Distributing Agreement

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Distributing Agreement Powered By Docstoc
					CARC Matrix by Organization Type

This is a dynamic tool for displaying the comparative responses of different organization types
       to the X12/WEDI Claims Adjustment Reason Code Matrix survey conducted in
       February of 2005.

Because of the volume of data (120+ rows of data by 4 columns by 30+ responses), it was
     a challenge to interpret the results in a fixed number of charts. Instead, we designed
     this tool to allow you to create your own breakdowns.

Two charts were created:
     Responses by Org Type (CARCMatrixbyOrgType.xls)
           This presents the raw numbers for an individual CARC. Because the number of
                responses varied between groups and among questions, and because a
                response could indicate more than one group code per question, the
                bars vary widely in length. Shorter segments indicate more unanimity among
                that group about how the CARC should be coded.

      Degree of Agreement Breakdown (This worksheet)
           This reduces the effect of the size of each group's sample by distributing their
                 responses on a percentage basis. Where color bars tend to line up between
                 groups, this indicates that those groups tend to agree on the coding of that
                 CARC. Different distributions indicate disagreement, and suggest areas for
                 further discussion.

How-To
     Select the worksheet tab for the chart you wish to display
     Click in the shaded cell (A2) containing the CARC code and description
     Select any of the 120+ CARCs from the drop-down list
     The numbers and corresponding graph will change instantly
     You can print or copy the results to preserve them
     To copy:
           Copy the range "Degree_of_Agreement_Chart"
           Use Paste As… | Excel Worksheet Object in Word
                 Or use Paste As… | Windows Metafile for smaller file size
            CARC-specific Agreement Between Respondents
 35 Lifetime benefit maximum has been
                                               CO          PI         PR        OA
 reached.
 Health Plan                                         2          1           6         0
 Provider                                            3          4          17         2
 Provider SW Vendor & Other                          0          0           2         0




       Health Plan

                                                                                CO
                                                                                PI
          Provider
                                                                                PR
                                                                                OA
    Provider SW
   Vendor & Other


                     0%    20%       40%       60%       80%        100%


           Percentage Chart: Color alignment indicates degree of agreement.


