Health Check Billing   received-adjudicated.                      program and provider
       Guide.                                                                     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 Administration     Remark Code must be provided (may          payment already made for same-
       and first Injectable            be comprised of either the Remittance      similar procedure within set time
       Immunization Administration     Advice Remark Code or NCPDP Reject         frame
       not allowed on the same day     Reason Code)

1624   Incorrect Immunization          A1 - Claim-Service denied. At least one N56 - Procedure code billed is not 259 - Frequency of service
       Administration Code             Remark Code must be provided (may       correct-valid for the services
       combination billed. This        be comprised of either the Remittance billed or the date of service billed.
       combination cannot be billed    Advice Remark Code or NCPDP Reject
       on the same date of service.    Reason Code)
       See billing guidelines

1625   No payment for add-on (zzz) 107 - The related or qualifying claim-         N19 - Procedure code incidental   454 - Procedure code for services
       code allowed if 'primary' code service was not identified on this claim.   to primary procedure.             rendered.
       in series is not paid for the                                              N161 - This drug-service-supply
       same date of service, same                                                 is covered only when the
       provider.                                                                  associated service is covered.

1626   No payment for add-on (zzz) 107 - The related or qualifying claim-         N19 - Procedure code incidental   454 - Procedure code for services
       code allowed if 'primary' code service was not identified on this claim.   to primary procedure.             rendered.
       in series is not paid for the                                              N161 - This drug-service-supply
       same date of service, same                                                 is covered only when the
       provider.                                                                  associated service is covered.




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1627   No payment for add-on (zzz) 107 - The related or qualifying claim-         N19 - Procedure code incidental   454 - Procedure code for services
       code allowed if 'primary' code service was not identified on this claim.   to primary procedure.             rendered.
       in series is not paid for the                                              N161 - This drug-service-supply
       same date of service, same                                                 is covered only when the
       provider.                                                                  associated service is covered.

1628   Related lab test included in   97 - The benefit for this service is        M80 - Not covered when             454 - Procedure code for services
       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 to    included in the payment-allowance for       performed during the same          rendered.
       allow reimbursement of panel   another service-procedure that has          session-date as a previously
       code.                          already been adjudicated.                   processed service for the patient.

1630   DME providers are required 4 - The procedure code is inconsistent          None                              453 - Procedure code modifier(s)
       to bill modifiers to establish with the modifier or a required modifier                                      for service(s) rendered.
       that the procedure billed is   is missing.
       new, used or rental. Correct
       claim and resubmit.

1632   Physical therapy re-           B15 - This service-procedure requires       N20 - Service not payable with    258 - Days-units for procedure-
       evaluation not allowed same    that a qualifying service-procedure be      other service rendered on the     revenue code.
       date of service as Physical    received and covered. The qualifying        same date.
       therapy evaluation.            other service-procedure has not been
                                      received-adjudicated.

1633   Physical therapy evaluation    B15 - This service-procedure requires       N20 - Service not payable with    258 - Days-units for procedure-
       not allowed same date of       that a qualifying service-procedure be      other service rendered on the     revenue code.
       service as Physical therapy    received and covered. The qualifying        same date.
       re-evaluation.                 other service-procedure has not been
                                      received-adjudicated.

1637   Service denied. This test is   97 - The benefit for this service is        M80 - Not covered when             454 - Procedure code for services
       included in a related panel    included in the payment-allowance for       performed during the same          rendered.
       code already paid for the      another service-procedure that has          session-date as a previously
       same date of service.          already been adjudicated.                   processed service for the patient.



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1642   Crossover percentage           170 - Payment is denied when              N95 - This provider type -           585 - Denied Charge or Non-
       payments are not allowed for   performed-billed by this type of provider provider specialty may not bill this covered Charge
       this provider type-specialty                                             service
       combination
1645   Total time billed for          152 - Payment adjusted because the      N225 - Incomplete-invalid              297 - Medical notes-report.
       psychological testing is not   payer deems the information submitted documentation-orders- notes-
       documented In the medical      does not support this length of service summary- report- chart.
       records. only documented
       time has been reimbursed.
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 Area    eligibility requirements.                service.                              for Service(s) Rendered.       475
       Mental Health Provider for                                              N216 - Patient is not enrolled in     - Procedure code not valid for
       recipients age 000-003 who                                              this portion of our benefit package   patient age
       are not CAP-MR-DD on the
       DOS billed
1650   Recoupment per medical or      B5 - Coverage-program guidelines were    MA67 - Correction to a prior claim 101 - Claim was processed as
       policy review                  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 already 18 - Duplicate claim-service.               M86 - Service denied because      259 - Frequency of service.
       paid for this calendar month.                                           payment already made for same-
                                                                               similar procedure within set time
                                                                               frame.



