Common Reason Codes for Conditional Claims
Reason Code 3SP25
The Medicare Secondary Payer insurer’s name contains unacceptable values. The Centers for Medicare
& Medicaid Services (CMS) has restrictions on what names are acceptable to report as the primary
payer in line 50A of the UB‐04 claim form. Providers are required to supply the actual complete name
of the primary payer. The following are not considered acceptable names:
• No (followed by a space)
• Attorney (as the first word)
• Blue Cross or Blue Shield (with no other characters following i.e., the Blue Cross name or plan
number must follow)
Reason Code 31303
The Payer ID is equal to a “C” (conditional) and MSP value code of 12, 13, or 43 is present, but there is
no occurrence code 24 on the claim.
Reason Code 31531
Value code 14 is reported on the claim, but there is no corresponding occurrence code and date.
Reason Code 31532
Value Code 15 is reported on the claim, but there is no corresponding occurrence code and date.
Reason Code 31905
Please provide the primary insurer’s complete address.
Reason Code(s) 34060, 34061, and 34066*
A conditional Medicare Secondary Payer (MSP) claim has been presented indicating the primary payer
has denied coverage because the patient (beneficiary) did not follow the guidelines indicated by the
health plan. The patient has been notified, in writing, that if they did not follow the plan guidelines in
the future, Medicare would not process the claim.
Reason Code 70104
Claim has been submitted conditionally; however, no two‐position explanation code was reported.
Reason Code 70105
Claim has been submitted conditionally; however, an unacceptable two‐position explanation code
Reason Code 70107*
A conditional claim has been submitted to Medicare indicating that the primary payer denied coverage
because the patient (beneficiary) did not follow the guidelines indicated by the primary group health
Reason Code 70108
The patient went outside the network as defined by their prepaid health plan. This is the first time this
has happened and Medicare will pay this claim. The patient is being notified that we will not process
or pay any additional claims if they go outside their network again.
Reason Code 70153
Two payers were listed as being primary to Medicare, however, the complete name and address was
only provided for one payer. Please provide the complete name and address for the other payer.
* For additional information regarding these reason codes, please review the external narrative on the
Fiscal Intermediary Standard System/Medicare Part A Direct Data Entry System.
Common Reason Codes for Conditional Claims 2
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