Contractor Interim Payment Claim - Excel

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					                        DEAN HEALTH PLAN CLAIM ADJUSTMENT REASON CODES - 10/27/10

        Hold           Paper
        code         Claim Adj.                                                           835 Claim Adj.    835 Description of ANSI code                      Group   835 Line Level
                                              Paper Description
       (Paper         Reason                                                               Reason code        (note will not print on 835)                    Codes    Adjustment
        only)          code

                                  Deductible amount                                                        Deductible amount

           DD            1                                                                      1                                                              PR        Deductible


                                  Coinsurance Amount.                                                      Coinsurance Amount.


           MI            2                                                                      2                                                              PR       Coinsurance



                                  Copayment amount.                                                        Copayment amount.


           WW            3                                                                      3                                                              PR          Copay



                                  Copayment amount.                                                        Copayment amount.
        CJ (Used
       only for CU
                         3                                                                      3                                                              PR       Non - Covered
        hold code
        process)
                                  The procedure code is inconsistent w/modifier                            The procedure code is inconsistent with the
                                  used or req. modifier is misiing. MA does not allow                      modifier used or required modifier is misiing.
           PV            4        svc.                                                          4                                                              OA       Non - Covered


                                  The procedure code is inconsistent w/modifier                            The procedure code is inconsistent with the
                                  used or req. modifier missing.                                           modifier used or a required modifier is missing.


           XM            4                                                                      4                                                              OA      Non - Covered




                                  The procedure code/bill type is inconsistent with                        The procedure code/bill type is inconsistent
                                  the place of service.                                                    with the place of service.
           ZJ            5                                                                      5                                                              OA       Non - Covered



                                  The procedure/revenue code is inconsistent with                          The procedure/revenue code is inconsistent
                                  the patient's age                                                        with the patient's age
           XL            6                                                                      6                                                              OA      Non - Covered


                                  The procedure/revenue code is inconsistent with                          The procedure/revenue code is inconsistent
                                  the patient's gender                                                     with the patient's gender
           XT            7                                                                      7                                                              OA      Non - Covered


                                  The procedure code is inconsistent with the prov.                        The procedure code is inconsistent with the
                                  type/specialty (taxonomy).                                               provider type/specialty(taxonomy).
           PY            8                                                                      8                                                              OA       Non - Covered


                                  The diagnosis is inconsistent with the patient's age                     The diagnosis is inconsistent with the patient's
                                                                                                           age
           XV            9                                                                      9                                                              OA      Non - Covered


                                  The diagnosis is inconsistent with the patient's                         The diagnosis is inconsistent with the patient's
                                  gender.                                                                  gender.
           XY            10                                                                     10                                                             OA      Non - Covered




2/7/2011                                                                                 2b37cbad-3ace-4df5-b785-769dc567eb8d.xls                                                       1
                   DEAN HEALTH PLAN CLAIM ADJUSTMENT REASON CODES - 10/27/10

        Hold      Paper
        code    Claim Adj.                                                             835 Claim Adj.    835 Description of ANSI code                     Group   835 Line Level
                                          Paper Description
       (Paper    Reason                                                                 Reason code        (note will not print on 835)                   Codes    Adjustment
        only)     code

                             The diagnosis is inconsistent with the procedure                           The diagnosis is inconsistent with the
                                                                                                        procedure
           DH       11                                                                       11                                                            OA       Non-Covered


                             The diagnosis is inconsistent with the provider type                       The diagnosis is inconsistent with the provider
                                                                                                        type
           DK       12                                                                       12                                                            OA       Non-Covered


                             The date of death precedes the date of service                             The date of death precedes the date of service

           DL       13                                                                       13                                                            OA       Non-Covered


                             The date of birth follows the date of service                              The date of birth follows the date of service

           DQ       14                                                                       14                                                            OA       Non-Covered


                             Clm/svc lacks info needed for adjudication. Refile                         Claim/service lacks information which is
                             w/ correct prov / vend#                                                    needed for adjudication. At least one Remark
           ZT      16W                                                                       16         Code must be provided (may be comprised of         OA       Non - Covered
                                                                                                        either the Remittance Advice Remark Code or
                                                                                                        NCPDP Reject Reason Code).
                             clm/svc lacks info for adjudication - refile with more                     Claim/service lacks information which is
                             appropriate CPT/ HCPC's code                                               needed for adjudication. At least one Remark
           YI      16V                                                                       16         Code must be provided (may be comprised of         OA      Non - Covered
                                                                                                        either the Remittance Advice Remark Code or
                                                                                                        NCPDP Reject Reason Code).
                             Claim/svc lacks info for adjudication. Submit                              Claim/service lacks information which is
                             Provider Name & Specialty                                                  needed for adjudication. At least one Remark
           ZS      16Q                                                                       16         Code must be provided (may be comprised of         OA       Non - Covered
                                                                                                        either the Remittance Advice Remark Code or
                                                                                                        NCPDP Reject Reason Code).
                             Claim/svc lacks info for adjudication - refile with                        Claim/service lacks information which is
                             itemzation sorted by days                                                  needed for adjudication. At least one Remark
           ZF      16K                                                                       16         Code must be provided (may be comprised of         OA       Non - Covered
                                                                                                        either the Remittance Advice Remark Code or
                                                                                                        NCPDP Reject Reason Code).
                             Claim/svc lacks info for adjudication. Submit                              Claim/service lacks information which is
                             description of procedure.                                                  needed for adjudication. At least one Remark
           X1      16X                                                                       16         Code must be provided (may be comprised of         OA      Non - Covered
                                                                                                        either the Remittance Advice Remark Code or
                                                                                                        NCPDP Reject Reason Code).
                             Clm/svc lacks info.needed for adjudication.                                Claim/service lacks information which is
                             Consent form does not meet age requirements.                               needed for adjudication. At least one Remark
           CF      16Z                                                                       16         Code must be provided (may be comprised of         OA       Non-Covered
                                                                                                        either the Remittance Advice Remark Code or
                                                                                                        NCPDP Reject Reason Code).
                             Clm /svc lacks info for adjudication. Submit                               Claim/service lacks information which is
                             Medicaid Consent Form.                                                     needed for adjudication. At least one Remark
           GF      16J                                                                       16         Code must be provided (may be comprised of         OA       Non-Covered
                                                                                                        either the Remittance Advice Remark Code or
                                                                                                        NCPDP Reject Reason Code).
                             Duplicate claim/service.                                                   Duplicate claim/service.