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1653   Care plan oversight for Home 18 - Duplicate claim-service.               M86 - Service denied because         259 - Frequency of service.
       Health recipient already paid                                            payment already made for same-
       for this calendar month.                                                 similar procedure within set time
                                                                                frame.
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 month.                                            similar procedure within set time
                                                                                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 recouped. received and covered. The qualifying        same date.
                                    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 month.     already been adjudicated.               processed service for the patient.

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 billed   another service-procedure that has      session-date as a previously         Justify services outside composite
       separately for same calendar     already been adjudicated.               processed service for the patient.   rate.
       month
1663   Prior claim for case             18 - Duplicate claim-service.     M86 - Service denied because               259 - Frequency of service.
       management has been paid                                           payment already made for same-
       for this month.                                                    similar procedure within set time
                                                                          frame.
1664   Service denied. Drug allows 119 - Benefit maximum for this time    M86 - Service denied because               258 - Days-units for procedure-
       1200 units per calendar     period or occurrence has been reached. payment already made for same-             revenue code.
       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 150.00   period or occurrence has been reached. payment already made for same-        612 - Per Day Limit Amount
       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.
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.

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1675   Drug is limited to 240 units   119 - Benefit maximum for this time   None                                  259 - Frequency of service
       per calendar month. Units      period or occurrence has been reached
       have been cutback to
       allowable units for this
       timeframe
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 were N59 - Alert- Please refer to your 585 - Denied Charge or Non-
       suspended for non-             not met or were exceeded.             provider manual for additional    covered Charge.
       compliance of false claim                                            program and provider information 615 - Policy Compliance Code.
       act. Please submit
       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.

1685   The procedure billed requires 4 - The procedure code is inconsistent    MA130 - Your claim contains       21 - Missing or invalid information.
       a modifier which will establish with the modifier used or a required    incomplete and-or invalid
       the number of patients          modifier is missing.                    information, and no appeal rights
       served for this DOS. Please                                             are afforded because the claim is
       check your procedure,                                                   unprocessable. Please submit a
       correct your claim and                                                  new claim with the complete-
       resubmit                                                                correct information. N180 - This
                                                                               item or service does not meet the
                                                                               criteria for the category under
                                                                               which it was billed.

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


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1690   Related MRI procedures not B15 - This service-procedure requires           M86 - Service denied because      258 - Days-units for procedure-
       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.

1691   DMA 3000 PCS PACT is             A1 - Claim-Service denied. At least one   N29 - Missing documentation-      21 - Missing or invalid information.
       missing, incomplete or           Remark Code must be provided (may         orders-notes-summary-report-      294 - Supporting documentation
       invalid. Please attach the       be comprised of either the Remittance     chart.
       required information and         Advice Remark Code or NCPDP Reject        N225 - Incomplete-invalid
       resubmit the claim               Reason Code)                              documentation-orders-notes-
                                                                                  summary-report-chart
1692   Signatures are missing-          A1 - Claim-Service denied. At least one   N29 - Missing documentation-      21 - Missing or invalid information.
       illegible. Please check-         Remark Code must be provided (may         orders-notes-summary-report-      294 - Supporting documentation
       include all attachments that     be comprised of either the Remittance     chart.
       require signatures with          Advice Remark Code or NCPDP Reject        N205 - Information provided was
       legible copies and resubmit      Reason Code)                              illegible.
                                                                                  N225 - Incomplete-invalid
                                                                                  documentation-orders-notes-
                                                                                  summary-report-chart
1693   Required certificates missing-   A1 - Claim-Service denied. At least one   N29 - Missing documentation-      21 - Missing or invalid information.
       invalid. Home Aide info, RN      Remark Code must be provided (may         orders-notes-summary-report-      294 - Supporting documentation
       PCS Cert info, licenses of       be comprised of either the Remittance     chart.
       staff rendering svc must be      Advice Remark Code or NCPDP Reject        N225 - Incomplete-invalid
       attached. Resubmit claims        Reason Code)                              documentation-orders-notes-
       with appropriate documents                                                 summary-report-chart