35 Lifetime benefit maximum has been reached.




                                                                                     February 2005
1 Deductible Amount
2 Coinsurance Amount
3 Co-Payment Amount
4 The procedure code is inconsistent with the modifier used or a required modifier is missing.
5 The procedure code/bill type is inconsistent with the place of service.
6 The procedure/revenue code is inconsistent with the patient's age.
7 The procedure/revenue code is inconsistent with the patient's gender.
8 The procedure code is inconsistent with the provider type/specialty (taxonomy)
9 The diagnosis is inconsistent with the patient's age.
10 The diagnosis is inconsistent with the patient's gender.
11 The diagnosis is inconsistent with the procedure.
12 The diagnosis is inconsistent with the provider type.
13 The date of death precedes the date of service.
14 The date of birth follows the date of service.
15 Payment adjusted because the submitted authorization number is missing invalid or does not apply to the billed services or
16 Claim/service lacks information which is needed for adjudication. Additional information is supplied using remittance advice
17 Payment adjusted because requested information was not provided or was insufficient/incomplete. Additional information is
18 Duplicate claim/service.
19 Claim denied because this is a work-related injury/illness and thus the liability of the Worker's Compensation Carrier.
20 Claim denied because this injury/illness is covered by the liability carrier.
21 Claim denied because this injury/illness is the liability of the no-fault carrier.
22 Payment adjusted because this care may be covered by another payer per coordination of benefits.
23 Payment adjusted because charges have been paid by another payer.
24 Payment for charges adjusted. Charges are covered under a capitation agreement/managed care plan.
25 Payment denied. Your stop loss deductible has not been met.
26 Expenses incurred prior to coverage.
27 Expenses incurred after coverage terminated.
29 The time limit for filing has expired.
30 Payment adjusted because the patient has not met the required eligibility spend down waiting or residency requirements.
31 Claim denied as patient cannot be identified as our insured.
32 Our records indicate that this dependent is not an eligible dependent as defined.
33 Claim denied. Insured has no dependent coverage.
34 Claim denied. Insured has no coverage for newborns.
35 Lifetime benefit maximum has been reached.
38 Services not provided or authorized by designated (network/primary care) providers.
39 Services denied at the time authorization/ precertification was requested.
40 Charges do not meet qualifications for emergent/urgent care.
42 Charges exceed our fee schedule or maximum allowable amount.
43 Gramm-Rudman reduction.
44 Prompt-pay discount.
45 Charges exceed your contracted/legislated fee arrangement.
47 This (these) diagnosis(es) is (are) not covered missing or are invalid.
49 These are non-covered services because this is a routine exam or screening procedure done in conjunction with a routine e
50 These are non-covered services because this is not deemed a 'medical necessity' by the payer.
51 These are non-covered services because this is a pre-existing condition.
52 The referring/prescribing/rendering provider is not eligibile to refer/prescribe/order/perform the service billed.
53 Services by an immediate relative or a member of the same household are not covered.
54 Multiple physicians/assistants are not covered in this case.
55 Claim/service denied because procedure/treatment is deemed experimental/ investigational by the payer.
56 Claim/service denied because procedure/treatment has not been deemed 'proven to be effective' by the payer.
57 Payment denied/reduced because the payer deems the information submitted does not suport this level of service this many
58 Payment adjusted because treatment was deemed by the payer to have been rendered in an inappropriate or invalid place o
59 Charges are adjusted based on multiple surgery rules or concurrent anesthesia rules.
60 Charges for outpatient services with this proximity to inpatient services are not covered.
61 Charges adjusted as penalty for failure to obtain second surgical opinion.
62 Payment denied/reduced for absence of or exceeded pre-certification/authorization.
66 Blood deductible.
69 Day outlier amount.
70 Cost-outlier - Adjustment to compensate for additional costs.
74 Indirect Medical Education Adjustment.
75 Direct Medical Education Adjustment.
76 Diaproportionate Share Adjustment.
78 Non-Covered days/Room charge adjustment.
85 Interest amount.
87 Transfer amount.
88 Adjustment amount represents collection against receivable created in prior overpayment.
89 Professional fees removed from charges.
90 Ingredient cost adjustment.
91 Dispensing fee adjustment.
94 Processed in Excess of charges.
95 Benefits adjusted. Plan procedures not followed.
96 Non-covered charge(s).
97 Payment is included in the allowance for another service/procedure.
100 Payment made to patient/insured/responsible party.
101 Predetermination: anticipated payment upon completion of services or claim adjudication.
102 Major Medical Adjustment.
103 Provider promotional discount (e.g. Senior citizen discount).
104 Managed care withholding.
105 Tax withholding.
106 Patient payment option/election not in effect.
107 Claim/service denied because the related or qualifying claim/service was not previously paid or identified on this claim.
108 Payment adjusted because rent/purchase guidelines were not met.
109 Claim not covered by this payer/contractor. You must send the claim to the correct payer/contractor.
110 Billing date predates service date.
111 Not covered unless the provider accepts assignment.
112 Payment adjusted as not furnished directly to the patient and/or not documented.
113 Payment denied because service/procedure was provided outside the United States or as a result of war.
114 Procedure/product not approved by the Food and Drug Administration.
115 Payment adjusted as procedure postponed or canceled.
116 Payment denied. The advance indemnification notice signed by the patient did not comply with requirements.
117 Payment adjusted because transportation is only covered to the closest facility that can provide the necessary care.
118 Charges reduced for ESRD network support.
119 Benefit maximum for this time period or occurrence has been reached.
121 Indemnification adjustment.
122 Psychiatric reduction.
125 Payment adjusted due to a submission/billing error(s). Additional information is supplied using the remittance advice remar
126 Deductible -- Major Medical.
127 Coinsurance -- Major Medical.
128 Newborn's services are covered in the mother's Allowance.
129 Payment denied - Prior processing information appears correct.
130 Claim submission fee.
131 Claim specific negotiated discount.
132 Prearranged demonstrated project adjustment.
133 The disposition of this claim/service is pending further review.