           XD       18                                                                       18                                                            OA      Non - Covered


2/7/2011                                                                              2b37cbad-3ace-4df5-b785-769dc567eb8d.xls                                                      2
                   DEAN HEALTH PLAN CLAIM ADJUSTMENT REASON CODES - 10/27/10

        Hold      Paper
        code    Claim Adj.                                                             835 Claim Adj.    835 Description of ANSI code                       Group          835 Line Level
                                          Paper Description
       (Paper    Reason                                                                 Reason code        (note will not print on 835)                     Codes           Adjustment
        only)     code

                             This is a work-related injury/illness and thus the                         This is a work-related injury/illness and thus
                             liability of the worker's compensation carrier.                            the liability of the worker's compensation
           S1       19                                                                       19         carrier.                                               OA           Non - Covered


                             This care may be covered by another payer                                  This care may be covered by another payer
                             (Medicare)                                                                 per coordination of benefits.
           MP      22B                                                                       22                                                                OA            Non- Covered



                             This care may be covered by another payer.                                 This care may be covered by another payer
                                                                                                        per coordination of benefits.
           OI       22                                                                       22                                                                OA            Non - Covered


                             The impact of prior payer adj. Including payments                          The impact of prior payer(s) adjudication
                             and/ or adjustments.                                                       including payments and / or adjustments.
           S5       23                                                                       23                                                                OA            COB Savings


                             Expenses incurred prior to coverage.                                       Expenses incurred prior to coverage.

           CV       26                                                                       26                                                                PR            Non-Covered


                             Expenses incurred after coverage terminated.                               Expenses incurred after coverage terminated.

           CX       27                                                                       27                                                                PR            Non-Covered


                             Time limit for filing has expired. Per review, service                     Time limit for filing has expired.
                             remains denied.
           YU      29B                                                                       29                                                           (1) CO, (2) PR     Non - Covered


                             The time limit for filing has expired.                                     The time limit for filing has expired.

           TF       29                                                                       29                                                                PR            Non - Covered


                             The time limit for filing has expired.                                     The time limit for filing has expired.

           X6       29                                                                       29                                                           (1) CO, (2) PR    Non - Covered


                             Patient cannot be identified as our insured                                Patient cannot be identified as our insured

           FF       31                                                                       31                                                                PR            Non- Covered


                             Our records indicate that this dependent is not an                         Our records indicate that this dependent is not
                             eligible dependent as defined                                              an eligible dependent as defined
           CW       32                                                                       32                                                                PR            Non - Covered


                             Insured has no dependent coverage                                          Insured has no dependent coverage

           CZ       33                                                                       33                                                                PR            Non - Covered


                             Insured has no coverage for newborns.                                      Insured has no coverage for newborns.

           C2       34                                                                       34                                                                PR            Non - Covered




2/7/2011                                                                              2b37cbad-3ace-4df5-b785-769dc567eb8d.xls                                                               3
                   DEAN HEALTH PLAN CLAIM ADJUSTMENT REASON CODES - 10/27/10

        Hold      Paper
        code    Claim Adj.                                                        835 Claim Adj.    835 Description of ANSI code                    Group                835 Line Level
                                         Paper Description
       (Paper    Reason                                                            Reason code        (note will not print on 835)                  Codes                 Adjustment
        only)     code

                             Lifetime Benefit maximum has been reached                             Lifetime Benefit maximum has been reached

           BM       35                                                                  35                                                             PR                   Non-Covered


                             Services not provided or authorized by designated                     Services not provided or authorized by
                             network/primary care prov.                                            designated (network/primary care) providers.
           NA       38                                                                  38                                                             PR                   Non - Covered



                             Services denied at the time                                           Services denied at the time
                             authorization/precertification was req                                authorization/precertification was requested

           NZ       39                                                                  39                                                             PR                   Non - Covered