1694   Information on Aide's time-      A1 - Claim-Service denied. At least one   N29 - Missing documentation-    21 - Missing or invalid information.
       task sheet (work log) not        Remark Code must be provided (may         orders-notes-summary-report-    294 - Supporting documentation
       complete or is an illegible      be comprised of either the Remittance     chart.
       copy. Please resubmit claim      Advice Remark Code or NCPDP Reject        N205 - Information provided was
       with legible copy and-or         Reason Code)                              illegible.
       completed log if it exists                                                 N225 - Incomplete-invalid
                                                                                  documentation-orders-notes-
                                                                                  summary-report-chart



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1695   Documentation submitted          B5 -Coverage-program guidelines were N35 - Program integrity-utilization 294 - Supporting documentation
       with claim does not support      not met or were exceeded.            review decision
       that coverage requirements
       (as stated in Medicaid
       Coverage Policy) were met

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 Modifier(s)
                                                                             similar procedure within set time     for Service(s) Rendered
                                                                             frame.
                                                                             N362 - The number of Days or
                                                                             Units of Service exceeds our
                                                                             acceptable maximum
1697   First treatment date not valid, 125 - Submission-billing error(s).    MA122 - Missing-incomplete-           21 - Missing or invalid information.
       please resubmit claim with                                            invalid initial treatment date.       192 - Date of first service for
       correct first treatment date                                                                                current series-symptom-illness.

1699   Service is not consistent with   125 - Submission-billing error(s).        M76 - Missing-incomplete-invalid 488 - Diagnosis code(s) for the
       or not covered for this                                                    diagnosis or condition           services rendered
       diagnosis or description of
       service does not match
       diagnosis
1706   Non-Physican Counseling          A1 - Claim-Service denied. At least one   M86 - Service denied because      259 - Frequency of service
       Immunization Administration      Remark Code must be provided (may         payment already made for same-
       procedure not allowed same       be comprised of either the Remittance     similar procedure within set time
       day as Physician Counseling      Advice Remark Code or NCPDP Reject        frame
       Immunization                     Reason Code)

1707   Procedure recouped.              A1 - Claim-Service denied. At least one   M86 - Service denied because      259 - Frequency of service
       Administration with Non-         Remark Code must be provided (may         payment already made for same-
       Physician Counseling not         be comprised of either the Remittance     similar procedure within set time
       allowed same day as              Advice Remark Code or NCPDP Reject        frame
       Physician Counseling             Reason Code)
1720   NDC validity cannot be           125 - Submission-billing error(s)         M119 - Missing-incomplete-       218 - NDC number
       confirmed                                                                  invalid-deactivated-withdrawn
                                                                                  National Drug Code (NDC).



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                                                       EOB Code Crosswalk to HIPAA Standard Codes


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.

1722   Prior authorization required. 197 - Precertification-authorization-       N54 - Claim information is         48 - Referral-authorization.
       Prescriber must call ACS at 1- notification absent.                       inconsistent with pre-certified-
       866-246-8505.                                                             authorized services.
1723   Non-Preferred agent            38 - Services not provided or authorized   None                               1 - For more detailed information,
       prescriber must call ACS at 1- by designated (network-primary care)                                          see remittance advice.
       866-246-8505.                  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.
       primary procedure.             another service-procedure that has         session-date as a previously
                                      already been adjudicated.                  processed service for the patient.
                                                                                 N20 - Service not payable with
                                                                                 other service rendered on the
                                                                                 same date.