134 Technical fees removed from charges.
135 Claim denied. Interim bills cannot be processed.
136 Claim Adjusted. Plan procedures of a prior payer were not followed.
137 Payment/Reduction for Regulatory Surcharges Assessments Allowances or Health Related Taxes.
138 Claim/service denied. Appeal procedures not followed or time limits not met.
139 Contracted funding agreement - Subscriber is employed by the provider of service.
140 Patient/Insured health identification number and name do not match.
141 Claim adjustment because the claim spans eligible and ineligible periods of coverage.
142 Claim adjusted by the monthly Medicaid patient liability amount.
143 Portion of payment deferred.
144 Incentive adjustment e.g. preferred product/service.
145 Premium payment withholding.
146 Payment denied because the diagnosis was inalid for the date(s) of service reported.
147 Provider contracted/negotiated rate expired or not on file.
148 Claim/service rejected at this time because information from another provider was not provided or was insufficient/incompl
149 Lifetime benefit maximum has been reached for this service/benefit category.
150 Payment adjusted because the payer deems the information submitted does not support this level of service.
151 Payment adjusted because the payer deems the information submitted does not support this many services.
152 Payment adjusted because the payer deems the information submitted does not support this length of service.
153 Payment adjusted because the payer deems the information submitted does not support this dosage.
154 Payment adjusted because the payer deems the information submitted does not support this day's supply.
155 This claim is denied because the patient refused the service/product.
156 Flexible spending account payments.
157 Payment denied/reduced because service/procedure was provided as a result of an act of war.
158 Payment denied/reduced because the service/procedure was provided outside of the United States.
159 Payment denied/reduced because the service/procedure was provided as a result of terrorism.
160 Payment denied/reduced because injury/illness was the result of an activity that is a benefit exclusion.
161 Provider performance bonus.
162 State-mandated Requirement for Property and Casualty see Claim Payment Remarks Code for specific explanation.
163 Claim/Service adjusted because the attachment referenced on the claim was not received.
164 Claim/Service adjusted because the attachment referenced on the claim was not received in a timely fashion.
A0 Patient refund amount.
A1 Claim denied charges.
A2 Contractual Adjustment.
A4 Medicare Claim PPS Capital Day Outlier Amount.
A5 Medicare Claim PPS Capital Cost Outlier Amount.
A6 Prior hospitalization or 30 day transfer requirement not met.
A7 Presumptive Payment Adjustment.
A8 Claim denied; ungroupable DRG.
B1 Non-covered visits.
B4 Late filing penalty.
B5 Payment adjusted because coverage/program guidelines were not met or were exceeded.
B6 This payment is adjusted when performed/billed by this type of provider by this type of provider in this type of facility or by a
B7 This provider was not certified/eligible to be paid for this procedure/service on this date of service.
B8 Claim/service not covered/reduced because alternative services were available and should have been utilized.
B9 Services not covered because the patient is enrolled in a Hospice.
B10 Allowed amount has been reduced because a component of the basic procedure/test was paid. The beneficiary is not liabl
B11 The claim/service has been transferred to the proper payer/processor for processing. Claim/service not covered by this pa
B12 Services not documented in patient's medical records.
B13 Previously paid. Payment for this claim/service may have been provided in a previous payment.
B14 Payment denied because only one visit or consultation per physician per day is covered.
B15 Payment adjusted because this procedure/service is not paid separately.
B16 Payment adjusted because 'New Patient' qualifications were not met.
B17 Payment adjusted because this service was not prescribed by a physician not prescribed prior to delivery the prescription i
B18 Payment denied because this procedure code/modifier was invalid on the date of service or claim submission.
B20 Payment adjusted because procedure/service was partially or fully furnished by another provider.
B22 This payment is adjusted based on the diagnosis.
B23 Payment denied because this provider has failed an aspect of a proficiency testing program.
W1 Workers Compensation State Fee Schedule Adjustment.
CO        PI        PR        OA        CO-v       PI-v       PR-v       OA-v       CO-h
     1                   22                                          3
                         21        1                                 3
      1                  22                                          3
      8        14         2         4                     1                     2          3
      9        14         2         4                     2                     1          3
      9        14         3         4                     2                     1          1
      9        14         3         4                     2                     1          2
      9        14         1         4                     2                     1          3
     10        13         3         4                     2                     1          2
     10        13         2         4                     2                     1          2
     10        14         3         4                     2                     1          3
     10        13         2         4                     2                     1          2
     10        10         2         6                     2                     1          2
     10        10         1         6          1          2                                2
     11        13         5         3          1          2                     1          1
     10        14         8         4          1          2                                3
     11        16         8         5          1          2                                3
      9        11         2         8          1          1                                3
      5        13         5         6                     1          1                     2
      4        13         5         6                     1          1                     1
      5        13         5         6                     1          1                     2
      7        16         6         7                     1          1                     3
      8        12         5        11          1          1                     1          4
     19        10         2         3          2          1                                5
      3         3        16         2                                2                     1
      2         3        17         4                                2