                             Charges do not meet qualifications for                                Charges do not meet qualifications for
                             emergent/urgent care.                                                 emergent/urgent care.
           NE       40                                                                  40                                                             PR                   Non - Covered


                             Charge exceeds fee schedule/maximum allowable.                        Charge exceeds fee schedule/maximum
                             Discount applied.                                                     allowable or contracted /legislated fee
                                                                                                   arrangement.                                                     Difference between charged and
           50       45                                                                  45                                                        (1.) CO, (2) PR
                                                                                                                                                                            allowed amount



                             Charge exceeds contracted fee arrangement. No                         Charge exceeds fee schedule/maximum
                             HPSA Incentive applied                                                allowable or contracted /legislated fee
                                                                                                   arrangement.                                                     Difference between charged and
           SE      45A                                                                  45                                                             CO
                                                                                                                                                                            allowed amount



                             Charge exceeds contracted fee arrangement.                            Charge exceeds fee schedule/maximum
                             HPSA Incentive applied                                                allowable or contracted /legislated fee
                                                                                                   arrangement.                                                     Difference between charged and
           SB      45B                                                                  45                                                             CO
                                                                                                                                                                            allowed amount



                             Charge exceeds contracted fee arrangement. No                         Charge exceeds fee schedule/maximum
                             Discount applied                                                      allowable or contracted /legislated fee
                                                                                                   arrangement.                                                     Difference between charged and
           BE      45C                                                                  45                                                             CO
                                                                                                                                                                            allowed amount



                             Charge exceeds contracted fee arrangement.                            Charge exceeds fee schedule/maximum
                             Reduced by Managed care.                                              allowable or contracted /legislated fee
                                                                                                   arrangement.                                                     Difference between charged and
           BX      45D                                                                  45                                                        (1) CO, (2) PR
                                                                                                                                                                            allowed amount



                             Charge exceeds contracted fee arrangement. Svc                        Charge exceeds fee schedule/maximum
                             not on your fee sched.                                                allowable or contracted /legislated fee
                                                                                                   arrangement.
           X7      45W                                                                  45                                                             CO                  Non - Covered




2/7/2011                                                                         2b37cbad-3ace-4df5-b785-769dc567eb8d.xls                                                                            4
                   DEAN HEALTH PLAN CLAIM ADJUSTMENT REASON CODES - 10/27/10

        Hold      Paper
        code    Claim Adj.                                                        835 Claim Adj.    835 Description of ANSI code                    Group        835 Line Level
                                         Paper Description
       (Paper    Reason                                                            Reason code        (note will not print on 835)                  Codes         Adjustment
        only)     code

                             Charge exceeds contracted fee schedule. Submit                        Charge exceeds fee schedule/maximum
                             notes to rev for add'l $                                              allowable or contracted /legislated fee
                                                                                                   arrangement.                                             Difference between charged and
           YQ      45X                                                                  45                                                           CO
                                                                                                                                                                    allowed amount



                             Charge exceeds contracted fee arrangement.                            Charge exceeds fee schedule/maximum
                             Provider discount applied.                                            allowable or contracted /legislated fee
                                                                                                   arrangement.
           DT      45Z                                                                  45                                                           CO             Discount field



                             These are noncovered services because this is not                     These are noncovered services because this
                             deemed a "medical necessity"                                          is not deemed a "medical necessity" by the
                                                                                                   payer
           MT       50                                                                  50                                                           PR            Non - Covered



                             These are noncovered services because this is a                       These are noncovered services because this
                             preexisting condition                                                 is a preexisting condition

           DP       51                                                                  51                                                           PR             Non- Covered



                             Services by an immediate relative or member of                        Services by an immediate relative or a member
                             same household are not covered                                        of the same household are not covered

           N1       53                                                                  53                                                           PR            Non - Covered



                             Multiple physicians/assistants are not covered in                     Multiple physicians/assistants are not covered
                             this case.                                                            in this case.

           X4       54                                                                  54                                                           OA            Non - Covered



                             Procedure/treatment is deemed                                         Procedure/treatment is deemed
                             experimental/investigational by the payer                             experimental/investigational by the payer

           EV       55                                                                  55                                                           PR             Non-Covered



                             Treatment deemed to have been rendered in                             Treatment was deemed by the payer to have
                             inappro. or invalid POS                                               been rendered in an inappropriate or invalid
                                                                                                   place of service.
           ZX       58                                                                  58                                                           OA             Non -covered



                             Processed based on mulitple or concurrent                             Processed based on mulitple or concurrent
                             procedure rules.                                                      procedure rules.
                                                                                                                                                            Difference between charged and
           2X       59                                                                  59                                                           OA
                                                                                                                                                                    allowed amount



                             Noncovered days/room charge adjustment                                Noncovered days/room charge adjustment


           PN       78                                                                  78                                                           PR             Non-covered




2/7/2011                                                                         2b37cbad-3ace-4df5-b785-769dc567eb8d.xls                                                                    5
                   DEAN HEALTH PLAN CLAIM ADJUSTMENT REASON CODES - 10/27/10

        Hold      Paper
        code    Claim Adj.                                                           835 Claim Adj.    835 Description of ANSI code                     Group        835 Line Level
                                         Paper Description
       (Paper    Reason                                                               Reason code        (note will not print on 835)                   Codes         Adjustment
        only)     code

                             Transfer Amount                                                          Transfer Amount


           C1       87                                                                     87                                                            PR                Copay



                             Plan procedures not followed.                                            Plan procedures not followed.