1725   Related Mammography            119 - Benefit maximum for this time   M80 - Not covered when             259 - Frequency of service.
       screenings not allowed on      period or occurrence has been reached performed during the same          453 - Procedure Code Modifier(s)
       the same date of service                                             session-date as a previously       for Service(s) Rendered
                                                                            processed service for the patient.
                                                                            N20 - Service not payable with
                                                                            other service rendered on the
                                                                            same date

1730   Drug screenings and-or         119 - Benefit maximum for this time    M86 - Service denied because       259 - Frequency of service.
       confirmations are limited to   period or occurrence has been reached. payment already made for same-
       16 within a calendar 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


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                                                          EOB Code Crosswalk to HIPAA Standard Codes



1746   The core (billing) and service    A1 - Claim-Service denied. At least one N95 - This provider type -           454 - Procedure code for services
       level (attending) provider type   Remark Code must be provided (may       provider specialty may not bill this rendered
       and specialty combination         be comprised of either the Remittance service
       are not valid for the service     Advice Remark Code or NCPDP Reject
       billed                            Reason Code)

1747   Related radiology procedures B15 - This service-procedure requires         N20 - Service not payable with     258 - Days-units for procedure-
       not allowed on the same date that a qualifying service-procedure be        other service rendered on the      revenue code.
       of service.                  received and covered. The qualifying          same date.
                                    other service-procedure has not been
                                    received-adjudicated.

1749   Related fetal biophysical         B15 - This service-procedure requires    N20 - Service not payable with     258 - Days-units for procedure-
       profile procedures not            that a qualifying service-procedure be   other service rendered on the      revenue code.
       allowed on the same date of       received and covered. The qualifying     same date.
       service.                          other service-procedure has not been
                                         received-adjudicated.

1750   Fluoride varnish application      107 - The related or qualifying claim-    N19 - Procedure code incidental   42 - Awaiting related charges
       must be billed with related       service was not identified on this claim. to primary procedure.
       procedure codes on the                                                      N161 - This drug-service-supply
       same claim                                                                  is covered only when the
           .                                                                       associated service is covered.

1751   Related prostate specific         B15 - This service-procedure requires    N20 - Service not payable with     258 - Days-units for procedure-
       antigen (PSA) procedures          that a qualifying service-procedure be   other service rendered on the      revenue code.
       not allowed on the same date      received and covered. The qualifying     same date.
       of service.                       other service-procedure has not been
                                         received-adjudicated.

1753   Vitamin, unspecified not on       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.
       vitamins A or K.                  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

1758   This procedure included in a    97 - The benefit for this service is     M80 - Not covered when             454 - Procedure code for services
       more comprehensive              included in the payment-allowance for    performed during the same          rendered.
       audiometry procedure billed     another service-procedure that has       session-date as a previously
       on same date of service.        already been adjudicated.                processed service for the patient.

1759   Procedure recouped to allow 97 - The benefit for this service is         M80 - Not covered when             454 - Procedure code for services
       reimbursement of more       included in the payment-allowance for        performed during the same          rendered.
       comprehensive procedure.    another service-procedure that has           session-date as a previously
                                   already been adjudicated.                    processed service for the patient.

1761   Related CAP service not      B15 - This service-procedure requires       N20 - Service not payable with     258 - Days-units for procedure-
       allowed on same day as CAP- that a qualifying service-procedure be       other service rendered on the      revenue code.
       MR-DD institutional respite. received and covered. The qualifying        same date.
                                    other service-procedure has not been
                                    received-adjudicated.

1762   Cap-MR-DD habilitation      B15 - This service-procedure requires        N20 - Service not payable with     258 - Days-units for procedure-
       service not allowed on same that a qualifying service-procedure be       other service rendered on the      revenue code.
       date as adult day health.   received and covered. The qualifying         same date.
                                   other service-procedure has not been
                                   received-adjudicated.

1763   Cap-MR-DD supported living      B15 - This service-procedure requires    N20 - Service not payable with     258 - Days-units for procedure-
       hourly procedure not allowed    that a qualifying service-procedure be   other service rendered on the      revenue code.
       on same date as supported       received and covered. The qualifying     same date.
       living.                         other service-procedure has not been
                                       received-adjudicated.

1764   Cap-MR-DD group respite         B15 - This service-procedure requires    N20 - Service not payable with     258 - Days-units for procedure-
       and institutional respite are   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.
       date of service.                other service-procedure has not been
                                       received-adjudicated.

1765   CAP dollar limitation has       45 - Charge exceeds fee schedule-        N381 - Consult our contractual      483 - Maximum coverage amount
       been exceeded for this          maximum allowable or contracted-         agreement for restrictions-billing- met or exceeded for benefit period.
       service.                        legislated fee arrangement. (Use         payment information related to
                                       Group Codes PR or CO depending           these charges
                                       upon liability).