      2         3        17         4                                2
     15         8         3         3          2          2                                6
      6         7        16         1                                2
      3         4        16         2                                2                     2
      1         3        18         1                                2
      1         2        19         1                                2
      1         2        18         1                                2
      3         4        17         2                                2                     2
     14        11        11         3          2          1          1                     4
     10         7        15         2          2                     2                     4
     10         6        13         2          1                     2                     2
     21         3         1         2          2                     1                     5
     19         1                   1          1                                           3
     20         2         1         1          2                                           5
     22         1                   3          2                                           5
     10        14        10         6                     1                                3
     10         7        13         2          2                     2                     1
     12         9        10         5          2                     2                     3
      2         4        16         2                                2
     10         9         4         4          1                     1                     3
      7         2        14         3                                2                     1
     11         6         3         5          1          1                                3
      9        13         8         4                     2
      9        13         5         4                     2                                1
     10        12         6         4                     2                                3
 9   13    2   5       2           4
15    5    2   2   2   1           5
13    6    2   2   2   1           2
 6    6   12   4   1       1       2
12    9   10   3   1               6
 1        14   2           1
 8         2   3   1   1           4
 9         1   3   1   1           4
 7    2    1   4   1   1           3
 7    2    1   4   1   1           4
 7    2    1   5   1   1           3
 7    6    5   4   1       1       2
 5    3        9       1       1   2
 4    3        7       1       1   2
 5    7        7       2           3
10    3        4   1   1           1
 7    2        4       1           1
 7    3        3       1           1
12    4        4   1               2
 9    9    7   4           1       2
11    7   15   1   1   1   2       3
15    7    1   4   2               4
 2    4   15   3           2       1
 3    4        9               1   1
 2    3   10   4           1       1
10    3        3   1               3
16    3        1   1               3
10    1        5   1               1
 3    2    9   3           1       1
 9    9    2   6       1           3
 8    6    5   4   1       1       1
 7    9    2   6       1   1       3
 8   11    1   5       1   1       2
 6    6    4   4       1           4
 8    9    1   5       1           2
 5    5   10   3           2       1
11    6   10   3   1               2
 9    7    2   6   1   2           1
 9    3    6   4   1               1
 9    3    9   5       1   2       1
 8    9        5       1
 9    3   17   1           2       1
 5    3    1   4   1               3
 8    7    8   2       1           1
 9   13        5       1           4
 1        20               2
 1        20               2
16   3     4   2   2   1           1
 9   6     4   6       2           2
 6   9     1   5   1               2
17   2         2   1               4
15   5         1   1               3
 2    7    1   14               1   1
 7    9         5       1           1
 7   12    1    4       2           3
 9    7    5    4   1   1           1
13    5    1    1   1               3
14    9    6    2   1   1           2
16    4    2    1   1               3
 4    8   10    4           2       1
 6    5   13    3           2       1
 5    2   15    2           2
 3    6         9               1   1
13    2         3   1               2
 3    4    6    5   1               1
 9    9    1    5       2           1
 9    6    3    2   1   1           3
 6    9    4    4       1           1
 3    3   17    1           2
 9   12    4    4       2           2
 9   13    2    4       2           2
 8   13    1    4       2           2
 8   13    1    4       2           1
 7   12    1    4       2           1
 7    3    5    5   1   1           1
 2    1    7    6           1
 5    3    9    6           2
 4    4    8    5           2
 5    5    6    4           2
 3    2   15    1           2
 7    1         5   1               3
 2    3         6   1               2
 9    8    2    4       2           1
13    9    2    3       2           1
 2    1   11    6           2
 9   10    7    4       1           2
20                  2               5
10    1        4    1               3
10    1        4    1               3
 7    6    2   2    1               1
10    2    3   5    1               2
 5    9        4        2           2
 7    5   12   2            2
15    4    1   3    1   1           3
11    5    8   4                    2
13    9    3   4            1       5
10   11    3   4    1               4
 9   11    8   4            1       3
12    7    4   6    1               1
18    2    1   3    2   1           3
 5   11    5   9        2           2
10    7        6        2           2
 6   11    2   7        2           3
10    7    6   5    1       1       2
16    6   2   3   1   1   4
10    7   2   5   1       1
 5    9   6   5       1   2
 9   11   1   6       1   3
11   12   1   5       1   3
10   12   4   6       1   2
 9    7       5   1       2
14    2       6   1       2
PI-h       PR-h       OA-h
                  6
                  6
                  6
       5          2          1
       4          2
       4          2
       4          2
       3          2
       3          2
       3          2
       5          1
       3          2
       3
       2          2
       2          3
       4          3
       4          2
       3          2          2
       2          1          3
       2                     2
       2          2          2
       3          2          2
       4          3          2
       2          2          1
                  3
                  6
                  6
       1          4
       1          6
       3          3
       1          5
       1          5
       1          4
       1          6
       2          4
       1          4
       1          5
       2          3
       1