           XP       95                                                                     95                                                            PR            Non - Covered


                             Plan procedures not followed.Penalty applied                             Plan procedures not followed.


           P5      95E                                                                     95                                                            PR            Non - Covered



                             Plan procedures not followed. S/B enrolled w/                            Plan procedures not followed.
                             Medicare Part B
           RB      95C                                                                     95                                                            PR             Non- Covered



                             Noncovered charges. Noncovered per policy                                Noncovered charges


           NC       96                                                                     96                                                            PR            Non - Covered



                             Noncovered charges. Service covered at 50%.                              Noncovered charges.


           C5      96J                                                                     96                                                            PR             Non-covered



                             Payment included in the allowance for another                            Payment included in the allowance for another
                             service. Svc pd at DRG/PerDiem                                           service/procedure
                                                                                                                                                                Difference between charged and
           LO      97E                                                                     97                                                            CO
                                                                                                                                                                        allowed amount


                             Payment made to patient/insured/responsible party                        Payment made to patient/insured/responsible
                                                                                                      party
           PJ      100                                                                    100                                                            PR            Non - Covered



                             Managed care withholding ***note should only be                          Managed care withholding
                             on Provider EOP, not printed on Member EOB
           WH      104                                                                    104                                                            CO               With hold



                             The related claim/service was not identified on this                     The related or qualifying claim/service was not
                             claim.                                                                   identified on this claim
           N2      107                                                                    107                                                            OA             Non-Covered



                             Rent/purchase guidelines were not met                                    Rent/purchase guidelines were not met


           RT      108                                                                    108                                                            PR             Non -covered




2/7/2011                                                                            2b37cbad-3ace-4df5-b785-769dc567eb8d.xls                                                                     6
                   DEAN HEALTH PLAN CLAIM ADJUSTMENT REASON CODES - 10/27/10

        Hold      Paper
        code    Claim Adj.                                                         835 Claim Adj.    835 Description of ANSI code                   Group   835 Line Level
                                         Paper Description
       (Paper    Reason                                                             Reason code        (note will not print on 835)                 Codes    Adjustment
        only)     code

                             Claim not covered by this payer. You must send                         Claim not covered by this payer/contractor.
                             the clm to North Central Opthalmology.                                 You must send the claim to the correct
           Y1      109                                                                  109         payor/contractor                                 OA      Non - Covered



                             Claim not covered by this payor. You must send                         Claim not covered by this payer/contractor.
                             the claim to contracted repricer.                                      You must send the claim to the correct
           RW      109                                                                  109         payor/contractor                                 OA       Non - Covered



                             Claim not covered by this payor. You must send                         Claim not covered by this payer/contractor.
                             the claim to Interlink.                                                You must send the claim to the correct
           Z1      109                                                                  109         payor/contractor                                 OA       Non-Covered



                             Claim not covered by this payor. You must send                         Claim not covered by this payer/contractor.
                             the claim to URN.                                                      You must send the claim to the correct
           Z2      109                                                                  109         payor/contractor                                 OA       Non - Covered



                             Claim not covered by this payer. You must send                         Claim not covered by this payer/contracter.
                             the claim to the correct payer                                         You must send the claim to the correct
           TI      109                                                                  109         payer/contracter                                 OA      Non - Covered


                             Billing date predates service date. Resubmit                           Billing date predates service date
                             w/correct DOS
           YF      110                                                                  110                                                          OA      Non - Covered


                             Not covered unless the provider accepts                                Not covered unless the provider accepts
                             assignment                                                             assignment

           AA      111                                                                  111                                                          OA       Non-Covered



                             Procedure postponed, cancelled or delayed                              Procedure postponed, cancelled or delayed


           C6      115                                                                  115                                                          PR       Non-Covered



                             Transportation is only covered to the closest                          Transportation is only covered to the closest
                             facility.                                                              facility that can provide the necessary care
           TV      117                                                                  117                                                          PR       Non-Covered


                             Benefit max for this period/occurrence is reached.                     Benefit maximum for this time period or
                             2 Yr Eyeglass benefit met.                                             occurrence has been reached

           EG      119                                                                  119                                                          PR       Non- Covered




2/7/2011                                                                          2b37cbad-3ace-4df5-b785-769dc567eb8d.xls                                                    7
                   DEAN HEALTH PLAN CLAIM ADJUSTMENT REASON CODES - 10/27/10

        Hold      Paper
        code    Claim Adj.                                                         835 Claim Adj.    835 Description of ANSI code                     Group        835 Line Level
                                         Paper Description
       (Paper    Reason                                                             Reason code        (note will not print on 835)                   Codes         Adjustment
        only)     code

                             Benefit max for this period/occurrence is reached.                     Benefit maximum for this time period or
                             Benefit maximum met                                                    occurrence has been reached



           BN      119                                                                  119                                                            PR            Non - Covered




                             Benefit max for this period/occurrence is                              Benefit maximum for this time period or
                             reached.Benefit maximum met                                            occurrence has been reached



           MX      119                                                                  119                                                            PR            Non - Covered




                                                                                                    Submission/billing error(s). At least one
                                                                                                    Remark Code must be provided (may be
                             Submission/billing error(s). Submit HCFA for add'l
           Z3      125                                                                  125         comprised of either the Remittance Advice          OA            Non - Covered
                             $
                                                                                                    Remark Code or NCPDP Reject Reason
                                                                                                    Code).
                             Prior processing information appears incorrect.                        Prior processing information appears incorrect.
                             Need EOB.