   January 1, 2009                                                         Page 255
                                                      EOB Code Crosswalk to HIPAA Standard Codes

1766   Service denied. Drug allows 119 - Benefit maximum for this time    M86 - Service denied because            258 - Days-units for procedure-
       2000 units per calendar      period or occurrence has been reached payment already made for same-          revenue code.
       month                                                              similar procedure within set time       259 - Frequency of service
                                                                          frame.                 N362 - The
                                                                          number of Days or Units of
                                                                          Service exceeds our acceptable
                                                                          maximum
1767   Units were changed to        119 - Benefit maximum for this time   N362 - The number of Days or            258 - Days-units for procedure-
       maximum allowable,           period or occurrence has been reached Units of Service exceeds our            revenue code.
       limitation has been reached.                                       acceptable maximum.                     294 - Supporting documentation
       Submit adjustment with                                             N381 - Consult our contractual
       necessary documentation.                                           agreement for restrictions-billing-
                                                                          payment information related to
                                                                          these charges

1768   Fee adjusted to maximum        45 - Charge exceeds fee schedule-        N381 - Consult our contractual      483 - Maximum coverage amount
       allowable, limitation 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).
1769   No additional payment made 97 - The benefit for this service is         M80 - Not covered when             454 - Procedure code for services
       for hearing and-or vision      included in the payment-allowance for    performed during the same          rendered.
       service. Payment is included another service-procedure that has         session-date as a previously
       in Health Check                already been adjudicated.                processed service for the patient.
       reimbursement.
1770   Invalid procedure-modifier-    4 - The procedure code is inconsistent   None                               255 - Diagnosis code.
       diagnosis code combination with the modifier or a required modifier
       for Health Check or Family     is missing.
       Planning services. Correct
       and resubmit as a new claim.

1771   All components were not       95 - Benefits adjusted. Plan procedures N78 - The necessary components 107 - Processed according to
       rendered for this Health      not followed                            of the child and teen checkup  contract-plan provisions.
       Check Screening.                                                      (EPSDT) were not completed

1772   Maximum allowable for       B13 - Previously paid. Payment for this     None                               483 - Maximum coverage amount
       Health Department           claim-service may have been provided                                           met or exceeded for benefit period.
       Immunization Administration in a previous payment
       has already been paid.


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                                                     EOB Code Crosswalk to HIPAA Standard Codes



1773   Only one HRI level IV         119 - Benefit maximum for this time    M86 - Service denied because         259 - Frequency of service.
       residential procedure allowed period or occurrence has been reached. payment already made for same-       612 - Per Day Limit Amount
       per day.                                                             similar procedure within set time
                                                                            frame.
1774   Services 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.

1775   Only one HRI level III        119 - Benefit maximum for this time    M86 - Service denied because         259 - Frequency of service.
       residential procedure allowed period or occurrence has been reached. payment already made for same-       612 - Per Day Limit Amount
       per day.                                                             similar procedure within set time
                                                                            frame.
1776   Related immunization          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 day                  received and covered. The qualifying   same date.
                                     other service-procedure has not been
                                     received-adjudicated.

1777   HRI level II group home not   119 - Benefit maximum for this time    M86 - Service denied because      259 - Frequency of service.
       allowed with level II         period or occurrence has been reached. payment already made for same-
       therapeutic foster care.                                             similar procedure within set time
                                                                            frame.
1778   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 on the same day by    received and covered. The qualifying   same date.
       same or different Health      other service-procedure has not been
       Department.                   received-adjudicated.

1779   Newborn Assessment limited 149 - Lifetime benefit maximum has         N117 - This service is paid only    259 - Frequency of service.
       to once per lifetime        been reached for this service-benefit     once in a patients lifetime.
                                   category
1780   Therapeutic leave quarterly 119 - Benefit maximum for this time       M86 - Service denied because      454 - Procedure code for services
       limit exceeded              period or occurrence has been reached.    payment already made for same- rendered.
                                                                             similar procedure within set time
                                                                             frame.