                  1
       4          4
       1          4
       3          4
                  6
       3          3
       2          3
       2          3
       4          4
       4          3
       5          5
4   4
2   1
2   4
2   5
2   6
    5


2   1
2
1
1   2
        2
1
1   2   1
2   1
2
2
1   1   1
2   4
2   5
3   4   1
3   3
1   1   1
1   1   1
1       1
2
1   1   1
1   3
3   2
1   2
4   4   1
3
3   2
2   2   1
1   4   1
2   3
3   2
1   3
2   3
4
    5
1   2
2   3
5   1
    3
    3
2   1
3   1
2
3   1   2
3
3   1
2   2
1
2   3
    2
3   1
2   2
    3
2   1
        1
    2
3
    1
3   1
    4
4   4
2   2
2   1
2   1
2   2
1   1
2
2   3
2   4
3   2
    3


2   1
2   1
2       2
2   3   1
1   1
1
1
2
    1   1
4
    5

1   6
3   3
3   4
3   3
3   4
1   2
3   1   3
2       1
5   1   1
2   2
3   1
2   1
3   3   1
5   1   1
4   2
4   2   1
2       1
1
Indicate the appropriate group codes for each Reason Code (check all that may apply)
                                 CO                           PI          PR         OA
1 Deductible Amount
2 Coinsurance Amount
3 Co-Payment Amount
4 The procedure code is inconsistent with the modifier used or a required modifier is missing.
5 The procedure code/bill type is inconsistent with the place of service.
6 The procedure/revenue code is inconsistent with the patient's age.
7 The procedure/revenue code is inconsistent with the patient's gender.
8 The procedure code is inconsistent with the provider type/specialty (taxonomy)
9 The diagnosis is inconsistent with the patient's age.
10 The diagnosis is inconsistent with the patient's gender.
11 The diagnosis is inconsistent with the procedure.
12 The diagnosis is inconsistent with the provider type.
13 The date of death precedes the date of service.
14 The date of birth follows the date of service.
15 Payment adjusted because the submitted authorization number is missing invalid or does not apply to the billed services or