           OC      129                                                                  129                                                            OA            Non - Covered



                             Claim specific negotiated discount. Negotiated fee                     Claim specific negotiated discount
                             with prov.
                                                                                                                                                              Difference between charged and
           NF      131                                                                  131                                                            CO
                                                                                                                                                                      allowed amount



                             Claim specific negotiated discount. TRPN/HFN                           Claim specific negotiated discount
                                                                                                                                                              Difference between charged and
           R1      131                                                                  131                                                            CO
                                                                                                                                                                      allowed amount


                             Claim specific negotiated discount. First Choice                       Claim specific negotiated discount
                             Health Netwk.
                                                                                                                                                              Difference between charged and
           R2      131                                                                  131                                                            CO
                                                                                                                                                                      allowed amount


                             Claim specific negotiated discount. PPO                                Claim specific negotiated discount
                             Next/PHN/Healthstar
                                                                                                                                                              Difference between charged and
           R3      131                                                                  131                                                            CO
                                                                                                                                                                      allowed amount


                             Claim specific negotiated discount. HFNID                              Claim specific negotiated discount

                                                                                                                                                              Difference between charged and
           R4      131                                                                  131                                                            CO
                                                                                                                                                                      allowed amount



                             Claim specific negotiated discount. Primary Health                     Claim specific negotiated discount
                             Services
                                                                                                                                                              Difference between charged and
           R5      131                                                                  131                                                            CO
                                                                                                                                                                      allowed amount

2/7/2011                                                                          2b37cbad-3ace-4df5-b785-769dc567eb8d.xls                                                                     8
                   DEAN HEALTH PLAN CLAIM ADJUSTMENT REASON CODES - 10/27/10

        Hold      Paper
        code    Claim Adj.                                                        835 Claim Adj.    835 Description of ANSI code        Group        835 Line Level
                                         Paper Description
       (Paper    Reason                                                            Reason code        (note will not print on 835)      Codes         Adjustment
        only)     code

                             Claim specific negotiated discount. Novanet                           Claim specific negotiated discount
                                                                                                                                                Difference between charged and
           R6      131                                                                 131                                               CO
                                                                                                                                                        allowed amount


                             Claim specific negotiated discount. Galaxy Health                     Claim specific negotiated discount
                             Network
                                                                                                                                                Difference between charged and
           R7      131                                                                 131                                               CO
                                                                                                                                                        allowed amount


                             Claim specific negotiated discount.                                   Claim specific negotiated discount
                             NPPN/Accountable
                                                                                                                                                Difference between charged and
           R8      131                                                                 131                                               CO
                                                                                                                                                        allowed amount



                             Claim specific negotiated discount. Hygeia                            Claim specific negotiated discount
                             Corporation
                                                                                                                                                Difference between charged and
           R9      131                                                                 131                                               CO
                                                                                                                                                        allowed amount



                             Claim specific negotiated discount. TRPN/FPN                          Claim specific negotiated discount

                                                                                                                                                Difference between charged and
           RA      131                                                                 131                                               CO
                                                                                                                                                        allowed amount



                             Claim specific negotiated discount. PHCS Healthy                      Claim specific negotiated discount
                             Directions contract
                                                                                                                                                Difference between charged and
           RE      131                                                                 131                                               CO
                                                                                                                                                        allowed amount


                             Claim specific negotiated discount.Health Payors                      Claim specific negotiated discount
                             organization contract
                                                                                                                                                Difference between charged and
           RF      131                                                                 131                                               CO
                                                                                                                                                        allowed amount


                             Claim specific negotiated discount. PPO Next                          Claim specific negotiated discount
                             contract.
                                                                                                                                                Difference between charged and
           RG      131                                                                 131                                               CO
                                                                                                                                                        allowed amount



                             Claim specific negotiated discount. PHCS contract                     Claim specific negotiated discount
                                                                                                                                                Difference between charged and
           RH      131                                                                 131                                               CO
                                                                                                                                                        allowed amount


                             Claim specific negotiated discount. Hygeia Corp                       Claim specific negotiated discount
                             contract
                                                                                                                                                Difference between charged and
           RI      131                                                                 131                                               CO
                                                                                                                                                        allowed amount


                             Claim specific negotiated discount. Multiplan                         Claim specific negotiated discount
                             contract
                                                                                                                                                Difference between charged and
           RJ      131                                                                 131                                               CO
                                                                                                                                                        allowed amount


                             Claim specific negotiated discount. HealthEOS                         Claim specific negotiated discount
                             contract
                                                                                                                                                Difference between charged and
           RK      131                                                                 131                                               CO
                                                                                                                                                        allowed amount


2/7/2011                                                                         2b37cbad-3ace-4df5-b785-769dc567eb8d.xls                                                        9
                   DEAN HEALTH PLAN CLAIM ADJUSTMENT REASON CODES - 10/27/10

        Hold      Paper
        code    Claim Adj.                                                          835 Claim Adj.    835 Description of ANSI code        Group        835 Line Level
                                         Paper Description
       (Paper    Reason                                                              Reason code        (note will not print on 835)      Codes         Adjustment
        only)     code

                             Claim specific negotiated discount Accountable                          Claim specific negotiated discount
                             Health Plans.