   January 1, 2009                                                      Page 257
                                                         EOB Code Crosswalk to HIPAA Standard Codes


1781   The RX clarification code        177 - Patient has not met the required   MA130 - Your claim contains       21 - Missing or invalid information.
       specified is not valid for the   eligibility requirements.                incomplete and-or invalid         91 - Entity not eligible-not approved
       recipient and drug. Only                                                  information, and no appeal rights for dates of service.
       Long-Term Care recipients                                                 are afforded because the claim is
       are valid for this override.                                              unprocessable. Please submit a
                                                                                 new claim with the complete-
                                                                                 correct information.

1782   Adjustment due to refund      45 - Charge exceeds fee schedule-           None                               1 - For more detailed information,
       from provider                 maximum allowable or contracted-                                               see remittance advice.
                                     legislated fee arrangement. (Use
                                     Group Codes PR or CO depending
                                     upon liability).
1784   Service denied. An            97 - The benefit for this service is        M86 - Service denied because       259 - Frequency of service.
       ultrasound has already been included in the payment-allowance for         payment already made for same-
       paid for this date of service another service-procedure that has          similar procedure within set time
                                     already been adjudicated.                   frame.
1786   Please resubmit with medical 151 - Payment adjusted because the           M53 - Missing-incomplete-invalid 259 - Frequency of service.
       records supporting units      payer deems the information submitted       days or units of service. MA130
       billed.                       does not support this many services.        - Your claim contains incomplete
                                                                                 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.

1788   One follow-up ultrasound         119 - Benefit maximum for this time    M86 - Service denied because      259 - Frequency of service.
       allowed per day. If more than    period or occurrence has been reached. payment already made for same- 612 - Per Day Limit Amount
       one fetus, please resubmit                                              similar procedure within set time
       procedure code with                                                     frame.
       appropriate modifier and
       diagnosis to support
       additional unit(s)
1789   One OB transvaginal              119 - Benefit maximum for this time      M86 - Service denied because      259 - Frequency of service.
       ultrasound allowed per date      period or occurrence has been reache     payment already made for same- 612 - Per Day Limit Amount
       of service                                                                similar procedure within set time
                                                                                 frame.


   January 1, 2009                                                          Page 258
                                                        EOB Code Crosswalk to HIPAA Standard Codes

1793   No payment allowed if           107 - The related or qualifying claim-    N19 - Procedure code incidental     454 - Procedure code for services
       "primary" code is not paid in   service was not identified on this claim. to primary procedure                rendered
       the past 30 day history, same
       or different provider
1800   The procedure/diagnosis         4 - The procedure code is inconsistent    M51 - Missing-incomplete-invalid 21 - Missing or invalid information.
       billed indicates a family       with the modifier used or a required      procedure code(s)                453 - Procedure Code Modifier(s)
       planning service and requires   modifier is missing                                                        for Service(s) Rendered.
       modifier FP to be appended
       to the procedure

1801   Service Provider ID Qualifier A1 - Claim-Service denied. At least one     N277 - Missing-incomplete-invalid 21 - Missing or invalid information.
       is not 01                       Remark Code must be provided (may         other payer rendering provider    562 - Entitys National Provider
                                       be comprised of either the Remittance     identifier                        Identifier (NPI)
                                       Advice Remark Code or NCPDP Reject
                                       Reason Code)
1802   Service Provider ID is invalid. A1 - Claim-Service denied. At least one   N277 - Missing-incomplete-invalid 21 - Missing or invalid information.
                                       Remark Code must be provided (may         other payer rendering provider    562 - Entitys National Provider
                                       be comprised of either the Remittance     identifier                        Identifier (NPI)
                                       Advice Remark Code or NCPDP Reject
                                       Reason Code)
1803   Service no longer covered by 22 - This care may be covered by             N196 - Alert- Patient eligible to   116 - Claim submitted to incorrect
       Medicaid for recipients who another payer per coordination of             apply for other coverage which      payer
       are also enrolled with          benefits.                                 may be primary
       Medicare
1804   Admit date is prior to          125 - Submission-billing error(s).        MA130 - Your claim contains       21 - Missing or invalid information.
       program coverage date.                                                    incomplete 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.