Total Respondents
(filtered out)
(skipped this question)


Indicate the appropriate group codes for each Reason Code (check all that may apply)

16 Claim/service lacks information which is needed for adjudication. Additional information is supplied using remittance advice
17 Payment adjusted because requested information was not provided or was insufficient/incomplete. Additional information is
18 Duplicate claim/service.
19 Claim denied because this is a work-related injury/illness and thus the liability of the Worker's Compensation Carrier.
20 Claim denied because this injury/illness is covered by the liability carrier.
21 Claim denied because this injury/illness is the liability of the no-fault carrier.
22 Payment adjusted because this care may be covered by another payer per coordination of benefits.
23 Payment adjusted because charges have been paid by another payer.
24 Payment for charges adjusted. Charges are covered under a capitation agreement/managed care plan.
25 Payment denied. Your stop loss deductible has not been met.
26 Expenses incurred prior to coverage.
27 Expenses incurred after coverage terminated.
29 The time limit for filing has expired.
30 Payment adjusted because the patient has not met the required eligibility spend down waiting or residency requirements.

Total Respondents
(filtered out)
(skipped this question)


Indicate the appropriate group codes for each Reason Code (check all that may apply)

31 Claim denied as patient cannot be identified as our insured.
32 Our records indicate that this dependent is not an eligible dependent as defined.
33 Claim denied. Insured has no dependent coverage.
34 Claim denied. Insured has no coverage for newborns.
35 Lifetime benefit maximum has been reached.
38 Services not provided or authorized by designated (network/primary care) providers.
39 Services denied at the time authorization/ precertification was requested.
40 Charges do not meet qualifications for emergent/urgent care.
42 Charges exceed our fee schedule or maximum allowable amount.
43 Gramm-Rudman reduction.
44 Prompt-pay discount.
45 Charges exceed your contracted/legislated fee arrangement.
47 This (these) diagnosis(es) is (are) not covered missing or are invalid.
49 These are non-covered services because this is a routine exam or screening procedure done in conjunction with a routine e
50 These are non-covered services because this is not deemed a 'medical necessity' by the payer.

Total Respondents
(filtered out)
(skipped this question)


Indicate the appropriate group codes for each Reason Code (check all that may apply)

51 These are non-covered services because this is a pre-existing condition.
52 The referring/prescribing/rendering provider is not eligibile to refer/prescribe/order/perform the service billed.
53 Services by an immediate relative or a member of the same household are not covered.
54 Multiple physicians/assistants are not covered in this case.
55 Claim/service denied because procedure/treatment is deemed experimental/ investigational by the payer.
56 Claim/service denied because procedure/treatment has not been deemed 'proven to be effective' by the payer.
57 Payment denied/reduced because the payer deems the information submitted does not suport this level of service this many
58 Payment adjusted because treatment was deemed by the payer to have been rendered in an inappropriate or invalid place o
59 Charges are adjusted based on multiple surgery rules or concurrent anesthesia rules.
60 Charges for outpatient services with this proximity to inpatient services are not covered.
61 Charges adjusted as penalty for failure to obtain second surgical opinion.
62 Payment denied/reduced for absence of or exceeded pre-certification/ authorization.
66 Blood deductible.
69 Day outlier amount.
70 Cost-outlier - Adjustment to compensate for additional costs.