                                                                                                                                                  Difference between charged and
           RL      131                                                                   131                                               CO
                                                                                                                                                          allowed amount




                             Claim specific negotiated discount. NPPN                                Claim specific negotiated discount
                             Community Health Partners.
                                                                                                                                                  Difference between charged and
           RN      131                                                                   131                                               CO
                                                                                                                                                          allowed amount



                             Claim specific negotiated discount. URN Network                         Claim specific negotiated discount
                             contract)
                                                                                                                                                  Difference between charged and
           RO      131                                                                   131                                               CO
                                                                                                                                                          allowed amount



                             Claim specific negotiated discount. ARAZ/Americas                       Claim specific negotiated discount
                             PPO
                                                                                                                                                  Difference between charged and
           RP      131                                                                   131                                               CO
                                                                                                                                                          allowed amount


                             Claim specific negotiated discount. Coalition                           Claim specific negotiated discount
                             America contract
                                                                                                                                                  Difference between charged and
           RQ      131                                                                   131                                               CO
                                                                                                                                                          allowed amount


                             Claim specific negotiated discount. Provider Select                     Claim specific negotiated discount
                                                                                                                                                  Difference between charged and
           RU      131                                                                   131                                               CO
                                                                                                                                                          allowed amount


                             Claim specific negotiated discount. HMN/RAN/AMN                         Claim specific negotiated discount

                                                                                                                                                  Difference between charged and
           RX      131                                                                   131                                               CO
                                                                                                                                                          allowed amount



                             Claim specific negotiated discount. NPPN Direct                         Claim specific negotiated discount
                                                                                                                                                  Difference between charged and
           RY      131                                                                   131                                               CO
                                                                                                                                                          allowed amount


                             Claim specific negotiated discount. Medical                             Claim specific negotiated discount
                             Resource/Natl Prvd
                                                                                                                                                  Difference between charged and
           RZ      131                                                                   131                                               CO
                                                                                                                                                          allowed amount


                             Claim specific negotiated discount. PlanCare                            Claim specific negotiated discount
                             America.
                                                                                                                                                  Difference between charged and
           T1      131                                                                   131                                               CO
                                                                                                                                                          allowed amount


                             Claim specific negotiated discount. Negotiated fee                      Claim specific negotiated discount
                                                                                                                                                  Difference between charged and
           Y6      131                                                                   131                                               CO
                                                                                                                                                          allowed amount




2/7/2011                                                                           2b37cbad-3ace-4df5-b785-769dc567eb8d.xls                                                        10
                   DEAN HEALTH PLAN CLAIM ADJUSTMENT REASON CODES - 10/27/10

        Hold      Paper
        code    Claim Adj.                                                        835 Claim Adj.    835 Description of ANSI code                     Group   835 Line Level
                                          Paper Description
       (Paper    Reason                                                            Reason code        (note will not print on 835)                   Codes    Adjustment
        only)     code

                             The disposition of the clm/svc is pending review.                     The disposition of the claim/service is pending
                             Submit NDC/ name of RX drug.                                          further review.

           YA      133                                                                 133                                                            OA      Non - Covered



                             The disposition of the clm/svc is pending further                     The disposition of the claim/service is pending
                             review. Submit office notes/ records.                                 further review.

           XO      133                                                                 133                                                            OA      Non - Covered



                             The disposition of the clm/svc is pending review.                     The disposition of the claim/service is pending
                             Notes req. w/ medical need.                                           further review.

           ZY      133                                                                 133                                                            OA      Non - Covered



                             Interim bills cannot be processed                                     Interim bills cannot be processed


           I2      135                                                                 135                                                            CO       Non-Covered



                             Failure to follow prior payer's coverage rules.                       Failure to follow prior payer's coverage rules.


           GG      136                                                                 136                                                            OA       Non-Covered



                             Appeal procedures not followed or time limits not                     Appeal procedures not followed or time limits
                             met                                                                   not met

           TL      138                                                                 138                                                            CO       Non-Covered



                             Patient/insured health identification number and                      allowed amt reduced because component of
                             name do not match.                                                    the basic prodcedure/test was paid. The
                                                                                                   beneficiary is not liable for more than the
           N3      140                                                                 140         charge limit for the basic procedure/test          PR       Non-Covered



                             Claim spans eligible & ineligible periods of                          Claim spans eligible & ineligible periods of
                             coverage.                                                             coverage.