1805   Claim denied for recipient 21 9 - The diagnosis is inconsistent with      M76 - Missing-incomplete-invalid 21 - Missing or invalid information.
       years of age or older with    the patients age.                           diagnosis or condition.          255 - Diagnosis code.
       invalid diagnosis.
1806   Invalid condition code.       125 - Submission-billing error(s).          M44 - Missing-incomplete-invalid 431 - Provide condition-functional
       Resubmit claim with a valid                                               condition code                   status at time of service.
       condition code                                                                                             460 - NUBC Condition Code(s).



   January 1, 2009                                                         Page 259
                                                        EOB Code Crosswalk to HIPAA Standard Codes

1808   UB information/code is       125 - Submission-billing error(s).           MA130 - Your claim contains       21 - Missing or invalid information
       invalid. Check admit type,                                                incomplete and-or invalid
       patient status, condition,                                                information, and no appeal rights
       value or occurrence code(s),                                              are afforded because the claim is
       correct & resubmit if                                                     unprocessable. Please submit a
       applicable.                                                               new claim with the complete-
                                                                                 correct information

1809   Pharmacy management fee         A1 - Claim-Service denied. At least one   N185 - Alert- Do not resubmit this 585 - Denied Charge or Non-
       is reimbursed only through      Remark Code must be provided (may         claim-service                      covered Charge
       system generated claims         be comprised of either the Remittance
                                       Advice Remark Code or NCPDP Reject
                                       Reason Code)
1810   Your claim denied for           A1 - Claim-Service denied. At least one   N29 - Missing documentation-        21 - Missing or invalid information.
       incomplete PCS                  Remark Code must be provided (may         orders-notes-summary-report-        294 - Supporting documentation
       documentation. Resubmit         be comprised of either the Remittance     chart.
       claim with all required         Advice Remark Code or NCPDP Reject        N225 - Incomplete-invalid
       documentation attached          Reason Code)                              documentation-orders-notes-
                                                                                 summary-report-chart
1816   Room and board is not        A1 - Claim-Service denied. At least one      N61 - Rebill services on separate   103 - Claim combined with other
       allowed on the same claim    Remark Code must be provided (may            claims.                             claim(s).
       as therapeutic leave.        be comprised of either the Remittance
       Separate services and re-billAdvice Remark Code or NCPDP Reject
                                    Reason Code)
1817   Second approach procedure 59 - Charges are adjusted based on              N381 - Consult our contractual      259 - Frequency of service.
       reduced 50% of allowed       multiple or concurrent procedure rules.      agreement for restrictions-billing- 453 - Procedure Code Modifier(s)
       amount if performed on the (For example multiple surgery or               payment information related to      for Service(s) Rendered
       same day.                    diagnostic imaging, concurrent               these charges
                                    anesthesia.)
1818   Second repair-reconstruction 59 - Charges are adjusted based on           N381 - Consult our contractual      259 - Frequency of service.
       code for skull base surgery multiple or concurrent procedure rules.       agreement for restrictions-billing- 453 - Procedure Code Modifier(s)
       reduced 50% of allowed       (For example multiple surgery or             payment information related to      for Service(s) Rendered
       amount if performed on the diagnostic imaging, concurrent                 these charges
       same day.                    anesthesia.)

1819   Second definitive procedure     59 - Charges are adjusted based on        N381 - Consult our contractual      259 - Frequency of service.    453
       code reduced 50% of the         multiple or concurrent procedure rules.   agreement for restrictions-billing- - Procedure Code Modifier(s) for
       allowable if performed on the   (For example multiple surgery or          payment information related to      Service(s) Rendered
       same day.                       diagnostic imaging, concurrent            these charges
                                       anesthesia.)

   January 1, 2009                                                          Page 260
                                                       EOB Code Crosswalk to HIPAA Standard Codes

1820   Only one vagotomy 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-        612 - Per Day Limit Amount
                                                                             similar procedure within set time
                                                                             frame.
1821   Only one gastrectomy           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-        612 - Per Day Limit Amount
                                                                             similar procedure within set time
                                                                             frame.
1822   Medicaid has paid the          108 - Rent-purchase guidelines were    M7 - No rental payments after the     65 - Claim-line has been paid.
       maximum allowable for this     not met.                               item is purchased, or after the       186 - Purchase and rental price of
       equipment code.                                                       total of issued rental payments       durable medical equipment
                                                                             equals the purchase price.
                                                                             N381 - Consult our contractual
                                                                             agreement for restrictions-billing-
                                                                             payment information related to
                                                                             these charges

1823   Payment reduced to equal       45 - Charge exceeds fee schedule-       M7 - No rental payments after the 184 - Purchase price for the rented
       the purchased new price for    maximum allowable or contracted-        item is purchased, or after the   durable medical equipment.
       each unit allowed Medicaid     legislated fee arrangement. (Use        total of issued rental payments
       has previously paid for the    Group Codes PR or CO depending          equals the purchase price
       equipment code.                upon liability).