Total Respondents
(filtered out)
(skipped this question)


Indicate the appropriate group codes for each Reason Code (check all that may apply)

74 Indirect Medical Education Adjustment.
75 Direct Medical Education Adjustment.
76 Diaproportionate Share Adjustment.
78 Non-Covered days/Room charge adjustment.
85 Interest amount.
87 Transfer amount.
88 Adjustment amount represents collection against receivable created in prior overpayment.
89 Professional fees removed from charges.
90 Ingredient cost adjustment.
91 Dispensing fee adjustment.
94 Processed in Excess of charges.
95 Benefits adjusted. Plan procedures not followed.
96 Non-covered charge(s).
97 Payment is included in the allowance for another service/procedure.
100 Payment made to patient/insured/responsible party.

Total Respondents
(filtered out)
(skipped this question)


Indicate the appropriate group codes for each Reason Code (check all that may apply)

101 Predetermination: anticipated payment upon completion of services or claim adjudication.
102 Major Medical Adjustment.
103 Provider promotional discount (e.g. Senior citizen discount).
104 Managed care withholding.
105 Tax withholding.
106 Patient payment option/election not in effect.
107 Claim/service denied because the related or qualifying claim/service was not previously paid or identified on this claim.
108 Payment adjusted because rent/purchase guidelines were not met.
109 Claim not covered by this payer/contractor. You must send the claim to the correct payer/contractor.
110 Billing date predates service date.
111 Not covered unless the provider accepts assignment.
112 Payment adjusted as not furnished directly to the patient and/or not documented.
113 Payment denied because service/procedure was provided outside the United States or as a result of war.
114 Procedure/product not approved by the Food and Drug Administration.
115 Payment adjusted as procedure postponed or canceled.

Total Respondents
(filtered out)
(skipped this question)


Indicate the appropriate group codes for each Reason Code (check all that may apply)

116 Payment denied. The advance indemnification notice signed by the patient did not comply with requirements.
117 Payment adjusted because transportation is only covered to the closest facility that can provide the necessary care.
118 Charges reduced for ESRD network support.
119 Benefit maximum for this time period or occurrence has been reached.
121 Indemnification adjustment.
122 Psychiatric reduction.
125 Payment adjusted due to a submission/billing error(s). Additional information is supplied using the remittance advice remar
126 Deductible -- Major Medical.
127 Coinsurance -- Major Medical.
128 Newborn's services are covered in the mother's Allowance.
129 Payment denied - Prior processing information appears correct.
130 Claim submission fee.
131 Claim specific negotiated discount.
132 Prearranged demonstrated project adjustment.
133 The disposition of this claim/service is pending further review.

Total Respondents
(filtered out)
(skipped this question)


Indicate the appropriate group codes for each Reason Code (check all that may apply)

134 Technical fees removed from charges.
135 Claim denied. Interim bills cannot be processed.
136 Claim Adjusted. Plan procedures of a prior payer were not followed.
137 Payment/Reduction for Regulatory Surcharges Assessments Allowances or Health Related Taxes.
138 Claim/service denied. Appeal procedures not followed or time limits not met.
139 Contracted funding agreement - Subscriber is employed by the provider of service.
140 Patient/Insured health identification number and name do not match.
141 Claim adjustment because the claim spans eligible and ineligible periods of coverage.
142 Claim adjusted by the monthly Medicaid patient liability amount.
143 Portion of payment deferred.
144 Incentive adjustment e.g. preferred product/service.
145 Premium payment withholding.
146 Payment denied because the diagnosis was inalid for the date(s) of service reported.
147 Provider contracted/negotiated rate expired or not on file.
148 Claim/service rejected at this time because information from another provider was not provided or was insufficient/incompl

Total Respondents
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Indicate the appropriate group codes for each Reason Code (check all that may apply)