           N4      141                                                                 141                                                            PR       Non-Covered



                             Monthly Medicaid patient liability amount.                            Monthly Medicaid patient liability amount.


           N5      142                                                                 142                                                            PR       Non-Covered



                             Diagnosis was invalid for date(s) of service                          Diagnosis was invalid for date(s) of service
                             reported.                                                             reported.

           N7      146                                                                 146                                                            OA       Non-Covered




2/7/2011                                                                         2b37cbad-3ace-4df5-b785-769dc567eb8d.xls                                                     11
                   DEAN HEALTH PLAN CLAIM ADJUSTMENT REASON CODES - 10/27/10

        Hold      Paper
        code    Claim Adj.                                                          835 Claim Adj.    835 Description of ANSI code                     Group   835 Line Level
                                         Paper Description
       (Paper    Reason                                                              Reason code        (note will not print on 835)                   Codes    Adjustment
        only)     code

                             Diagnosis was invalid for date(s) of service                            Diagnosis was invalid for date(s) of
                             reported.                                                               service reported.
           XX      146                                                                   146                                                            OA      Non - Covered



                             Provider contracted/negotiated rate expired or rate                     Provider contracted/negotiated rate expired or
                             not on file.                                                            rate not on file.

           N9      147                                                                   147                                                            CO       Non-Covered



                             Information from another provider was not provided                      Information from another provider was not
                             or was incomplete.                                                      provided or was insufficient/incomplete.

           FA      148                                                                   148                                                            PR       Non-Covered



                             Lifetime benefit maximum has been reached for                           Lifetime benefit maximum has been reached
                             this service/benefit category.                                          for this service/benefit category.

           M5      149                                                                   149                                                            PR       Non-Covered



                             Payer deems the information submitted does not                          Payer deems the information submitted does
                             support level of svc.                                                   not support this level of service.

           M7      150                                                                   150                                                            OA       Non-Covered



                             Payer deems the information submitted does not                          Payer deems the information submitted does
                             support level of svc.                                                   not support this level of service.

           XC      150                                                                   150                                                            OA      Non - Covered



                             Payment adj. because the payer deems the info                           Payment adjusted because the payer deems
                             rec'd does not support these svc.                                       the information submitted does not support this
                                                                                                     many/frequency of services.
           M8      151                                                                   151                                                            OA       Non-Covered



                             This (these) diagnosis (es) is (are) not covered                        This (these) diagnosis(es) is (are) not covered


           DX      167                                                                   167                                                            PR       Non-Covered



                             Payment is denied when billed by this type of                           Payment is denied when performed/billed by
                             provider. Included in NH rate.                                          this type of provider in this type of facility.

           ZK      171                                                                   171                                                            CO       Non - Covered



                             Payment adjusted when performed/billed by a                             Payment adjusted when perfomed/billed by a
                             provider of this specialty                                              provider of this specialty

           P4      172                                                                   172                                                            OA       Non-Covered




2/7/2011                                                                           2b37cbad-3ace-4df5-b785-769dc567eb8d.xls                                                      12
                   DEAN HEALTH PLAN CLAIM ADJUSTMENT REASON CODES - 10/27/10

        Hold      Paper
        code    Claim Adj.                                                           835 Claim Adj.    835 Description of ANSI code                   Group        835 Line Level
                                          Paper Description
       (Paper    Reason                                                               Reason code        (note will not print on 835)                 Codes         Adjustment
        only)     code

                             Procedure code was invalid on the date of service.                       Procedure code was invalid on the date of
                                                                                                      service.

           XN      181                                                                    181                                                            OA          Non-Covered



                             Procedure modifer was invalid on the date of                             Procedure modifer was invalid on the date of
                             service.                                                                 service.

           M9      182                                                                    182                                                            OA          Non-Covered



                             The rendering provider is not eligible to perform the                    The rendering provider is not eligible to
                             service billed                                                           perform the service billed

           P1      185                                                                    185                                                        1)CO 2) PR      Non-Covered



                             Unlisted procedure code billed when there is a                           "Not otherwise classified " or "unlisted"
                             specific code for this svc.                                              procedure code (CPT/HCPCS) was billed
                                                                                                      when there is a specific procedure code for
           T3      189                                                                    189         this procedure/service                             OA          Non-Covered



                             Precertification/authorization/notification absent.                      Precertification/authorization/notification
                                                                                                      absent.

           X8      197                                                                    197                                                        1) CO 2) PR    Non - Covered



                             Precertification/authorization/notification absent.                      Precertification/authorization/notification
                             Medicaid Member, file w/EDS.                                             absent.

           YR      197                                                                    197                                                        1) CO 2) PR     Non-covered



                             Noncovered personal comfort or convenience                               Non covered personal comfort or convenience
                             services.                                                                services.