1824   The comprehensive              97 - The benefit for this service is    M80 - Not covered when             454 - Procedure code for services
       metabolic panel includes the   included in the payment-allowance for   performed during the same          rendered.
       basic metabolic & hepatic      another service-procedure that has      session-date as a previously
       function panels.               already been adjudicated.               processed service for the patient.
       Reimbursement is based on
       CPT 80053.
1829   Repair codes billed in         119 - Benefit maximum for this time    M86 - Service denied because      259 - Frequency of service.
       conjunction with a space       period or occurrence has been reached. payment already made for same-
       maintainer are paid at the                                            similar procedure within set time
       secondary maximum allowed                                             frame.
       rate.
1830   Carolina access II enhanced    125 - Submission-billing error(s).      N185 - Alert- Do not resubmit this 107 - Processed according to
       care management fee is                                                 claim-service                      contract-plan provisions.
       reimbursed only through                                                                                   585 - Denied Charge or Non-
       system generated claims.                                                                                  covered Charge.



   January 1, 2009                                                         Page 261
                                                      EOB Code Crosswalk to HIPAA Standard Codes



1834   Jejunostomy allowed once      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-          612 - Per Day Limit Amount
                                                                            similar procedure within set time
                                                                            frame.
1835   Service recouped.             B15 - This service-procedure requires M86 - Service denied because             258 - Days-units for procedure-
       Jejunostomy previously paid that a qualifying service-procedure be   payment already made for same-          revenue code.
       for the same date of service. received and covered. The qualifying   similar procedure within set time
                                     other service-procedure has not been   frame.
                                     received-adjudicated.

1847   Claim denied. Exceeds the 119 - Benefit maximum for this time           M86 - Service denied because         258 - Days-units for procedure-
       allowable 100 Medicaid units period or occurrence has been reached payment already made for same-            revenue code.
       per 84 day period                                                       similar procedure within set time    259 - Frequency of service
                                                                               frame.                      N362 -
                                                                               The number of Days or Units of
                                                                               Service exceeds our acceptable
                                                                               maximum
1860   OPT must be billed with       107 - The related or qualifying claim-    M51 - Missing-incomplete-invalid     21 - Missing or invalid information.
       verteporfin, verteporfin must service was not identified on this claim. procedure code(s) and-or dates.
       be also be billed with OPT.

1861   Exceeds 10 treatments of      119 - Benefit maximum for this time       M86 - Service denied because      259 - Frequency of service.
       OPT per year.                 period or occurrence has been reached. payment already made for same-
                                                                               similar procedure within set time
                                                                               frame.
1862   Add on code for concurrent    107 - The related or qualifying claim-    N19 - Procedure code incidental 454 - Procedure code for services
       eye must be billed with       service was not identified on this claim. to primary procedure.             rendered.
       primary code for OPT.                                                   N161 - This drug-service-supply
                                                                               is covered only when the
                                                                               associated service is covered.

1863   Intravenous infusion services B15 - This service-procedure requires    N20 - Service not payable with        21 - Missing or invalid information.
       not allowed when OPT is       that a qualifying service-procedure be   other service rendered on the         454 - Procedure code for services
       paid.                         received and covered. The qualifying     same date.                            rendered.
                                     other service-procedure has not been
                                     received-adjudicated.




   January 1, 2009                                                        Page 262
                                                       EOB Code Crosswalk to HIPAA Standard Codes



1864   Only 3 units allowed per date 119 - Benefit maximum for this time       M86 - Service denied because          259 - Frequency of service.
       of service.                      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.                      N362 -
                                                                               The number of Days or Units of
                                                                               Service exceeds our acceptable
                                                                               maximum
1865   Dollar amount cutback to         45 - Charge exceeds fee schedule-      N381 - Consult our contractual        483 - Maximum cover