149 Lifetime benefit maximum has been reached for this service/benefit category.
150 Payment adjusted because the payer deems the information submitted does not support this level of service.
151 Payment adjusted because the payer deems the information submitted does not support this many services.
152 Payment adjusted because the payer deems the information submitted does not support this length of service.
153 Payment adjusted because the payer deems the information submitted does not support this dosage.
154 Payment adjusted because the payer deems the information submitted does not support this day's supply.
155 This claim is denied because the patient refused the service/product.
156 Flexible spending account payments.
157 Payment denied/reduced because service/procedure was provided as a result of an act of war.
158 Payment denied/reduced because the service/procedure was provided outside of the United States.
159 Payment denied/reduced because the service/procedure was provided as a result of terrorism.
160 Payment denied/reduced because injury/illness was the result of an activity that is a benefit exclusion.
161 Provider performance bonus.
162 State-mandated Requirement for Property and Casualty see Claim Payment Remarks Code for specific explanation.
163 Claim/Service adjusted because the attachment referenced on the claim was not received.

Total Respondents
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Indicate the appropriate group codes for each Reason Code (check all that may apply)
164 Claim/Service adjusted because the attachment referenced on the claim was not received in a timely fashion.
A0 Patient refund amount.
A1 Claim denied charges.
A2 Contractual Adjustment.
A4 Medicare Claim PPS Capital Day Outlier Amount.
A5 Medicare Claim PPS Capital Cost Outlier Amount.
A6 Prior hospitalization or 30 day transfer requirement not met.
A7 Presumptive Payment Adjustment.
A8 Claim denied; ungroupable DRG.
B1 Non-covered visits.
B4 Late filing penalty.
B5 Payment adjusted because coverage/program guidelines were not met or were exceeded.
B6 This payment is adjusted when performed/billed by this type of provider by this type of provider in this type of facility or by a
B7 This provider was not certified/eligible to be paid for this procedure/service on this date of service.
B8 Claim/service not covered/reduced because alternative services were available and should have been utilized.

Total Respondents
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Indicate the appropriate group codes for each Reason Code (check all that may apply)

B9 Services not covered because the patient is enrolled in a Hospice.
B10 Allowed amount has been reduced because a component of the basic procedure/test was paid. The beneficiary is not liabl
B11 The claim/service has been transferred to the proper payer/processor for processing. Claim/service not covered by this pa
B12 Services not documented in patient's medical records.
B13 Previously paid. Payment for this claim/service may have been provided in a previous payment.
B14 Payment denied because only one visit or consultation per physician per day is covered.
B15 Payment adjusted because this procedure/service is not paid separately.
B16 Payment adjusted because 'New Patient' qualifications were not met.
B17 Payment adjusted because this service was not prescribed by a physician not prescribed prior to delivery the prescription i
B18 Payment denied because this procedure code/modifier was invalid on the date of service or claim submission.
B20 Payment adjusted because procedure/service was partially or fully furnished by another provider.
B22 This payment is adjusted based on the diagnosis.
B23 Payment denied because this provider has failed an aspect of a proficiency testing program.
W1 Workers Compensation State Fee Schedule Adjustment.

Total Respondents
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not apply to the billed services or provider.




supplied using remittance advice remark codes whenever appropriate.
omplete. Additional information is supplied using the remittance advice codes whenever appropriate.

er's Compensation Carrier.




ed care plan.




 ng or residency requirements.
one in conjunction with a routine exam.




 the service billed.


al by the payer.
 ective' by the payer.
port this level of service this many services this length of service this dosage or this day's supply.
an inappropriate or invalid place of service.
aid or identified on this claim.




s a result of war.




y with requirements.
rovide the necessary care.




using the remittance advice remarks codes whenever appropriate.
ovided or was insufficient/incomplete.




this level of service.
this many services.
this length of service.

this day's supply.




ode for specific explanation.
d in a timely fashion.




vider in this type of facility or by a provider of this specialty.

d have been utilized.




s paid. The beneficiary is not liable for more than the charge limit for the basic procedure/test.
im/service not covered by this payer/processor.




 prior to delivery the prescription is incomplete or the prescription is not current.
 or claim submission.

				
DOCUMENT INFO
Description: Distributing Agreement document sample