           NP      202                                                                    202                                                            PR          Non-covered



                             Information requested from the                                           Information requested from the
                             patient/insured/responsible party was not provided                       patient/insured/responsible party was not
                             or was insufficient/incomplete                                           provided or was insufficient/incomplete. At
           FN      227                                                                    227         least one Remark Code must be provided             PR          Non- Covered
                                                                                                      (may be comprised of either the Remittance
                                                                                                      Advice Remark Code or NCPDP Reject
                                                                                                      Reason Code).
                             Information requested from the                                           Information requested from the
                             patient/insured/responsible party was not provided                       patient/insured/responsible party was not
                             or was insufficient/incomplete. Medical Records                          provided or was insufficient/incomplete. At
           MR      227       Requested.                                                   227         least one Remark Code must be provided             PR          Non-Covered
                                                                                                      (may be comprised of either the Remittance
                                                                                                      Advice Remark Code or NCPDP Reject
                                                                                                      Reason Code).
                             Information requested from the                                           Information requested from the
                             patient/insured/responsible party was not provided                       patient/insured/responsible party was not
                             or was insufficient/incomplete                                           provided or was insufficient/incomplete. At
           WN      227                                                                    227         least one Remark Code must be provided             PR         Non - Covered
                                                                                                      (may be comprised of either the Remittance
                                                                                                      Advice Remark Code or NCPDP Reject
                                                                                                      Reason Code).
2/7/2011                                                                           2b37cbad-3ace-4df5-b785-769dc567eb8d.xls                                                         13
                   DEAN HEALTH PLAN CLAIM ADJUSTMENT REASON CODES - 10/27/10

        Hold      Paper
        code    Claim Adj.                                                           835 Claim Adj.    835 Description of ANSI code                       Group        835 Line Level
                                         Paper Description
       (Paper    Reason                                                               Reason code        (note will not print on 835)                     Codes         Adjustment
        only)     code

                             Mutually exclusive procedures cannot be done in                          Mutually exclusive procedures cannot be done
                             the same day/setting.                                                    in the same day/setting.

           YG      231                                                                    231                                                            1) CO 2) PR     Non-covered




                             Ungroupable DRG                                                          Ungroupable DRG


           UG       A8                                                                     A8                                                                OA          Non - Covered



                             Non Covered visits. This visit is not covered.                           Non Covered visits


           NV       B1                                                                     B1                                                                PR          Non - Covered



                             Coverage/program guidelines were not met or were                         Coverage/program guidelines were not met or
                             exceeded.                                                                were exceeded.

           HB       B5                                                                     B5                                                                PR          Non- Covered



                             Alternative services were available and not used.                        Alternative services were available and should
                                                                                                      have been utilized.

           AS       B8                                                                     B8                                                                PR          Non -covered



                             Allowed amt reduced because component of the                             Allowed amt reduced because component of
                             basic prodcedure/test was paid                                           the basic prodcedure/test was paid. The
                                                                                                      beneficiary is not liable for more than the
           YD      B10                                                                    B10         charge limit for the basic procedure/test              OA          Non - Covered



                             Services not documented in patient's medical                             Services not documented in patient's medical
                             records. No documentation for svc.                                       records

           ZU      B12                                                                    B12                                                                OA          Non - Covered



                             Previously paid. Payment for this clm/svc provided                       Previously paid. Payment for this claim/service
                             in a previous payment.                                                   may have been provided in a previous
                                                                                                      payment.
           YK      B13                                                                    B13                                                                OA         Non - Covered



                             Only one visit or consultation per physician per day                     Only one visit or consultation per physician per
                             is covered.                                                              day is covered.

           ZV      B14                                                                    B14                                                                OA          Non - Covered




2/7/2011                                                                            2b37cbad-3ace-4df5-b785-769dc567eb8d.xls                                                             14
                   DEAN HEALTH PLAN CLAIM ADJUSTMENT REASON CODES - 10/27/10

        Hold      Paper
        code    Claim Adj.                                                         835 Claim Adj.    835 Description of ANSI code                     Group          835 Line Level
                                          Paper Description
       (Paper    Reason                                                             Reason code        (note will not print on 835)                   Codes           Adjustment
        only)     code

                             This service requires that a qualifying service be                     This service/procedure requires that a
                             received and covered. Included in other service.                       qualifying service/procedure be received and
                                                                                                    covered. The qualifying other
           XA      B15                                                                  B15         service/procedure has not been                  (1) CO, (2) PR      Non - Covered
                                                                                                    received/adjudicated.


                             "New Patient" qualifications were not met                              "New Patient" qualifications were not met


           XK      B16                                                                  B16                                                              OA             Non - Covered



                             Coinsurance Amount met. Member has reached
                             their out of pocket maximum.

           M2      02G                                                                No Set up     Used for paper only



                             Correction to a prior claim

                                                                                                     **Do not set up reason code per Cyndy - file
           76       63                                                                No Set up                                                                      Negatives - all buckets
                                                                                                                   places in bucket



                             Correction to a prior claim


           RV      63C                                                                No Set up                  Used for paper only



                             Interest amount. Interest payment.

                                                                                                     **Do not set up reason code per Cyndy - file
           YL       85                                                                No Set up                                                                             To - Pay
                                                                                                                 places $'s in bucket


                             No claim level adjustments. Excluded from
                             DRG/Flat fee.

                   93A                                                                No Set up                  Used for paper only


           LE




2/7/2011                                                                          2b37cbad-3ace-4df5-b785-769dc567eb8d.xls                                                                     15

				
DOCUMENT INFO
Description: Contractor Interim Payment Claim document sample